Abstracts
Morphometric determinants of the sagittal dimensions of the Cervical spinal canal in Achondroplasia : An analysis of the reliability of the Torg Ratio
Dr Swapnil Keny , Dr Suh.S MD
Dr Swapnil Keny Consultant Pediatric Orthopaedic Surgeon,Dr L.H.Hiranandani Hospital, Mumbai
Dr Suh.S MD
Korea University Medical Centre Seoul,Korea
Abstract Introduction
The Torg ratio has been considered a reliable indicator of cervical spinal canal stenosis.
Material and MethodsWe sought to evaluate the accuracy of the Torg ratio on the lateral cervical spine radiograms by trying to establish its correlation with the corresponding effective sagittal canal diameter (ESCD) and Dural sac ratio (DSR) on the MRI of the cervical spine in 18 asymptomatic Achondroplasic subjects from C3 to C7 levels .90 levels were evaluated on the lateral radiograph and on the mid sagittal T2 MR image .
ResultsThe highest correlation coefficient for the Torg ratio compared with the ESCD was 0.74 at C6 level and the least was 0.45 at the C5 level .The highest correlation coefficient between the Torg ratio and the DSR was 0.79 at C3 level and the least was 0.42 at the C5 level. The highest coefficient of determination for the ESCD was 54 % at C6 which translates into a poor correlation. The highest coefficient of determination for the DSR was 62% at C3 level indicating a variable correlation.
ConclusionWe infer that the Torg ratio is of limited value in assessment of the true sagittal spinal canal diameter in Achondroplasia and its reliability as an indicator of severe cervical canal stenosis is questionable.
Ponseti’s Technique Of Clubfoot Management, Analysing The Results
Dr P N Gupta
Senior Lecturer, Department of Orthopedics,
Govt. Medical College & Hospital,
Chandigarh.
Phone: +91-172-2661206
E-mail - drpgupta123@rediffmail.com, drpgupta123@yahoo.com
Initial treatment of clubfoot is non-operative and various techniques are described for the same including the Kite’s, Ponseti’s, French techniques. Early management takes advantage of the favorable fibroelastic properties of the connective tissue of the ligaments, joint capsules and tendons; early operation induces fibrosis, scarring and stiffness.
This study was carried out to study the efficacy of Ponseti’s technique for idiopathic clubfoot.
Methods59 clubfeet in 38 children, 11 females and 27 males were included in the study, who were managed using Ponseti’s principle of clubfoot management. Out of these, in 21 patients, clubfeet were bilateral; in 17 unilateral patients, 7 left and 10 right clubfeet were there. The age ranged from newborn to one year of age. Patients with non-idiopathic clubfoot, age more than one year, and those feet, who had undergone surgery prior to presentation to Govt. Medical College & Hospital, were excluded from the study. Percutaneous tenotomy of tendoachilles was done as and when needed. In all cases orthotic support in the form of foot abduction orthosis and clubfoot shoes were given after achieving correction with plaster casts. Relapses were initially managed by re-manipulation and serial casting, and re-tenotomy if needed. Re-tenotomy was not done more than 2 times and those cases with residual deformity after 2nd tenotomy were subjected to open surgical release. Results were evaluated according to a modified score based upon the score of Lavage and Ponseti.
ResultsNone of the patients had calcaneus deformity following tenotomy. Tendoachilles reformed in every case. Based on Lavage and Ponseti score, excellent results were achieved in 59% feet good in 17% cases, fair in 12% cases and poor in 12% feet. Most unsatisfactory results were due to poor compliance by the parents either during manipulation and plastering or during use of orthotic support. 7 clubfeet had a relapse of deformity, of which 3 feet yielded to re-manipulation and re-tenotomy. In the rest 4 feet, surgery in the form of posteromedial soft tissue release was done out of which 1 patient (2 feet) had a re-relapse.
ConclusionPonseti method can be effectively employed for treatment of congenital clubfoot and gives good overall results in children less than 1 year of age. Strict adherence to protocol and compliance regarding orthotic treatment must for good results. Postoperative orthotic support is essential to prevent relapse.
Adolescent Blount's disease: Is fibular osteotomy necessary?
Mark Eidelman, Alexander Katzman, Viktor Bialik
IntroductionThe standard treatment of adolescent Blount's disease includes proximal tibial valgus osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. We performed correction of deformities in eight patients (10 tibiae) with adolescent Blount's disease using the Taylor Spatial Frame (TSF). In all patients, the origin (virtual hinge) was placed at the level of the proximal tibial fibular joint. The purpose of this study was to review treatment outcome of proximal tibial osteotomy without osteotomy of the fibula in patients with adolescent Blount disease.
MethodsEight patients (ten tibiae) were treated by proximal tibial osteotomies and gradual correction by TSF without fibular osteotomy over a period of three years. All patients were males with a mean age of 14.6 years (range, 14-17 years). All patients had severe proximal tibial varus, four had significant proximal tibial procurvatum, and six had internal tibial torsion. The fibula was not fixed in five patients, and fixed distally in three.
ResultsFrames were removed at an average of 12.8 weeks (range, 12-15 weeks). The mean preoperative proximal tibial varus was 16.2° (range, 12-19°), corrected to normal values in all patients. The mean preoperative MPTA was 71.4° (range, 67-77°) and corrected to a mean MPTA 87.1° (range, 85-89°). In four patients (5 tibiae) with proximal tibial procurvatum, the PPTA was corrected to normal range. Mean correction of internal tibial torsion was 10° (range, 5-15°), performed in six patients (8 tibias). Preoperative MAD was 55.8 mm medial to center of the knee (range, 44-77 mm), corrected to a mean MAD of 4.9 mm medial to center of the knee (range, 2-11 mm). Complications included superficial pin tract infections in seven patients. No complications related to the fibula were observed during/after correction.
ConclusionBased on our initial experience, we believe that most patients with adolescent Blount disease could have successful and predictable correction of tibial deformities without a need for osteotomy and fixation of the fibula.
Advances in the Management of Severe Paediatric Neuro-muscular Scoliosis
Dr. K. B. Mukherjee Andrew Clarke J. K. Webb
Rama Krishna Mission Home of Service, Varanasi, India, University Hospital Queen’s Medical Centre Nottingham, England;
Study Design retrospective, no financial support received,Evidence level IV.
Email - kbmukherjee@bst.rcsed.ac.uk
The surgical management of paediatric neuromuscular-scoliosis continues to evolve with newer techniques of combined anterior-posterior surgery, minimal access anterior release and more refined fixation techniques, including growing and hybrid constructs. We report a consecutive series of 28 cases of severe, rigid neuromuscular scoliosis due to dystrophic-neurofibromatosis, cerebral-palsy(groupI) and spina-bifida, non-dystrophic-neurofibromatosis(groupII) treated by minimally invasive anterior vertebrectomy and posterior fusion. The aim is to determine whether vertebrectomy significantly improves curve correction.
Materials and MethodsBetween 1997-2004, 28 patients (19 females, 9 males) underwent surgical correction of neurofibromatosis-scoliosis. The mean age at surgery was 11.5 years (range 6-16 yrs). All underwent staged, minimally invasive anterior vertebrectomy at minimum two levels and posterior instrumented fusion. Outcome was assessed using Lenke’s modified SRS criteria.
ResultsThe mean follow up was 20.1 months ( 9months-4.5 years). The mean extra coronal Cobb correction over bending films in group I was 49.4degrees (65%), group II 16.5degrees (41.2%) absolute correction 54.9degrees(68.2%) and 34 degrees (60%) respectively. Mean preoperative kyphosis was 68.2degrees(-25to90), lumbar lordosis 69.3degrees(43-85) correcting to mean 38 (44%) and 38.6degrees respectively. Mean correction of global AVT was 34.6 mms.(56.2%) in groupI and 31.4mms. (55.28%)in group II. Mean regional AVT correction was 19.2 mms.(63%) in group I, 15.4 mms.(55%) in group II. Mean pelvic tilt correction was 70%.Complications included, 2 superficial infections, 3 dural tears, one worsening of preoperative leg weakness, 1 massive postoperative bleeding and one transient brachial plexus injury.
ConclusionsEven in these extremely rigid, severely rotated curves with very wide apical translation, minimally-invasive apical-vertebrectomy and posterior fusion can achieve 63% coronal curve correction (an additional 43% correction over bending films), a significant 70% correction of pelvic tilt and over 60% reduction of apical translation. No pseudarthroses have been identified with corrections maintained thus far in both groups to great satisfaction of patient and care-giver alike.
Role of Thrombophilia in Perthes disease
Vinu Mathew George, Vrisha Madhuri, Sukesh Chandran, Jeyaprakash Muliyil
Vinu Mathew George - post graduate registrar
Vrisha Madhuri - professor
Sukesh Chandran - professor
Jeyaprakash Muliyil - professor
Department of Orthopaedics, Clinical pathology* and Community health
Christian Medical College
Vellore
Perthes disease results from an interruption of the blood supply to the capital femoral epiphysis. During the susceptible age of 5 to preadolescence the thrombosis of the postero-superior vessels is considered to be the single most important cause of Perthes disease. Recent studies have implicated pro-thrombotic tendencies in patients involving protein C, protein S and factor V leiden mutation among others. This etiological factor has not been investigated in children from India. This study looked at the role of Thrombophilia in the etiology of Perthes disease by evaluating genetic mutations and pro-thrombotic tendencies in Perthes disease.
Material and methods:A prospective case control study was carried out. Only children with severe disease, familial disease and recurrent Perthes were included. Severe disease was classified as Salter and Thomson B, Catterall 3 or 4 or Herring C if patient presented after collapse. Patients with any chronic infection or those with surgeries with in 6 months were excluded. There were 20 patients ( 17 boys and 3 girls) and 23 controls. A complete thrombotic work up was done for all patients.
Results:13 out of 20 children had one or more risk factors for thrombosis only 2 of the controls had any risk factor for thrombosis. Odds ratio for having a risk factor among children with Perthes disease was 19.5 with a highly significant chance that children with Perthes would have a concomitant risk factor for Perthes (p =0.0002). Twenty five percent of all children had more than one independent risk factor versus none in the control group. Factor VIII, Antithrombin, antiphospholipid antibody and genetic mutation of MTHFR were involved.
Discussion:Perthes disease is a multi-causal disease with thrombophilia, vascular supply, and hip effusion of various etiologies influencing the disease onset and severity. In our study we found a significant number of children with Thrombophilia, an etiological factor not previously studied in India.
Analysis of the risk factors and prospective tools for reinjury - rate reduction in unorganized sports related overuse injuries in skeletally immature
Ajai Singh, M. Dhingra
Department of Orthopaedics, K. G. Medical University, Lucknow
Objectives:- To study the incidence and types of such injuries in Indian scenario
- To correlate the extrinsic / intrinsic factors with these injuries
- To formulate a general protocol to avoid recurrence of these injuries
It is difficult to estimate the actual magnitude of this problem. Unfortunately no official Indian data is available. Recent American data indicates that 30% to 50% of all pediatric sports injuries are due to overuse. The American College of Sports Medicine estimates that 50% of overuse injuries in children and adolescents are preventable. These overuse injuries may affect each and every joint / region of the body such as Shoulder joint, Elbow, Knee (anterior knee pain), Tibial Region , Ankle, foot , Sprains & Strains etc. In simple terms, overuse injuries can be defined as the product of "too much, too fast, too soon." How much is too much? How fast is too fast? How soon is too soon? The answers vary from child to child. Unorganized sports activities include those that are performed without any qualified supervision and / or protocol. These may include playing at local level, performing during annual day at school or college, in the Gym, at some summer camps, during or before an interview / selection etc.
Method & Material:All the patients below 16 years of age attending OPD, Deptt. of Orthopaedic Surgery and presenting with these injuries subjected to a detail clinical evaluation. After making a clinical impression, all patients subjected to relevant investigations. All the data were collected & analysed. Result – Overuse injuries were about 60% of the total sport injuries in this study. There was no statistical difference between both sexes. Lower limb lesions were statistically higher. The most common cause of these injuries was sudden increase in the quantum of activities. We prepared a activity oriented protocol for these children to avoid these injuries or reinjuries.
Conclusion :Though overuse injuries are becoming common, but these are preventable if children follow a are related and activity related protocol.
The Pathological Anatomy of Clubfoot
Charles Howard, M.K.Benson, Migal Sheva, Beer-Sheva
Charles Howard, M.K.Benson*
Macabee Health Fund, Migal Sheva, Beer-Sheva, Israel; and *The Nuffield Orthopaedic Centre, Headington, Oxford, England The pathologic anatomy of clubfoot is complex, and the opportunities to examine neonatal specimens are inevitably rare. Three clubfeet were dissected and compared with a normal foot. Dissections were performed with the aid of magnifying loupes, and the specimens were photographed at each stage. The close up photographs will be presented.
The clubfoot tali and calcanei were smaller than the normal bone. The talar necks were angulated medially; in the most severely deformed specimen, the body-neck angle was 90°.
The posterior processes of the calcanei were bowed medially, exaggerating the appearance of varus. The medial and anterior calcaneal facets support the neck of the talus just proximal to its head. In the normal foot, the three facets are aligned in an axis so that external rotation of the calcaneum beneath the talus is associated inevitably with dorsiflexion and internal rotation is associated with plantarflexion. In the clubfoot, the medial and plantar angulation of the talus brings with it the medial and anterior calcaneal facets as they grip the talar neck. Thus, the anterior and medial facets are compulsorily medially rotated in an axis which is out of true with that of the posterior facet: It is locked in plantarflexion and supination.
The most striking soft tissue abnormality was noted on the medial side of the clubfeet: The tibialis posterior tendon and its sheath was thickened and bulbous at its insertion. The fibrous tissue mass was widely attached to the naviculocal-caneo-cuboid articulation, the navicular, the medial malleolus, the neck of the talus, and the medial and inferior calcaneal surfaces. It blended intimately with the capsule of the middle facet and had the appearance of “sucking” all the elements medially and a little inferiorly, producing the clubfoot deformity.
Aneurysmal bone cyst:Outcome and preliminary report of a new technique
Kaushik Bhowmik, Vrisha Madhuri
Kaushik Bhowmik Registrar
Vrisha Madhuri Professor
Department of Orthopaedics Unit 2
Christian Medical College
Vellore
Aneurysmal bone cyst is a common aggressive benign tumor in the 1st and second decade. 12 children with primary aneurysmal bone cyst were diagnosed in the paediatric Orthopaedic clinic in the last 5 years. 7 were treated with a new technique We report the results of these cases.
Material and methods:Children were aged 3 to 17 years. Male and female incidence was equal. Duration of symptoms varied from 10 days to 2 years. There were 3 proximal femur, 3 proximal tibia, There were I case each of mid femur,distal tibia, proximal humerus, distal radius, talus and metatarsal. All except one were treated with curettage and bone grafting. Autograft was used in all supplemented by bone substitutes tricalcium phosphate and hydroxyapatite) where the cavity was large. In 2 cases ( both recurrences) allograft was used. In 7 children a new technique consisting of crushing of cortices to reduce cyst size was used.
Results:There was an over all recurrence of 25%. All recurrences were treated with curettage and bone grafting. There was no recurrence in the group treated with the new technique. One patient who underwent excision and nailing had infection.
Discussion:Recurrences are common in aneurysmal bone cyst. The new technique helped by reducing the number of recurrences and decreasing the amount of graft required. sArthroscopic Ally Assisted Percutaneous Fixation Of Triplane Fracture Of The Distal Tibia.
Arthroscopically Assisted Percutaneous Fixation Of Triplane Fracture Of The Distal Tibia
Mr McGillion, Mr Jackson, Mr O Lahoti
Kings College Hospital
London
Triplane ankle fractures typically occur in adolescent age group. Although many are minimally displaced and can be managed non-operatively, some are displaced and difficult to reduce by closed methods and need open reduction and internal fixation. Traditionally satisfactory articular reduction is achieved through an open reduction, which can be extensive. We describe our experience of treating displaced triplane fractures in four patients.
Methods:Since 2002 we treated four patients who were identified as having displaced triplane fracture on plain radiographs. There were two girls (aged 13) and two boys (aged 14). Three left and one left ankle was involved. Post operatively patients were followed at 2, 6 and 12 weeks intervals. They also remain under long term follow up there after.
Results:In all four patients the fractures were clearly visualised on arthroscopy. In three patients we were able to reduce the fracture in to acceptable alignment percutaneously. In one patient we could not achieve reduction by closed means due to comminution and resorted to open reduction through minimal approach. All patients regained full range of movement in six weeks.
Conclusions:We conclude that ankle arthroscopy is not only useful in assessing the extent of the fracture but also in assessing accuracy of reduction. It aids minimally invasive fixation of this rare injury.
Bifocal tibial osteotomy with lengthening in achondroplasiat
Vaidya, Sandeep V, Song, Hae-Ryong
Vaidya, Sandeep V; MS, DNB, MRCS (Ed, UK).
Pediatric orthopaedic surgeon, Mumbai, India.
Song, Hae-Ryong; MD, PhD.
Department of Orthopaedics,
Korea University, Guro Hospital, Seoul, Korea.
Objectives:
The purpose of the study was to analyze the results and complications of bifocal tibial osteotomies with gradual correction and lengthening by Ilizarov ring fixator performed in 47 tibiae in 24 achondroplasia patients.
Methodology and results:Comparison was made between the parameters of angular and torsional deformities of the tibia pre-operatively, at fixator removal and at last follow-up. Out of these parameters, statistically significant change was seen post-operatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation and tibial torsion which changed from 78.8±7.05º, 103.2±11.8º, 25.1±14.6 mm (medial) and 22.7±10º (internal) preoperatively to 87.3±6.3º, 90.9±5.4º, 5.3±10 cm (medial) and 15.8±4.2º (external), respectively at the time of fixator removal and this correction was maintained during the follow-up period. Mean total tibial lengthening was 6.84±1.3 cm. Average healing index was 26.06 days/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations and 3 fibula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. 100% incidence of equinus was observed in limbs when the total tibial lengthening exceeded 40% with lengthening at the distal tibial osteotomy site being more than 15%. To minimize the risk of occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15% even though total tibial lengthening may exceed 40%. Fibula malalignment was not observed after double fibula osteotomy.
Conclusion:We conclude that this procedure is safe and efficacious if performed with strict adherence to prescribed technique.
Treatment of Severe Blount's Disease by Medial Plateau Elevation, Lateral Epiphysiodesis, Corrective Osteotomy & Lengthening with Taylor Spatial Frame
E. Bar-On; D. Weigl; K. Katz; T. Becker
Schneider Children's Medical Center, Petah Tikva - Israel
Severe Blount's Disease causes varus and internal torsion of the tibia, depression of the medial tibial plateau with knee instability, and leg length discrepancy. Simple metaphyseal correction addresses only the varus and the torsion, and has a high rate of recurrence due to physeal bar formation. We present our experience with a combined approach addressing all components of the deformity as well as preventing recurrence.
Four patients were treated for severe Blount's disease. Mean age was 8.1 years (6.9-9.1). All had early onset of the disease graded Langenskjold V or VI. Three patients had no previous treatment and one had undergone a corrective osteotomy at age 5.3. Mean pre-operative mechanical varus was 230 (130-300). Internal tibial torsion averaged 50 (00-100) and two pts had a leg length discrepancy of 1&2 cm.
Surgical Procedure: Epiphysiodes of the lateral tibia and proximal fibula & peroneal n. release.
- Osteotomy & elevation of medial tibial plateau
- Application of Taylor Spatial Frame.
- Proximal metaphyseal + fibular osteotomy.
Surgery was staged in one patient who had a concomitant lateral hemiepiphysiodesis of the contralateral tibia & fibula. Correction was initiated on POD 5-7 according to the TSF Total Residual program with a planned overlengthening of 1.1-3.5 cm. Correction time was 21 (15-27) days. Total time in the frame was 96 (77-112) days.
Results:All limbs were corrected to within 3 degrees of planned correction. One patient had a transient drop foot. Two patients had knee flexion contractures - one resolved with physiotherapy and the other one had a hamstring release. At follow up of 12-24 months, all patients were asymptomatic and had resumed full activity. Mechanical axis was 00 in 2 pts, 20 valgus in 1 and 50 varus in 1 pt. Thigh foot ankle was 00 in 3 and +150 in 1. Leg length discrepancy showed 0.5-3 cm of overlengthening as planned.
Discussion:Conventional osteotomies for early onset Blount's disease do not address the intra-articular component and have been showed to recur if performed above age 5. The method presented corrects all components of the deformity. The lateral epiphysiodesis is essential to prevent recurrence, however it implies a future leg length discrepancy. This is addressed by a pre-emptive lengthening. A shoe lift is used temporarily and final adjustments can be made towards skeletal maturity. Asymmetric bilateral cases pose additional treatment dilemmas.
Femoral Neck Lengthening for Premature Arrest of the Femoral Capital Growth Plate: Long-Term Follow-up of Seven Hips
Noam Bor , Reiner Shlomo and Kaufman Basil.
Noam Bor M.D., Reiner Shlomo M.D., and Kaufman Basil M.D.
Orthopedic Department
Central Emek Hospital
Afula, Israel
Ischemic necrosis of the femoral head is the most devastating complication that can arise during the treatment of congenital hip dislocation, Perthes disease, septic arthritis, or intracapsular fractures of the femoral neck. The ischemic necrosis results in a typical deformity of the hip joint: coxa vara and magna, short femoral neck, and high-standing greater trochanter. Biomechanically, a short femoral neck corresponds to a short lever arm of the hip abductor muscles (gluteus medius and minimus) and the high-standing trochanter decreases their tension. The muscular insufficiency results in a positive Trendelenburg test and a very unsightly limp. To improve function by restoring normal anatomy and biomechanics in these severe deformities, Morscher developed a procedure in 1980 in which femoral neck lengthening is performed together with distalization of the greater trochanter. As opposed to the well known Wagner intertrochanteric osteotomy, the Morscher osteotomy does not alter the position of the femoral head within the acetabulum; however, the Morscher osteotomy creates a normal neck-shaft angle and distally transfers the trochanter. It is indicated when reorientation of the femoral head is not required, but still restores the abductor mechanism to normal tension. Therefore, it can be used to also treat a deformed femoral head. The aim of this retrospective study is to assess the outcome of the Morscher method in six patients who underwent the procedure between 1990 and 2004 with a mean follow-up of 12 years (range, 2–16 years)
Materials and Methods:During the last 16 years, four males and two females were treated in our department. The mean age at surgery was 16 years (age range, 13–20 years). Five patients developed the sequelae of femoral head avascular necrosis due to Perthes disease at an earlier age, one female patient as a sequelae to developmental hip dislocation (DDH). In one patient, both hips were operated on. Hence, seven hips were included in the study, four on the right side and three on the left. Five patients were assessed both clinically and radiologically; one of the patients left the country one year before the study and has been interviewed by phone. The operation is performed under image intensifier control and triple osteotomy is performed: (1) In line with the lower and (2) upper end of the femoral neck, and (3) 1 cm proximally to the latter, leaving a free rectangular graft that is removed. Fixation is done with a 130 degrees A-O blade-plate after lateral displacement of the femoral shaft. The trochanter is shifted distally and secured to the femur with a single circular wire. A few days after the operation, the patients are allowed to walk with crutches; weight bearing is restricted to toes touch only for the first 4 weeks.
Results:Duchene-Trendelenburg gait and/or a positive Trendelenburg test, which was present in all patients before the surgery, became normal or was substantially improved in all examined patients. The patient who underwent the procedure on both hips still had a slight lurch gait. Range of motion of all hip joints was not influenced by the operation and remained literally the same. An average leg lengthening of 1.5 cm was obtained in all patients. One patient experienced increasing pain and undewent total hip replacement 4 years following the Morscher procedure. Harris hip rating scores improved in all patients (the postoperative scores of the patient who underwent THR were taken before the hip replacement surgery). The average preoperative score was 60 (range, 50–75) and at the latest follow-up, the average score was 80 (range, 60–95). On radiological evaluation, the head trochanteric distance (HTD) was assessed and was found to have improved on average from -9 mm (range, -5 to -15 mm) to +16.5 mm (range, -5 to 27 mm). In one patient, the immediate postoperative HTD deteriorated from +15 mm to -5 mm because of partial loosening of the circular fixation of the greater trochanter. Except for the patient who underwent THR, all patients commented on being very pleased with the result of the operation, mainly with the improvement of their gait pattern.
Conclusion:Our series is small; however, it seems to be the longest follow-up described in the literature. The Morscher procedure does not change the position of the femoral head within the acetabulum; therefore, it is considered to be the appropriate osteotomy for patients who are not suffering from osteoarthritic changes of the femoral head and require valgization of the head-neck segment. The operation restores normal anatomy of hip joints with short femoral neck and high-standing greater trochanter. It improves leg length and abductor power. The technique is valid to any sequelae of avascular necrosis of the femoral head. Despite the long follow-up of the patients in our study, most of the patients are still very pleased with the result of the operation.
Common errors in executing Ponseti technique in the treatment of idiopathic clubfoot
Dr. Maulin M. Shah
M.S.Orth., D.N.B. Orth., Fellow Pediatric Orthopedics.
Department of Orthopedics & Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
Ponseti technique of clubfoot treatment is popular worldwide and is well accepted at most of the Pediatric Orthopedic centers in India. From communication with practicing Pediatric Orthopedic surgeons in India and reviewing their publications, it is reflected that the success rate of Ponseti technique is about 75-80%. The excellent results are achieved using this method in about 93%-100% of patients in different countries like USA, France, Germany, Israel & Turkey. After assisting Dr.Ponseti at University of Iowa, I have tried to observe the likely errors in the treatment which may lead to huge differences in the outcome of deformity using Ponseti plaster technique. These errors can be divided in to following subtypes: errors in understanding pathologic anatomy of the deformity, errors in plaster technique, errors in post plaster splinting protocols and errors in identifying the difference between typical & atypical (complex) clubfoot. Failures in the treatment are associated more often to faulty technique of manipulation and application of the cast than to the severity of the deformity. Relapses are related to the wrong post plaster foot-abduction brace protocols and noncompliance with it. Treatment related compliance of patient can be improved by using accelerated Ponseti protocols as they are equally effective to conventional protocols. Complex clubfoot differs from typical one in its pathologic anatomy and usually ends up in hyperabduction and equines of all metatarsals with severe hindfoot equines, if it is not recognized early in the course of treatment. It requires modified Ponseti technique to treat these feet successfully. Extensive corrective surgery can be avoided in these atypical cases.By improvising upon these errors, the failure rate of plaster method can be reduced. The objective of this paper is to emphasize on common misconceptions and errors in the management of idiopathic clubfoot by Ponseti plaster technique.
Comparative Analysis Of Podography And Radiography In The Management Of Idiopathic Clubfoot
Vikas Trivedi, Abhay Dube
Authors:
1. Dr Vikas Trivedi
2. Dr. Abhay Dube
Affiliation: Dept. of Orthopaedic Surgery, Subharati Institute of Medical Sciences, Meerut, India.
To compare the foot bimalleolar angle method (podography) and radiography with respect to management of idiopathic clubfoot and its functional evaluation.
Materials and Methods:75 feet of 48 patients with idiopathic clubfoot deformity were assessed in terms of foot bimalleolar angle (FBM) by podography and radiologically before starting treatment, after 6 weeks and at 6 monthly intervals with a maximum follow up period of 4.8 years (Range 1.2 to 4.8 years).Functional evaluation was done by Magone’s scoring system.
Results:Conservative Treatment group (32 feet): After treatment 90 percent patients had good correction (FBM greater than 70 degrees) which correlated well with post treatment Magone’s score of greater than 80 (good to excellent) in nearly 85 percent of cases. Radiologically, Talocalcaneal angles in both the views improved in only 60 percent of cases.
Surgical Group (43 feet):After Surgical release 87.5 percent showed good to excellent correction (FBM greater than 80 degrees).Magone’s scores showed greater than 80 in 83 percent of feet.Radiologically, Talocalcaneal angles improved in only 58 percent of feet.
CONCLUSIONS:- Radiological criteria show inconsistent correlation with functional outcome.
- Podography is a simple, objective, cost effective, radiation free, easily reproducible clinical criterion for the assessment of deformity correction with an excellent correlation with functional outcome.
Podography or foot print analysis employing Foot Bimalleolar Angle is a useful method to evaluate management of clubfoot. The study aims to compare podography with radiography with respect to functional outcome after conservative and surgical treatment and concludes that podography is safer, technically easier and easily reproducible criterion with good clinical correlation.
Does Complete Spontaneous Correction Of Congenital Postero-Medial Bowing Of The Tibia Occur?
Hitesh Shah, N.D. Siddesh, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
Though there has been a general impression that congenital postero-medial bowing of the tibia (CPMBT) spontaneously resolves and does not require any active intervention, we have encountered instances where residual problems warranted surgical intervention.
This prompted us to undertake this study with the following aims;
- To determine the rate and completeness of correction of CPMBT
- To identify the magnitude of shortening of the limb in association with CPMBT
- To identify the nature of associated deformities and functional defects of the ankle and foot in children with CPMBT
Radiographs of children with CPMBT that were available for retrospective review were studied. The following variables were noted on radiographs that were considered true AP and lateral radiographs:
- The inclination of the proximal and distal tibial growth plates
- The position of the distal fibular growth plate
- Presence of wedging of the distal tibial epiphysis
Wherever full length grid films were available, the limb-length inequality was calculated.
Children who were available for follow up were examined and the following variables were noted:
- The range of movement of the ankle
- The power of the dorsiflexors and plantarflexors of the ankle
- Presence of deformities of the hindfoot.
A rapid initial reduction of angulation in both planes was noted in the first year of life and thereafter the rate of resolution of the angulation slowed down. In some children the residual angulation was severe enough to warrant corrective osteotomy of the tibia. Complete equalization of limb lengths does not appear to occur in any child with CPMBT and in some children the discrepancy is severe enough to require limb equalization operations. In one instance it was noted that following limb length equalization in early childhood, limb length discrepancy recurred.
We noted that in a proportion of children with CPMBT there is abnormal inclination of the distal tibial articular surface, an inclined physis and a wedged distal epiphysis. Limitation of ankle movement and weakness of the plantarflexors of the ankle were also noted in some cases. We conclude that CPMBT does not always resolve spontaneously and all children with CPMBT need to be followed up periodically till skeletal maturity to identify problems that warrant intervention.
Congenital Pseudarthrosis Of The Tibia Treated By Intramedullary Rodding And Cortical Bone Grafting, A Ten-Year Follow-Up Study
N.D. Siddesh, Hitesh Shah, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
Of 38 patients with congenital pseudarthrosis of the tibia (CPT) treated over a 20-year period, 30 underwent cortical bone grafting and intramedullary rodding. Twelve of these children have a minimum 10-year follow-up. This group of children with CPT was reviewed to evaluate whether the encouraging results noted at a 2 to 4 year follow-up were maintained.
Each case was analyzed:
- To determine if the initial union that was achieved remained sound
- To determine if re-fracture of the tibia occurred during the period of follow-up
- To determine the frequency and nature of secondary operative procedures
- To determine the extent of limb length inequality.
The initial union that was achieved in early childhood remained sound in each case.
No re-fractures were encountered in any case. Secondary operative procedures (median: 2 procedures) were needed in every case for revision of the Rush rod when the bone grew to a point where the rod gave no support to the original pseudarthrosis site. This was achieved without having to osteotomise the tibia if bowing had not occurred proximal to tip of the rod. If however, bowing had occurred a new longer rod could be introduced only after an osteotomy. In these cases, cortical bone grafting was performed and in every instance sound healing of the osteotomy site occurred. No donor site morbidity was noted in these children. The final degree of shortening noted in children in whom union of the pseudarthrosis had been achieved less than three years of age was not severe enough to warrant any major limb equalization procedures.
We conclude that cortical bone grafting combined with intramedullary rodding yields long-lasting good results in children with CPT.
Current Concepts of Management of Lower Extremity In the Cerebral Palsy Child
Dr. K. B. Mukherjee
- Dr. K. B. Mukherjee
- D.Orth, DNB, MS, FRCS, AAOS
- Associate Professor, Consultant Paediatric Orthopaedic & Spinal Surgeon; Formerly Royal Liverpool, Alder Hey & Queen’s Medical Centre University Hospitals Nottingham NHS Trusts, England; Teaching Hospital, Tribhuvan University, Nepal, Ram Krishna Mission, B.K. Ram & HeritageHospitals, Varanasi, India
- Email kbmukherjee@bst.rcsed.ac.uk, No financial support received, Level of evidence IV
The aim of this paper is assessment of function and mobility of children with cerebral palsy after simultaneous multi-level minimally invasive orthopaedic surgery in the light of current literature. Despite the increasing popularity of alternative treatment methods for children with cerebral palsy, bony and soft-tissue surgery remains a common component in the management of ambulatory patients. Simultaneous multiple tendon surgery provides improvement in gait by correcting hip, knee, and ankle contractures together. The most common orthopaedic procedures included manipulation under anaesthesia, psoas, rectus release/ transfer, adductor tenotomy, obturator neurectomy, fractional hamstring lengthening, procedures to relax and release the Achilles tendon, foot reconstruction, pelvic osteotomy, containment procedures for the unstable hip and rotational femoral osteotomy.
Methods:A consecutive sample of 23 non-ambulatory children with spastic cerebral-palsy underwent minimally-invasive,bilateral orthopaedic lower-extremity soft-tissue surgery. All patients were presumed to have some ambulatory potential based on head-control, independent sitting-balance and ability to grasp a walker. Ten children were classified as having spastic-diplegia and 13 children were considered to have spastic-quadriplegia.
Results:All patients except one improved at least one grade in GMFCS(Gross-Motor-Function-Classification-System)mobility within two years after surgery. At final follow-up, five of the children with diplegia were level II ambulators(independent) and five were functioning at level III(community ambulation with mobility devices). In the quadriplegic group at long-term follow-up, two were classified as level III, five were functioning at level IV(self-mobility with limitations), and six had severely limited self-mobility(level V).
Conclusions:Lower extremity soft tissue-surgery is effective in helping children with spastic-diplegia to achieve and improve the level of mobility. For spastic-quadriplegia, while there may be short term benefits such as prevention of hip dislocation, improved self-image and improved self mobility, the goal of long-term independence and ambulation was not achieved by orthopaedic surgery. Alternative methods of spasticity management may be more beneficial in these children. Dega pelvic osteotomy ramni narsimmhan
Congenital pseudarthrosis of tibia A comparison of rush rodding with tibial onlay grafting and rush rodding with Ilizarov technique
Vivek Dutt Vrisha Madhuri
Vivek Dutt Post graduate registrar
Vrisha Madhuri Professor
Department of Orthopaedics Unit 2
Christian Medical College
Vellore
Congenital pseudarthrosis of tibia is a rare disorder. Management is challenging because of difficulty in obtaining and preserving union. We report our experience with 35 children with congenital pseudarthrosis of tibia under treatment in Paediatric Orthopaedics at Christian Medical College Vellore. 20 boys and 15 girls were seen with ages ranging from 1 to 12 years. The pseudarthrosis were classified according to Boyd’s classification 8 were type II , 6 were type III, 7 were type IV, and 14 were type V. Thirty four children have been operated. 18 were primarily treated with Ilizarov technique. Many of these later went on to have exchange rush rodding for internal splinting. 16 were treated primarily with rush rodding and bone grafting. Seven children underwent conversion from Ilizarov to rush rodding and onlay grafting because of nonunion. The number of surgeries ranged from 1 to 6 procedures which included valgus osteotomy and exchange rodding procedures The overall union rate was 31 out of 34 cases (91%) who underwent surgery. Two cases who had not united are lost to follow up. The others are being followed .The union rates are superior and complications and number of surgeries fewer in the primary rush rodding group.
Congenital vertical talus
Thomas Palocaren Vrisha Madhuri
Thomas Palocaren Lecturer
Vrisha Madhuri Professor
Department of Orthopaedics Unit 2
Christian Medical College
Vellore
Congenital vertical talus is a rare disorder refractory treatment. Majority of the patients are associated with spina bifida and and multiple congenital contractures. We review our cases for last 6 years.
Material and methods:We have treated 7 children with 11 feet with surgical correction. Four of these were bilateral. There were 3 females and 4 males. Ages ranged from 1 to 7 years. All underwent lateral and medial release with talonavicular joint reduction and Kwire fixation of the talonavicular joint. All except one child underwent transfer of half tibialis anterior to neck of talus. Post operative management consisted of cast for 3 months and splint for 3 months followed by shoes with arch support
Results:The follow up and results are presented. The complications were recurrence of deformity and in one older child (6 year) avascular necrosis of navicular. One child operated elsewhere had calcaneus because of tight transferred tibilais anterior and required tibialis anterior release.
Conclusion:Congenital vertical talus is a refractory foot deformity. The lateral release is the key to reduction. Relapse is a common complication Correction of Deformities in Children using the Taylor Spatial Frame
Correction of Deformities in Children using the Taylor Spatial FrameMark Eidelman, Alexander Katzman, Viktor Bialik
Aims:
Taylor Spatial Frame (TSF) is unique external fixator. Using computer software, the TSF can correct the most difficult deformities and simultaneously correct six-axis deformities. The purpose of this study was to determine the effectiveness of the TSF for treatment of various conditions in pediatric patients.
Materials and Methods:This is retrospective review of 40 patients (51 frames) who where operated on from January 2003 until December 2005.Mean age of patients at the time of surgery was 12.5 years(range 3.5-16 years). Eleven patients had complicated fractures, six Blount's disease, five had malunions with subsequent growth arrest, two congenital short femora and tibiae, four had knee flexion contractures, four clubfeet, and eight had various deformities of the lower limbs.
Results:All frames were removed after a mean time of 12.6 years(range, 8-20 weeks).All but one patient were anatomically corrected, and all contractures were corrected. Complications included superficial tract infection in 20 patients, three children had fractures of femora through regenerate, and two had complications related to half-pin insertions(transient peroneal nerve palsy and genicular artery bleeding).
Conclusion:We believe that TSF is excellent tool for the correction of multiple plane deformities in children and adolescents and significantly expands our ability to correct precisely the most difficult deformities. Current Concepts of Management of Lower Extremity.
Incomplete Trans-ilial Pelvic Osteotomy (DEGA) for Developmental Hip Dislocations
Dr. Ramani Narasimhan
Dr. Ramani Narasimhan, Sr. Consultant, Pediatric Orthopaedic Surgeon, Indraprastha Apollo Hospital, New Delhi.
The objective of this study is to present our experience with incomplete trans-ilial innominate pelvic osteotomy (DEGA) in Developmental Dislocation of Hips (DDH) in children older than 3 years of age. Twelve patients of DDH (14 dislocated hips with 2 bilateral) were operated at Indraprastha Apollo Hospital, New Delhi, between January 2001 and September 2003 and were followed up for a minimum period of 2 years. The average age of the patients was 6 &1/2 years approximately. Eleven out of the 12 patients had had surgical treatment earlier which failed. All patients had open reduction, varus-derotation osteotomy of proximal femur & femoral shortening, and the pelvic procedure, all done in a single stage. Hip spica was applied in all for a total period of 10 weeks post-operatively, followed by weight bearing. All hips were followed up in terms of both clinical and radiological assessment. The acetabular indices, CE angles, development of femoral ossification nuclei and shenton’s line were taken into consideration. Presence or absence of hip pain, limp or any limb-length discrepancy, along with the range of motion of the involved hip was also documented. One hip was found to be subluxated after 1 month post-op during the spica change, and was re-operated. Another older child had limited hip movements and abnormal gait which was treated conservatively on family’s request. All hips remained stable but only 10 patients out of 12 showed good results at the end of 2 years follow-up. We feel that DEGA pelvic osteotomy is a valuable surgical supplement in treating hip dislocations in the above age group. An ability to achieve a good anterior and lateral coverage of the femoral head, and the secure femoral graft obviating any need for internal fixation are important positives of this pelvic procedure.
Effect Of Trochanteric Epiphyseodesis In Perthes’ Disease
Rajesh K, Hitesh Shah, Siddesh ND, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
We evaluated the effect of trochanteric epiphyseodesis in children who had the procedure done during the active stage of Perthes’ disease and have now reached skeletal maturity. All the children included in the study had unilateral Perthes’ disease. Measurements were made on the anteroposterior radiograph of each patient taken at skeletal maturity. The height of the tip of the trochanter in relation to: a) the articular surface of the femoral head and b) the centre of the femoral head was measured. The length of the abductor lever arm was estimated by measuring the horizontal distance between the tip of the trochanter and the centre of the femoral head. All measurements were expressed as a percentage ratio of the normal value of the unaffected contralateral hip. These measurements were also compared to identical measurements made on untreated patients with Perthes’ disease who had reached skeletal maturity. Our results clearly show that trochanteric epiphyseodesis done in conjunction with a varus de-rotation osteotomy minimizes the risk of trochanteric overgrowth. In the light of our results we recommend that in the older child with Perthes’ disease, a trochanteric epiphyseodesis be performed routinely whenever containment surgery is undertaken.
Femoral Shaft Fractures
Manoj Mittal
Mittal Nursing Home
Lekhraj Nagar, Aligarh
Aim of this study was to delineate exact indications for these common fractures among children. We also analyzed other factors like early mobilization, minimization of hospital stay, medical and social factors associated with these fractures considering surgical treatment
Material and Methods:35 cases of femoral shaft were treated by steel Rush flexible nails of 2.5 to 3 mm nails between 6 to 14years of age (average 9 years). Out of 35 patients, 5 pts were of compound fractures, 6 pts of floating knee, rest24 were simple fractures. Two patients had history of Epilepsy, two polio paralysis and three patients were of cerebral palsy. Most common mechanism of injury was fall from height, sports injury, fall from cycle but compound and floating knee were due to road traffic accident. All closed fractures were fixed by stainless steel rush nails 2.5 to 3 mm leaving the growth plate from lower end. Two nails were introduced from medial and lateral side. The third nail was introduced from either side. Idea of three nails was to achieve better and three point fixation. All compound fractures were fixed primarily which facilitated soft tissue care as well. Initially 15 patients were given POP along with fixation, but later on no POP was given realizing that it is not required. In all the cases weight bearing was allowed as soon as soft callus was seen i.e. on an average 4 weeks after fixation. And knee mobilization was encouraged soon after the fixation.
RESULTS AND CONCLSION:Two year and nine months follow up was conducted. Callus formation was seen within one month but it was quite delayed in compound fractures. No limb length discrepancy or limb deformity was observed. Full knee movements were regained in all the cases. In the initial 10 cases it was delayed due to tethering of nail with the fascia lata. Femoral fractures should be fixed by noninvasive technique to reduce not only medical complications but also social, psychological among the parents. Even during grey period i.e. 6to8 years of age. Type of implant doesn’t matter whether titanium or steel
It’s Not Growing Pains! Repetitive Strain Injuries in Children and Adolescents
Dr. Deepak Sharan
Medical Director, RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore
Introduction:Repetitive strain injury (RSI) is a multifactorial overuse syndrome affecting the neck, back, shoulder, upper or lower extremeties, or a combination of these areas, which leads either to impairment or to participation problems. Musculoskeletal pain is reported to occur in over 50% of children and adolescents, but is usually dismissed as “growing pains.” Children in pain are more likely to grow up as adults with musculoskeletal disorders. Barring a few case reports in the International literature, we report the first clinical series of children and adolescents with RSI.
Objective:To describe the clinical features, predisposing factors, ergonomic risk factors and outcome of treatment of RSI in children and adolescents.
Methods:Chart review of 46 consecutive cases of RSI over a 5 year period in children and adolescents younger than 18 years. Results: The commonest predisposing factors identified were carrying overloaded backpacks (20 children), computer usage (10), mobile phone texting (7), playing musical instruments (3), playing video games (2), playing tennis (1), cycling (1) and dancing (2). The risk factors included excessive load, repetition, hazardous body posture, static loading, poor ergonomics and lack of rest breaks. The clinical syndromes identified were Myofascial Pain Syndrome (36 children), Thoracic Outlet Syndrome (8) and Tendinitis (3). All patients made full recoveries with physical therapy using a standardised protocol (SHARAN’S® Protocol for RSI: Skilled Hands-on Approach for Release of myofascia, Articular, Neural and Soft-tissue mobilisation), ergonomic modifications and posture alignment therapy.
Conclusions:With the increasing use of electronic gadgets, heavier school backpacks, and lack of awareness in children, parents, academicians and medical professionals, RSI’s in children is likely to increase in the years to come. A coordinated multidisciplinary approach focusing on prevention, early diagnosis and appropriate therapy is needed.
Contact details:
RECOUP Neuromusculoskeletal Rehabilitation Centre, 231, 37th Cross, 11th
Main, Jayanagar 4T Block, Bangalore-560041
Phone: +91-80-41214224 / 41214334 Mobile 98453 35062
E-mail: deepak.sharan@recoup.in
Joint salvage in malignant bone tumors of lower femur in children
Vrisha Madhuri
Vrisha Madhuri Professor
Department of Orthopaedics Unit 2
Christian Medical College
Vellore
Limb salvage in malignant bone tumor of lower femur in children is achieved by a number of reconstructive procedures such as rotationplasty, endoprosthetic replacement, osteo-articular allografts the complications and failure rate is very high with resection and turn graft the joint function and growth potential is lost. Joint salvage and preservation of growth potential using micro vascular transfer of vascularised fibula with its physis combined with structural bone grafts and bone marrow has been described. We have preserved the child’s knee joint in the metaphyseal 2b malignant bone tumors in children with good response to chemotherapy and these are presented.
Material and methods:Five children 2 boys and 3 girls aged 8 to 15 years with malignant lower femur tumors have been treated with a follow up of 1.5 to 4.5 years. Two had osteosarcoma and three had Ewing’s tumors. By using MRI as our mainstay for defining the true extent of tumor three different kinds of excisions and reconstructions were carried out preserving the patients own tibio-femoral joint in each case. Autograft and allografts were used to bridge the gaps with plate fixation and rush nail for support. Allchildren received neoadjuvant and postoperative chemotherapy
Results:In all children there was good union between the host and the graft bone. Allograft from femoral head was used in 4cases to supplement the bone graft. There was consolidation of bone graft in all cases. All 5 children have tumor free survival to date with the minimum follow up of 1 .5 years. There is no local recurrence. One child with osteosarcoma underwent excision of an isolated single lung metastasis diagnosed 6 months after surgery and is doing well 3 years later. A second surgery was done in two cases to improve knee range of motion in one and to remove an impingingplate in the other All children are able to weight bear on the leg without support. The post operative knee range of motion varied from 30 degrees to full normal motion. Shortening varies from 0 to 2 cm.
Discussion:Children responding well to chemotherapy and suitable lesions on MRI can be treated with Joint salvage surgery for lower femur high grade malignant tumors. The major advantage of this in the long term as compared to other forms of reconstruction is the longevity of this kind of reconstruction.
Corrective Osteotomies in Children using Temporary External Fixation and Percutaneous Locking Plates
E. Bar-On; T. Becker; K. Katz; D. Weigl Schneider Children's Medical Center, Petah Tikva - Israel
We present a new technique for corrective osteotomies in the lower limbs.
The method combines the advantages of both external and internal fixation as well as minimizing soft tissue disruption and scarring.
Between January 2004 and August 2006, eleven osteotomies were performed on six patients. Mean age was 9.5 yrs. (6.4-15.9) Underlying pathology included cerebral palsy (3 pts), microcephaly (1), giant axonal neuropathy (1) and post traumatic growth disturbance (1). Osteotomies were performed in seven femurs (bilateral in 3 pts and unilateral in 1) and 4 tibias (2 pts bilaterally). Correction was in the transverse plane in four pts (4 femurs & 4 tibias), in the sagittal plane in one pt (2 femurs) and in multiple planes in one pt (1 femur).
Surgical Technique:- Insertion of Schanz screws perpendicular to the deformed segments
- Osteotomy at planned level through small incision.
- Correction of deformity and application of temporary external fixator.
- Percutaneous insertion of submuscular extraperiosteal plate and fixation with locking screws.
- Removal of external fixator.
All limbs were corrected to within 3 degrees of planned correction. Patients were allowed full ambulation. Casts were applied only if soft tissue releases were performed concomitantly. Ambulation as tolerated was initiated post operatively. There were no surgical complications. All osteotomies showed good callus formation within 6 weeks. The plate was removed uneventfully from one patient.
Discussion:Multiple methods have been described for corrective osteotomies in long bones. They vary in the osteotomy level, degree of exposure, osteotomy technique and fixation method. The technique presented has the advantage of minimal violation of the periosteum and the surrounding musculature, inducing early bony union and good rehabilitation. The temporary external fixation enables accurate correction and intraoperative assessment.. Disadvantages include increased surgical time and radiation exposure – however these decrease with the learning curve and hardware improvements.
Management Of Severe Crouch In The Older Child With Cerebral Palsy
Kishore B, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
We have found it difficult to obtain satisfactory results in children with cerebral palsy with severe grouch gait when we merely released the hamstring contracture. It became clear that we had to adopt an approach that addressed the hamstring spasticity and contracture and at the same time restored the power of the quadriceps mechanism.
Seventeen ambulant children with cerebral palsy who presented with severe crouch gait in the last five years were treated in such a manner. The ages ranged from 10 to 17 years at the time of surgery. The treatment plan consisted of: 1) Femoral shortening, 2) Plication of the patellar tendon, 3) Hamstring transfer to the back of the femur.
This study evaluates the outcome of treatment of these children.
The variables evaluated included the degree of flexion deformity of the knee, the popliteal angle, the degree of spasticity of the hamstrings, the power of the quadriceps muscle, the Physiological Cost Index ((PCI), the Functional Mobility Score and the ambulatory status based on Hoffer’s grading. In addition the alteration in gait was assessed by observational gait analysis. 11 patients were evaluated one-and-a half years following surgery, while six children were evaluated sequentially at 3, 6 and 9 months following surgery to determine the pattern of change in each of the variables. All the variables improved following surgery. Significant improvement was noted in all the variables within 3 months following surgery with the exception of the PCI which actually increased at the 3 month follow-up and then showed a steady decline till nine months after surgery. There was a mild deterioration of some of the variables over time but overall there was quite dramatic improvement in the pattern of gait in all the patients. Our results suggest that this approach to treatment of severe crouch in the older child is promising. A longer follow-up is needed to determine if the improvement would be long-lasting.
Minimal invasive deformity correction: A new horizon
Dr. Premal Niak
Introduction:Knee deformity is a cosmetic and functional problem. Many patients present late with grotesque deformities which demands surgical correction. We present a newer modality of management of this deformity by Minimal Invasive Deformity Correction [MIDC].
Material and Methods:There were total 8 patients [6 bilateral, total 14 limbs]. Seven patients had genu valgum and one had genu vaurm. There were 3males and 5 female patients with age ranging from 10-17 years [Avg. 13.8 yrs]. The cause of deformity was renal osteodystrophy (2), post infective (1), idiopathic (1), Elis Van crevald syndrome (1),familial (1), rickets (1), Wilson’s disease (1). Six patient had femoral and two patients] had femoral and tibial surgeries. Osteotomy was fixed with K wires in 6, Ender’s nail in 1 and ext. fixator in 1. Patients were followed up from 3-34 months with average of 11 months. There was no infection or loss of correction. One patient had common peroneal palsy which recovered completely after 5 months. All patients achieved good correction and full ROM with improvements in ADL, walking ability.
Discussion:In our hands MIDC with limited incisions lead to early and predictive functional recovery with highest accuracy and without loss of correction. Patients had lesser hospital stay and lesser cost of surgery and implants. There were no major long lasting complication and problem of stiffness as following open surgery.
Conclusions:MIDC is highly accurate and reproducible method for correction of knee deformities. It allows preservation of biology that leads to early functional recovery without major complications
Odontoid fractures in children. The report of three cases
Dr.Vijay Sriram, Dr.K.Sriram, Dr.Balasubramaniam Chidambaram
Dr.Vijay Sriram
Flat 6, Sreyas Yogam,
4, Sriram Nagar North Street, Teynampet,
Chennai- 600018.
Email: vijaysriram@hotmail.com
Kanchi Kamakoti Childs Trust Hospital, Chennai
3 children aged 3yrs 6 months, 8 years and 12 years presented with odontoid fractures. In all three cases there was a delay in diagnosis, which ranged between 3 weeks to 2 months. One child presented with progressive neurological deficit whereas the other two presented with pain and stiffness in the neck. Imaging showed frank instability in one child and in the other 2 there was a maluniting odontoid compressing the cord at the occipito cervical level. The child with the instability and 3 week history of trauma was treated conservatively in a Minerva jacket. The other 2 children had trans-oral odontoidectomy followed by an occipito cervical fusion and immobilization in a halo. All three children healed well and follow up radiographs show no instability.
This short study is to show the management of odontoid fractures in delayed cases and the necessity of early diagnosis.
Osteomyelitis and septic arthritis in immunocompromised children
Abhay Gahukamble Vrisha Madhuri
Abhay Gahukamble - Postgraduate Registrar
Vrisha Madhuri - Professor
Department of Orthopaedics Unit 2
Christian Medical College
Vellore
Children under immunosuppressive therapy for malignancies are more susceptible to infections. Diagnosis in these children is complicated as bone pain are common in some hematological malignancies, and often there is a lack of local response. Multifocal osteomyelitis lesions can be mistaken for secondaries. The surgical decision making is affected as tumor biopsy entails avoiding spillage and decompression for infection requires large opening in the bone for adequate drainage. Even at the time of biopsy or drainage judgement has to be exercised about how aggressively to treat these lesion as some tumors can grossly have the appearance of granulation or pus.The management issues in these lesions relate to how aggressively to treat the lesion at the time of biopsy, the initial antibiotic management and the management of sequelae and chronicity. A review was undertaken of such children treated under our care.
Material and methods:Six children aged 18months to 12 years under treatment for hematological malignancies, Ewing’s tumor and neuroblastoma were seen with septic arthritis and osteomyelitis. 2 had septic arthritis and 5 had osteomyelitis
Results:Diagnosis was delayed in 3 cases. In one child the septic arthritis of ankle was diagnosed but osteomyelitis of talus was missed. MRI and ultrasound were helpful in confirmation of diagnosis. The Total counts were normal or low in all cases. All underwent surgery except for one child who underwent aspiration of the hip only. Three went on to develop chronic osteomyelitis. The infecting organisms were Salmonella typhimurium, Satphylcoccus albus, Methicillin resistant Satph aureus, Klebsiella and Enterobacter. C reactive protein was helpful in follow up.
Conclusion:Confirmation of the diagnosis of infection and ruling out metastasis in the clinical setting of a lytic osseous lesion or bone pain associated with local signs while on chemotherapy is the first step in managing these children. Antibiotic therapy should be initiated with second line drugs while awaiting culture results. Surgery with closed suction for draining osteomyeltis or septic arthritis is recommended. Clinical and radiological parameters along with CRP are useful for determining duration of therapy
Neglected Congenital Muscular Torticollis In Adults: Ferkel’s Release Revisited
Dr. Sandeep Patwardhan Dr. Parag Sancheti Dr. Rajeev Arora
Presenting author : Dr. Sandeep Patwardhan
Authors :
Dr. Sandeep Patwardhan
Dr. Parag Sancheti
Dr. Rajeev Arora
Congenital muscular torticollis, or congenital wry neck, is the most common cause of torticollis in the infant and young child. The deformity is caused by contracture of the sternocleidomastoid muscle, with the head tilted toward the involved side and the chin rotated toward the opposite shoulder. Neglected cases of congenial muscular torticollis presenting in adulthood are almost always associated with facial asymmetry, tilt of head, and ocular compensation for this tilt. Ferkel’s bipolar sternocleidomastoid release is usually performed for children presenting between 3 and 5 years of age. However literature support on neglected cases operated late in adulthood is lacking, with regards to efficacy, post operative results, and associated complications in form of post operative diplopia.
MATERIAL AND METHODS:We conducted a prospective study of 8 patients presenting with neglected congenital muscular torticollis presenting to out hospital.7 were males and 1 was a female. The age varied from 17 years to 31 years, with the average age of presentation being 24 years. We did not include those patients with other forms of torticollis such as those associated with Klippel-Feil syndrome or a neurologic disorder (ocular pathology, obstetric palsy, or central nervous system lesion) 1,2. The pre-operative evaluation consisted of clinical evaluation to assess the degree of rotatory restriction, laterocollis, and subjective assessment of facial asymmetry. Each case was evaluated in the form of radiographs of the cervical spine to rule out any atlanto-axial or other cervical anomalies as the cause of the torticollis3. Pre-operative hematological investigations were done for the anaesthesia fitness. Each case was treated by Ferkel’s bipolar release4. The post operative protocol included the use of a soft cervical collar for 2 weeks, with the head and neck held in neutral (corrected) position. Check dressings of the wound at 2nd, 5th and 8th post operative day. Suture removal was done on the 10th post operative day. Each patient was then given physiotherapy in the form of mobilization of the neck for 2 weeks after that. The post operative results were analyzed with respect to the correction achieved, improvement in function, range of movement, and restoration of symmetry. Each patient was followed up for a minimum period of 2 years.
RESULTS:Out of the 8 cases operated, 6 had excellent results as per the above mentioned criteria. 2 had good results, with slight restriction of the lateral rotation on the affected side. No patients had post operative diplopia after correcting of the head tilt. All patients were satisfied with the correcting of the deformity with respect to cosmesis, and the improvement of range of motion. Complications included a superficial wound infection in one patient. However, with repeated dressings, it resolved without any sequele. One case had a transient facial nerve palsy which resolved within a month without any intervention. None of the cases developed loss of correction over the 2 years.
DISCUSSION: Various theories have been put forth regarding the etiology of congenital muscular torticollis. Due to its high association with breech or difficult deliveries, one theory is that of a compartment syndrome occurring from soft tissue compression of the neck at the time of delivery5. Another theory is in utero crowding, because three of four children have the lesion on the right side6 and up to 20% have developmental hip dysplasia7. Another theory is the neurogenic theory8. Some patients have a familial association, prompting research into any genetic predisposition of the same9.Yet another theory is the persistence of mesenchymal cells in the muscle belly which covert to fibroblasts and cause the deformity10.
In childhood, characteristically, it presents as a nontender, soft enlargement beneath the skin, and is located within the sternocleidomastoid muscle belly. This tumor reaches its maximum size within the first 4 weeks of life then gradually regresses. After 4 to 6 months of life the contracture and the torticollisare the only clinical findings. In some children the deformity is not noticed until after 1 year of life.
If the deformity is progressive, skull and face deformities can develop (plagiocephaly), often within the first year of life. The facial flattening occurs on the side of the contracted muscle, and is probably caused by the sleeping position of the child11. In children who usually sleep prone, and in this position, it is more comfortable for them to lie with the affected side down. The face, therefore, remodels to conform to the bed. If the child sleeps supine reverse modeling of the contralateral skull occurs. In the child who is untreated for many years the level of the eyes and ears becomes unequal and can result in considerable cosmetic deformity. Differential diagnosis of congenital muscular torticollis includes torticollis due to various other reasons such as atlanto-axial abnormalities, associated central nervous system tumors (i.e., of the posterior fossa or spinal cord), syringomyelia with or without cord tumor or Arnold-Chiari malformation. Ocular pathology is a common cause of torticollis too12,13.These children typically present around 1 year of age. The face can be turned about a vertical axis, the head can be tilted to one shoulder with the frontal plane of the face remaining coronal, the chin can be elevated or depressed, or a combination of any of these positions can occur. In these children the torticollis is a compensatory phenomenon, to restore binocular vision. . An ocular cause is likely if the head is tilted but not rotated, or if the tilt changes when the child is lying versus sitting or standing. These patients usually reveal a full range of cervical motion without the fibrotic sternocleidomastoid .Ophthalmologic evaluation is usually positive for paralytic squint or nystagmus. Detailed tests conducted by an experienced ophthalmologist are diagnostic. Treatment of ocular torticollis is usually surgical.
None of our cases were secondary to ocular causes. This was particularly important as our paper emphasizes the absence of any post operative diplopia. A pre-existing ocular etiology would have acted as a confounding factor with regards to our analysis. With regards to the treatment , stretching measures are usually unsuccessful after 1 year of age and thus had no role to play in our patients4. Established facial deformity or a limitation of more than 30 degrees of motion usually precludes a good result, and surgery is required to prevent further facial flattening and cosmetic deterioration14. Having all adult patients in our series, facial symmetry was already present, and the aim of the surgery was not to restore facial osseous symmetry. Asymmetry of the face and skull can improve as long as adequate growth potential remains after the deforming pull of the sternocleidomastoid is removed; good but not perfect results can be obtained as late as 12 years of life15. The best time for surgical release is between the ages of 1 and 4 years16. The youngest patient in our series was 17 years of age.
However, our efforts to find literature supporting surgical procedures for neglected congenital muscular torticollis in adults did not reveal any results. But from our experience, this procedure is definitely beneficial to even neglected cases presenting in adulthood.
Neglected congenital muscular torticollis presenting in late childhood, or in adulthood can be treated by Ferkel’s bipolar release effectively, with satisfactory correction of deformity, acceptable neck function, and without any post operative complications in the form of diplopia. However, pre-operative patient selection for the same is extremely important.
REFERENCES :- Marmor MA, Beauchamp GR, Maddox SF. Photophobia, epiphora, and torticollis: a masquerade syndrome. J Pediatr Ophthalmol Strabismus, 1990;27:202.
- Williams CRP, O'Flynn E, Clarke NMP, et al. Torticollis secondary to ocular pathology. J Bone Joint Surg Br, 1996;78:620
- MacAlister A. Notes on the development and variations of the atlas. J Anat Physiol, 1983;27:519., Bharucha EP, Dastur HM. Craniovertebral anomalies (a report on 40 cases). Brain, 1964;87:469.
- Ferkel RD, Westin GW, Dawson EG, et al. Muscular torticollis: a modified surgical approach. J Bone Joint Surg Am, 1983;65:894)
- Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop, 1993;13:141
- Ling CM, Low YS. Sternomastoid tumor and muscular torticollis. Clin Orthop, 1972;86:144
- Weiner DS. Congenital dislocation of the hip associated with congenital muscular torticollis. Clin Orthop, 1976;121:163
- Sarnat HB, Morrissy RT. Idiopathic torticollis: sternocleidomastoid myopathy and accessory neuropathy. Muscle Nerve, 1981;4:374
- Thompson F, McManus S, Colville J. Familial congenital muscular torticollis. Clin Orthop, 1986;202:193.
- Tang S, Liu Z, Quan X, et al. Sternocleidomastoid pseudotumor of infants and congenital muscular torticollis: fine structure research. J Pediatr Orthop, 1998;18:214.
- Brackbill Y, Douthitt TC, West H. Psychophysiologic effects in the neonate of prone versus supine placement. J Pediatr, 1973;81:82.
- Williams CRP, O'Flynn E, Clarke NMP, et al. Torticollis secondary to ocular pathology. J Bone Joint Surg Br, 1996;78:620
- Rubin SE, Wagner RS. Ocular torticollis. Surv Ophthalmol, 1986;30:366
- Canale ST, Griffin DW, Hubbard CN. Congenital muscular torticollis: a long-term follow-up. J Bone Joint Surg Am, 1982;64:810
- Coventry MB, Harris LE. Congenital muscular torticollis in infancy. J Bone Joint Surg Am, 1959;41:815.
- Tse P, Cheng J, Chow Y, et al. Surgery for neglected congenital torticollis. Acta Orthop Scand, 1987;58:270.
The Ponseti treatment for Clubfeet.The Afula experience with a minimum of five years follow-up
Noam Bor, M.D
Head, Pediatric Orthopedic Unit, Haemek Medical Center, Afula, Israel
E-mail address: noambor@yahoo.com
Introduction
Idiopathic congenital talipes equinovarus (clubfoot) is a common complex deformity that occurs in approximately one or two per 1000 newborns. Treatment of clubfeet has been controversial, for many years, most surgeons considered it as a “surgical disease”, with the only solution being surgery. The long term results of the surgical release are disappointing, with increased foot pain, joints stiffness and muscle weakness. Standard conservative treatment for clubfeet has been described by many authors, however, the reported success rates are only fair ranging from 11% to 58%.
It would appear that the most successful conservative treatment for clubfoot is the method developed in the late 1940s by Ponseti. In 1997 we abandoned our previous protocol for clubfoot treatment based on short leg casts and PMR and replaced it with the Ponseti method for clubfoot management. We recently reviewed the outcomes of treatment in Afula with the Ponseti method in our first 28 patients with minimum of five years follow-up.
In our study are included 28 patients (38 feet). There were 22 males and six females, 18 unilateral and ten bilateral cases, with idiopathic clubfoot. The average follow-up duration is of 6.5 years (range 5 – 8.5). All treatments started within the first three weeks of life, except for one patient who presented for treatment late at age 4 months, after being treated initialy in another hospital. The cases were evaluated using the 6-point clssfication system described by Pirani. Each foot was assigned a total score of 6 points or less, with higher scores indicating more severe deformity, 0 points indicate a normal foot.
Results:The average Pirani score for the 38 feet at initial presentation was 5.5 (range, score of 3-6). Only two patients, two feet out of 38 (7%), required complete surgical release, using the Turco method. One of these patients never used the orthosis as the parents were not compliant with the treatment suggested. The average number of casts applied before tenotomy was 7.5 (range, 5-13), and 35 of 38 (92%) feet required percutaneous Achilles tenotomy.
We used the Garceau classification to assess residual deformity, 4 points are assigned to normal appearing feet, 1 point to the worse appearing feet. The average scoring was 3.6 points (range 2-4). Twelve feet out of 36 (33%) (excluding the 2 feet who underwent PMR), ended up with some residual supination, according to the Garceau classification, 11 feet rated 3 points each, and only one foot 2 points.
Difficulties with the use of the foot abduction brace were noticed: 12 patients were defined as compliant with the treatment, as opposed to 16 noncompliant patients. Compliance was measured on the basis of the history obtained from the parents. In seven out of 36 feet (18% of the feet, six patients, excluding the post PMR patients) tibialis anterior transfer for residual supination was performed, only one of these patients was compliant with the use of the foot abduction brace. However, despite bad compliance with the use of the orthosis, eight out of 16 patients obtained good results, with no residual supination.
One of the patients who underwent bilateral tibialis anterior transfer, still remained with residual supination post surgery, it is considered a partial failure of the surgical procedure. An average of 13 degrees (range. 0-25) of dorsiflexion and 50 degrees (40 – 70) of plantarflexion was noticed in all 36 feet (again excluded the 2 post PMR feet), and very supple subtalar joints. In conclusion, if the 11 feet who ended up with some mild supination are included, (each rated 3 points according to Garceau), thirty - seven out of the 38 feet, at the latest follow-up, had an almost normal foot appearance.
Discussion:Clubfoot is a complex congenital foot deformity consisting of equinus, varus, adductus and cavus. Many methods of conservative treatment for clubfoot have been reported, with variable success rates, sometimes below 50%. During the last nine years, the Ponseti technique has become the gold standard of treatment for clubfoot, with countless surgeons abandoning the surgical technique in favor of the Ponseti method. However, strict adherence to the principles of treatment are required. One of the drawbacks of the technique is the continuous use of the foot abduction brace. As seen also in our study, parents are reluctant to use the brace, sometimes reacting to what they believe to be an inconvenience.
Without proper use of this orthosis, recurrence of clubfoot deformity is inevitable. As was shown also in our study, those patients who underwent tibials anterior transfer, were non-compliant with the use of the brace (five out of six who underwent surgery), and one of our patients whose parents refused to use the orthosis at all required complete open release with the Turco method. To notice, however, that some patients who are not compliant with the use of the foot abduction brace, still can end up with good result: Eight patients out of 16 in our study, six feet (43%) out of 14 in a study from the NYU. Since this is unpredictable, parents should be recommended to be fully commited as to the use of the brace.
Where Is The Limit Of The Surgery And The Surgeon In Cases With Extreme Pathology?
S Porat, N Simanovsky, R Lamdan
Pediatric Orthopedic Unit, Department of Orthopedic Surgery, The Hadassah-Hebrew University Medical Center, Jerusalem, Israel
Introduction:In three children with various conditions, congenital and developmental, an extreme pathology in their lower limbs demanded special and unique therapeutic approaches. All of these cases demonstrate the capacity of the surgery and the surgeon, and stress the question of where we should stop the reconstruction procedures and adopt rehabilitation approach. These three cases include Klippel-Trenaunay Syndrom, bone defect in both femora in a five year old girl, and PFFD associated with Ipsilateral tibial aplasia.
Patients, methods and results:- A seven years old girl was born with bilateral congenital cataract, congenital femoral deficiency, Paley type 2a and tibial aplasia type II. In successive surgical procedures the hip joint was successfully reconstructed, in contrast to failure of the leg which underwent BKA.
- A 6 years old boy with Gigantism of the left lower limb of 15 cm LLD in comparison to the right limb, at the age of 3.5 years, secondary to vascular malformations including A-V fistulae had bizarre Gait and severe deformities along the limb. So far in the last two years four surgical procedures enabled bracing and improved gait. In this child, the continuation of growth will necessitate repeated surgical procedures and rehabilitation process to maintain a reasonable function.
- A girl of 11 years old came to Israel at the age of 5 years old, after being wheelchair- bound between ages 4 and 5. Osteomyelitis caused destruction of the distal 1/4 of the femur in both limbs. Bone transport with pediatric LRS and complementary surgical procedures improved her function to be able to dance and perform all gymnastics. Presently she is undergoing angular deformities correction and elongation of the femur, one side at a time. Until her growth maturation she will have equal length of femora, with normal proportions of the fibulae.
unique procedures with long term planning have to be adopted for such extreme pathologies in order to solve the clinical problems.
Presenter:
Prof. Shlomo Porat
Head of Pediatric Orthopedic Unit
Department of Orthopedic Surgery
Hadassah Medical Center, P.O. Box 12000
Jerusalem 91120, Israel
Tel.: +972-507874218
Fax: +972-2-6428069
E-mail: shlomop@hadassah.org.il
The pathology of valgus knee in Ellis-van-Creveld syndrom, and its surgical treatment. Comparison to the equivalent pathology in Blount's disease
Eylon S., Simanovsky N., Porat S
Department of Orthopedic Surgery, The Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
The usual surgical treatment of valgus knee in Ellis van Creveld Syndrom EVC, is high tibial osteotomy. However, this approach failed to achieve the expected goal of lasting correction. Based on Dr. Paley's observations, and our previous unsuccessful treatment of valgus knee in EVC syndrome, we changed the surgical approach. The aim of the surgical treatment is to eradicate all the elements causing sever valgus knee: 1) dysplasic lateral tibial condyle, 2) progressive depression of the lateral tibial plateau, 3) short fibula, 4) short and contracted fascia lata, 5) short lateral collateral ligament and biceps femoris, 6) short lateral head of gastrocnemius, and 7) contracted lateral knee capsule and lateral retinaculum. In many aspects the pathology of Blount's disease grade 5 or 6 is similar, but located at the medial tibia causing genu vara.
Materials and methods:Three valgus knees of EVC syndrome and two varus knees of Blount's disease grade 5 & 6 underwent surgical treatment by a unique surgical approach to address all pathologies which contribute to the deformity. In the cases of EVC syndrome the first stage operation included: 1) peroneal nerve release and soft tissue release including T.F.L., B.F., L.C.L., capsule and gastrocnemius, 2) arthrogram, 3) fibulectomy, 4) elevation of lateral tibial plateau with bone graft, 5) reconstruction of L.C.L. and B.F., 6) lateral release of retinacula and rerouting of patella, and 7)cast application. In the second stage operation of these cases a corrective high tibial osteotomy was performed. In the Blount's disease knees the operative treatment was performed in one stage and included: 1) arthrogram, 2) elevation of the medial tibial plateau, 3) fibulotomy, 4) closing wedge tibial osteotomy based laterally, 5) transfer of the bony wedge under the elevated plateau and fixation.
Results:All deformities were corrected with no recurrence, and stability of the knees persisted. We had one common peroneal nerve neuropraxia that recovered and one wound dehiscence.
Conclusions:In both conditions, EVC syndrome and Blount's disease, corrective high tibial osteotomy does not address the pathology, and recurrence is to be expected. The described surgical technique fulfills that target – eradication of the pathologic elements that lead to valgus or varus.
Presenter:
Sharon Eylon, MD
Department of Orthopedic surgery
Hadassah Medical Center, P.O. Box 12000
Jerusalem 91120, Israel
Phone: +972-507-874-608
Fax: +972-2-6423074
e-mail: sharone@hadassah.org.il
Post infective sequelae of long bones in children
Manoj Mittal
Mittal Nursing HomeAligarh
Although acute osteomyelitis converting to chronic and then leaving behind sequelae are gradually decreasing because of better awareness of patients, better availability of treatment and better antibiotics . But even then we come across children with chronic long standing infection of long bones leading to many complications like pathological fractures with or without bone gap, deformities, contractures and shortening of limb leading to severe morbidity to the up coming generation of the society. To deal such children, surgeon has to face not only with nonunion with or without active infection (all the power of tissue regeneration has diminished or finished either by infection or by repeated surgeries),gap between bony ends, different deformities, may be growth plate disturbances and different contractures. So aim of this study was to find out and to solve such difficult problems to obviate permanent morbidities among children. I have tried to deal in one sitting rather than to expose such type of children to many surgeries.
From 1994 to 2006, 15 patients were dealt between 4 to 10 years of age.6 patients were simple nonunion because of maltreatment elsewhere and were not difficult. They all were treated by simple debridement and sequestrectomy followed by pop with or without bone grafting. Remaining 9 patients were very difficult having gap nonunion with deformities and shortening. All cases were already passed through one or more surgical intervention. Out of 9 patients 2 were of forearm, 2 femoral shafts, rest 5 were of tibia. 8 cases were following acute osteomyilitis and only one was due to maltreatment of compound grIII both bone leg fracture. All 9 difficult patients were dealt by illizarov fixation by simultaneous achieving the union, correcting the deformity and maintaining the limb length In all cases bone grafting was done except one where grafting was not possible.
All the 6 simple cases had good results. Remaining 2 patients of forearm, union was achieved but I couldn’t correct the deformity. In 2 cases of femur, union was achieved. Both the femora developed bowing with the lengthening of the bone. Out of 5 tibia cases union as well as deformity correction and lengthening was achieved in all the cases.
As these patients are the future of our nation so every case should be taken as an individual challenge and should be dealt in one surgery. Moreover one should always pay attention to the fact that potential of tissue regeneration has already been exhausted and almost finished due to infection and repeated surgeries.
Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by "flexion-extension cross pining" technique
Mark Eidelman,Alex Katzman;Viltor Bialik
PurposeThe standard treatment of displaced supracondylar fractures of the distal humerus in children today is closed reduction and pin fixation, but the optimal pin configuration is controversial.Cross-pin fixation of the humerus is more stable mechanically than any other type of pin configuration, but may cause iatrogenic ulnar nerve injury. We evaluate effectiveness of "flexion-extension cross-pining" technique in treatment 67 children with supracondylar humeral fractures.
MethodsAfter closed reduction and verification of acceptable antero-posterior reduction on the Jones view and external rotation lateral view, adhesive tape is applied above the fully flexed elbow and pronated forearm. After cleaning and draping of the elbow, two percutaneous 1.6 mm Kirschner wires are inserted from the lateral condyle into the medial cortex . Both wires should penetrate the medial cortex for better stability. After verification of acceptable alignment and wires position, tape is released and the elbow extended, cleaned and draped again. To prevent ulnar nerve injury the medial wire is inserted when the elbow is fully extended from the medial epicondyle to the opposite lateral cortex .After shortening of all wires, a cast is applied with the elbow flexed at 90º with the forearm in pronation. Between January 1999 and May 2005, we treated 91 patients with displaced supracondylar fractures of the distal humerus, 67 of whom were treated by flexion-extension cross-pinning technique. There were 42 boys and 25 girls with a mean age 5.8 years (range, 2.5-11 years) . Twenty-four fractures were of Gartland type 2 and 43 were Gartland type 3. Sixty-one fractures were reduced by closed reduction and percutaneous pinning; the remaining six fractures were reduced by open reduction.
ResultsFractures were fixed within an average of seven hours from presentation (range, 2-28 hours). Two patients had loss of reduction. Loss of fixation was related to technical errors - fractures were not reduced properly and the lateral wires did not penetrate the medial cortex All but two patients achieved full range of motion compared to the normal side at the last follow-up. Two patients had 10º loss of elbow motion compared to the opposite (normal) side.None of the patients in this study had ulnar nerve palsy before or after surgery.
ConclusionsCross-pin flexion-extension fixation provided excellent stability and, in our experience eliminated the risk of iatrogenic ulnar nerve palsy.
SignificanceBased on our experience flexion -extension cross pining of supracondylar humeral fractures is safe and relaible technique
Primary Management Of Idiopathic Clubfoot By Ponseti Technique
DR. AMOL PATEL DR. G. S. KULKARNI DR. RUTA M. KULKARNI
Name of the Author : - DR. AMOL PATEL
Name of the Co-authors :- DR. G. S. KULKARNI.
DR. RUTA M. KULKARNI.
Name of the Institution : - Post Graduation Institute of Swasthiyog Prathisthan,
Extension area
City : - MIRAJ- 416410
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 club foot 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 a traumatic remodeling of joint surfaces without fibrosis and scarring resulting from the surgical release. Biomechanics of subtalar joint is used to correct it.
Material:Since 2001 in our series at Swasthiyog Pratisthan, Miraj, we have treated 97 club feet in 66 patients. Bilateral deformity seen in 30 patients and unilateral deformity in 37 patients. 38 boys and 28 girls were affected. Average age of presentation was 3 months (from five days of age till one year two months of age).
Method:Cavus, adductus, varus, equinus (CAVE) which are the components of clubfoot deformity are all corrected simultaneously, except equinus which is corrected 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 counter pressure 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-degree flexion. Usually 8 to 10 serial casts corrects the deformity. After that foot is splinted continuously for three months and during night for three to four years to prevent relapse.
results: Assessed with Pirani’s score.
Average Pirani score precast was 5.5 and by the end of treatment was 0.5.
Full correction by Ponseti technique achieved in 64 patients
Percutaneous TA tenotomy performed in 97% of patients.
Recurrence and secondary surgery were required for following cases
1. For dynamic adductus correction by tibialis anterior transfer done in 1 case.
2. Relapse occurred in 1 case (due to late presentation) for which RPMR was performed.
Ponseti’s non-surgical management of clubfoot deformity is the best, safest and highly effective treatment modality, which was, minimized the use of surgical management and the associated morbidity resulting from extensile releases.
Principles Of Managing Bone Malignancies In Children
Dr.Anoop Jhurani M.S
Key Words: Bone Malignancies,Limb Salvage
Introduction:Bone malignancies mostly affect children between age group 5-18 and need a systematic and multi-disciplinary approach for achieving optimum results. While osteosarcoma mandates pre op neo adjuvant chemotherapy followed by limb salvage surgery wherever indicated, Ewings sarcoma has to treated by separate chemotherapeutic protocols combined with surgery and radiotherapy.
Materials and methods:20 cases of bone malignancies were evaluated between 2004 and 2006..Only those cases which required orthopaedic intervention and had minimum follow up of 12 months were evaluated .There were 14 cases of osteosarcoma, 4 of ewings sarcoma and 2 of haemato lymphoid malignancies.Out of 14 cases of osteosarcoma , 12 could be salvaged using neo adjuvant chemotherapy followed by limb sparing surgery using tumor endoprosthesis or biological grafts.2 patients underwent amputation .Out of 12 salvaged cases, 11 were surviving at the last follow up , 1 had died due to progression of disease. In 4 cases of Ewings sarcoma,all were evaluated using standard protocols and were salvaged using prosthesis or fibula .2 patients with lymphoma of bone presented with pathological fractures and were treated conservatively.
Results:Evidence suggests that most patients with bone malignancies can be salvaged using standard protocols.In our series of 20 cases, 18 patients underwent limb salvage and 2 patients had amputation. Those who underwent amputation were non salvageable because the tumor had encased the neuro vascular bundle.Though our follow up is still early, at 12 months of minimum follow up,19 patients were surviving and 1 died due to progression of disease.There were 3 complications,1 patient had intractable infection which required removal of humeral prosthesis. In 1 patient the anchoring wires at the glenoid neck cut through, but did not make any difference in the functional outcome. In another patient of knee prosthesis, there was early infection which settled with conservative means.
Conclusions:Limb salvage in bone malignancies is a rewarding treatment with great amount of patient satisfaction.The patients have to be managed in a multidisciplinary mode and the team has to care about the patient as a whole and not the limb only. The complication rate is about 5%, mostly implant related infections.
Correction of Lower Limb Deformities in Children with Renal Osteodystrophy by the Ilizarov Method
E. Bar-On; Z. Horesh; K. Katz; D. Weigl; T. Becker; M. Davidovich
Schneider Children's Medical Center, Petah Tikva - Israel
Material and Methods:Between January 1996 and December 2005, Correction of angular deformity by the Ilizarov method was performed on eight limb segments in five patients with Renal Osteodystrophy. Mean age was 14+9 yrs. Two patients were on hemodialysis and three had successfully functioning transplanted kidneys. There was one varus and seven valgus deformities. Four valgus deformities were femoral and two were in the tibia. One patient had intra articular valgus due to severe avascular necrosis of the lateral femoral condyles.The Ilizarov apparatus was used in all cases.
Results: Pre operative coronal deformity averaged 290. Clinical leg length discrepancy of 2-3 cm was found in 3 patients.
Restoration of a normal mechanical axis and leg length equalization was achieved in four out of the five patients. One case failed due to intra-articular instability.
In two patients the correction included a lengthening of 2 cm and 3 respectively. Correction time averaged 23 days. The time from completion of correction to frame removal averaged 71 days (48-113).
There were no changes in metabolic parameters or frequency of hemodialysis throughout treatment.
There were no major complications. Minor complications included pin tract infections which responded to antibiotic treatment, and premature consolidation in one case.
Follow up averaged 6.5 years (1-10). 4/5 patients were skeletally mature. Alignment was maintained in 4/5 patients and they were all fully functional and asymptomatic.
We did not experience a significantly higher infection rate or problems with bone regenerate when compared to patients with no systemic diseases or other metabolic diseases. We attribute this to the maintenance of normal metabolic parameters prior to and throughout the procedure. Maintenance of the correction was probably due to a combination of a well aligned limb, normal metabolic parameters, and decreased growth plate activity due to nearing skeletal maturity. The one case of failure in our series was due to avascular necrosis of the lateral femoral condyle.
Conclusions:- The Ilizarov method was found to be safe and effective for correction of malalignment due to Renal Osteodystrophy.
- Optimization of metabolic parameters is essential prior to surgery and throughout correction.
- The procedure is contra-indicated in patients with significant intra-articular knee pathology.
Role of FHL and FDL lengthening in Surgery for Congenital Club Foot
Mr Sunil Bajaj Mr O Lahoti (presenter)
Authors Mr Sunil Bajaj
Specialist Registrar
Consultant Orthopaedic Surgeon
Kings College Hospital
London, UK
Resistant clubfeet need surgical release and various procedures have been described. Although lengthening of Tendo Achilles and tibialis posterior, capsulotomies of ankle and subtalar joints and relocation of talonavicular joint are common to many of these procedures, there is no agreement in literature about flexor hallucis longus and flexor digitalis longus (FHL and FDL respectively) lengthening. We have randomised bilateral club feet to one or other group i.e. in one group we lengthened them in other we left them alone. We present the results in relation to recurrence in these two groups.
Methods:We randomised 13 children (consecutive group – 11 idiopathic and two syndromic children) with bilateral club feet to undergo FHL and FDL lengthening on one side only. The other side was used as a control. We carried out complete soft tissue release through Cincinnati incision. Senior surgeon (OL) carried out all the procedures and postoperative management was identical in each case. Children were evaluated independently by either a trainee or senior physiotherapist (both are blinded to the procedure) to assess the recurrence and particular attention was paid to the toes.
Results:We found no difference between two sides at six months follow up. Deformities recurred in three patients (two syndromic children and one idiopathic group) – bilaterally – irrespective of how the FHL and FDL were treated. Conclusions: We conclude that FHL and FDL can be safely left alone without any risk of recurrence. This reduces the complexity of surgery. However, parents should be alerted that the toes may look more deformed initially but will correct within six months without any adverse overall outcome.
Role of ulna lengthening in chronic dislocation of radial head Role of ulna lengthening in chronic dislocation of radial head
James George, Vrisha Madhuri
James George Postgraduate registrar
Vrisha Madhuri Professor
Department of Orthopaedics
Christian Medical college
Vellore
Chronic dislocation of radial head in our set up is often the result of a missed monteggia lesion. It is also seen in children with ulnar shortening due to a number of causes such as nonunion, physeal arrest and diaphyseal aclasis. We present our experience of ulnar lengthening in such cases.
Material methods:Eight children presenting with ulnar shortening aged 10 to 15 years were seen by us. There were 3 boys and 5 girls. Shortening was due to nonunion with shortening, diaphyseal aclasis, old Monteggia and physeal arrest of ulna. All patients had radial head dislocation with symptoms ranging from 6 months to 3 years. The surgical technique consisted of lengthening of ulna using LRS (Orthofix) in children. In smaller forearms the mini rail lengthener was used. Angulation was added in selected cases at the end of distraction. In these children a small DAF clamp was used in addition. Some children underwent additional procedure before and after ulna lengthening based on the indication
Results:Radial head dislocation were reduced in all patients. Mild subluxations occurred in 2 patients after frame removal. One radioulnar synostosis occurred in a child. Lengthening obtained ranged from 14 mm to 4.5 mm. The detailed out come is presented
Conclusion:Paediatric LRS with a DAF clamp is a good system for lengthening alone or combined with angulation of ulna. A closed reduction of the radial head can be obtained in a majority of cases. The penetration of the screw in the region of interosseous membrane could result in serios complication of radioulnar synostosis. We now prefer not to immobilize the forearm in flexion after reduction of radial head as weight of the cast tends to subluxate the radial head.
SEMLARASS: A new surgical approach to treat Cerebral Palsy
Dr. Deepak Sharan
Medical Director, RECOUP Neuromusculoskeletal Rehabilitation Centre,
Bangalore
We present a new surgical approach called Single Event Multilevel Lever Arm Restoration and Anti Spasticity Surgery (SEMLARASS) for cerebral palsy (CP). This procedure integrates 2 prevalent concepts for the surgical treatment of CP: Dr. Takashi Matsuo’s Orthopaedic Selective Spasticity Control Surgery (OSSCS), based on the concept that multiarticular muscles, which have less antigravity activity, are hyperactive in CP. Therefore, spasticity and athetotic movements can be controlled by releasing them selectively. The monoarticular muscles, which have antigravity activity and are responsible for maintaining an upright posture, are carefully preserved. Hence, there is no loss of antigravity activity (muscle weakness) and no loss of sensation and stereognosis. The second concept is that of simultaneous correction of lever arm dysfunction (e.g., hip subluxation, femoral anteversion, tibial torsion, hindfoot valgus) as proposed by Dr. James Gage. Objective: To describe the outcome of SEMLARASS in children and adolescents with CP.
Methods:Lever arm restoration (femoral and tibial rotational osteotomies, medial displacement sliding calcaneal osteotomies) and/or OSSCS was performed according to our established clinical protocols in 175 children with CP (spastic diplegia and hemiplegia). Innovative rehabilitation modalities including Manual Therapy, Constraint Induced Therapy, Hippotherapy, Functional Strength Training and Suspended Treadmill Training were used in the post-operative rehabilitation.
Results:Improved functional results were recorded in all patients using video gait recording, observational gait analysis, Gross Motor Function Classification System and other functional scales at a mean follow up of 2 years.
Conclusion:Currently, a well-planned and executed SEMLARASS, in the context of a multi-disciplinary team, provides the child with CP having contractures and lever arm disease with the only hope for a dramatic and predictable functional improvement.
Single event correction of paralytic rigid equinocavovarus deformities in children and adolescents*
Dr. Deepak Sharan
Medical Director, RECOUP Neuromusculoskeletal Rehabilitation Centre,
Bangalore
Rigid equinocavovarus is a common foot deformity presenting to Paediatric Orthopaedic Surgeons. Current treatment modalities include a combination of tendon transfers and soft tissue/bony operations, correction using external fixators, talectomy or decancellation of tarsal bones. In addition, a triple arthrodesis is frequently required when the foot is mature. Reports suggest that a triple arthrodesis does not correct the deformity adequately and may result in marked stress on the ankle and ultimate degenerative arthritis.
Objective:To describe the outcome of a new single-event surgical procedure (comprising of extra-articular osteotomies and soft tissue reconstruction) for rigid equincavovarus deformities in children and adolescents.
Methods:Chart review of 13 consecutive children and adolescents with rigid equincavovarus deformities (15 feet) over a 5 year period. The etiology of the deformity was post polio residual paralysis (7 patients), cerebral palsy (4), spina bifida (1) and Herediatry Motor Sensory Neuropathy (1). The surgical procedure involved open z-lengthening of tendoachilles, Steindler’s plantar release, midtarsal Akron dome osteotomy and Jones’ procedure (Arthrodesis of 1st IP joint, tenodesis of Extensor Hallucis Longus tendon on the neck of 1st metatarsal, and a dorsal closing wedge osteotomy at base of 1st metatarsal). In 3 patients (4 feet) a lateral displacement sliding calcaneal osteotomy was additionally performed. In 1 patient (bilateral), Stainsby’s reconstruction for the forefeet was additionally used. A JESS external fixator was used postoperatively in 6 patients (7 feet). The remaining feet were stabilised by K-wires.
Results:Good results, as judged by correction of all elements of the deformity, a plantigrade foot, improved gait and the distance that the patient could walk, ability to wear ordinary shoes and return to activities/work that involved walking and standing, were achieved in all the operated feet at a mean follow up of 2 years. No significant complications were reported.
Conclusions:The advantages include convenience (single-event), cost-effectiveness, satisfactory functional and cosmetic results, and no significant further shortening or stiffening of the foot. We recommend the described procedure for the treatment of rigid equinocavovarus deformities in the growing foot.
Treatment of Spastic Euino-Varus Feet in Patients with Ataxia Telangiectesia
Dr. Deepak Sharan
Uri Givon, MD(1,3), Niv Dreiengel, MD(2), Amos Schindler, MD(1), Alexander Blankstein, MD(1), Abraham Ganel MD(1),
- Pediatric Orthopaedics Unit, Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer.
- Orthopaedic Division, Sheba Medical Center, Tel Hashomer
- Motion Analysis Laboratory, Sheba Medical Center, Tel Hashomer.
Objective: To assess the efficacy of split Tibialis Posterior tendon transfers for the treatment of spastic equino-varus feet.
Design: Descriptive case series.
Setting: A national referral center for Ataxia Telangictasia (AT) patients.
Subjects: Four patients with 6 spastic equino-varus feet underwent split Tibialis Posterior tendon transfers. The spasticity was due to ataxia telangiectasia, a genetic disease found in Palestinians and Jews from Moroccan origin, and causing spasticity and ataxia. All the patients were non-ambulatory, had Ashworth 2-3 spasticity, and in all of them the forefoot was correctible in equinus. Evaluation of the results was by grading of the shape of the feet, pain and brace tolerance.
Results: All patients had good or excellent results, but one patient developed regional pain syndrome. No other complications were encountered. No over-correction or under-correction were seen.
Conclusions: Split Tibialis Posterior tendon transfer is a safe and efficacious procedure for the treatment of spastic equino-varus feet. Good alignment of the treated feet allows comfortable brace and shoe wear. AT patients had improved quality of life following the procedure.
Strategies For Management Of Loss Of Femoral Epiphysis Following Neonatal Septic Arthritis
Dr. Alaric Aroojis
AUTHOR: Dr. Alaric Aroojis, Paediatric Orthopaedic Surgeon
INSTITUTION: Bai Jerbai Wadia Hospital for Children & Holy Family Hospital, Mumbai
ADDRESS: 8/424 Church View, 14th Road, T.P.S. III, Bandra, Mumbai – 400050
Tel: (022) 26004334, 9820684402 Email: aaroojis@vsnl.net, aaroojis@gmail.com
ABSTRACT:
Catastrophic loss of the proximal femoral epiphysis (Choi Type IV deformity) or distal femoral epiphysis following neonatal septic arthritis presents a unique challenge to the Paediatric Orthopaedic surgeon. Besides loss of growth potential and subsequent limb length discrepancy of 4 – 6 inches at skeletal maturity; other problems include telescopy, vertical instability, angular deformity, significant lurch and fatigue pain. Various treatment options have been suggested to tackle this common sequel of neonatal hip sepsis, with varying degrees of success. These include Trochanteric arthroplasty, Pelvic support osteotomy, Ilizarov hip reconstruction, Harmon-L’Eppiscopo procedure etc. Even fewer options exist for management of angular deformity and limb length discrepancy following loss of medial or lateral femoral condyle following neonatal septic arthritis of the knee.
We present a series of patients treated by a variety of reconstructive procedures at our institute with a follow-up of 6months to 8 years. The purpose of this presentation is to discuss various practical solutions to this vexing problem by proper patient selection, pre-op planning and technical steps of execution. Complications and obstacles faced will also be discussed. Based on our medium-term results, we believe that by selecting the appropriate procedure, significant functional improvement can be gained to alleviate the problems arising from this disabling condition. Supracondylar Fractures in Children
Controversies in Paediatric Orthopaedic Trauma
Supracondylar Fractures in Children : Current Controversies and Consensus
- Dr. K. B. Mukherjee, D.Orth, DNB, MS, FRCS, AAOS
- Associate Professor, Consultant Paediatric Orthopaedic & Spinal Surgeon; Formerly Royal Liverpool, Alder Hey & Queen’s Medical Centre University Hospitals Nottingham NHS Trusts, England; Teaching Hospital, Tribhuvan University, Nepal, Ram Krishna Mission, B.K. Ram & HeritageHospitals, Varanasi, India
- Email kbmukherjee@bst.rcsed.ac.uk, No financial support received, Level of evidence IV
Supracondylar fractures in children are commonly encountered injuries, yet there are numerous controversies about treatment protocols that would reduce complications. This paper attempts to review these controversies in the light of current literature and then arrive at a semblance of consensus on these issues.
A complete assessment of circulation and neurological status before deciding on management protocol is not only imperative but also goes a long way in resolving these controversies. There is as yet no widely accepted consensus on how to assess adequacy and stability of reduction on table with a hyperflexed elbow and later through a plaster. Many would prefer the Baumann’s angle, some would consider the crescent sign, others would assess the anterior humeral cortical line’s relationship to capitellar physis and still others would measure the distal humeral medial physeal angle.
The presence of swelling, according to some surgeons, should decide whether to go ahead with closed reduction or fasciotomy/ open reduction, yet a lot of conservative orthopaedists would strongly support traction in even a grossly swollen limb and claim very good outcome. Here again, there is a lack of consensus on waiting period and the indications for fasciotomy, open reduction/ exploration versus traction.
Most orthopaedic surgeons generally agree that type III injuries should be fixed by smooth k-wires as the final outcome after closed reduction and plaster remains controversial in such widely displaced fractures. A lot of conservative surgeons would still continue to apply plaster in these cases with evidently acceptable results. Some would argue that an unstable reduction or comminution in even a type II fracture is an indication for percutaneous pinning. Terms like stability of reduction on table are highly subjective which remain to be defined in a reproducible form.
There is controversy about the degree of flexion at which the fracture should be immobilized after a stable reduction. Hyperflexion is preferable in a plaster without pinning, yet there is no consensus on how much further flexion beyond 90 degrees should be accepted under circumstances when the radial pulse is not satisfactorily palpable. The importance of radial pulse in the assessment of adequacy of circulation in impending Volkmann’s ischaemia is also not resolved. It is not yet resolved whether to immobilize the fracture in pronation or supination or whether this should be guided by the direction of rotational instability.
Even among surgeons who would fix the supracondylar fracture by pinning, there are lots of controversies on whether the pinning should be completely closed or medially mini-open or whether the ulnar nerve should be routinely exposed or whether open pinning is preferable. A lot of surgeons prefer crossed pinning, yet others blame the medial pin for higher incidence of nerve injuries. Yet others prefer two lateral pins or two lateral but crossed pins. Lateral pins do not give adequate stability according to others.
Apparently there are still controversies surrounding the clinical presentation of compartment syndrome versus pressure measurements and indications for fasciotomy, exploration, arterial repair, neurolysis and nerve repair or the waiting period there of. The place of arteriography in such an emergency situation also needs to be clarified.
Finally, there are several methods of corrective osteotomy for persistent cubitus varus deformity. The importance of asymmetric growth in deformity progression and lateral epiphesiodesis is a new addition to the list of controversies.
A simple summary of current consensus from the literature is that without doubt treatment of type II, type III supracondylar fractures of the humerus in children with closed reduction and percutaneous pinning has, of late, dramatically lowered the rate of complications from this injury. The incidence rates of malunion (cubitus varus) and compartment syndrome have both decreased. Nerve injury accompanying this type of fracture (prevalence, 5% to 19%) is usually a neurapraxia, which should be managed conservatively. Vascular insufficiency at presentation (prevalence, 5% to 17%) should be managed initially by rapid closed reduction and pinning without arteriography. Persistent vascular insufficiency necessitates exploration and vascular reconstruction. A meticulously pre-planned and sized, lateral closing wedge osteotomy with internal fixation, after maturity should be planned for residual cubitus varus deformity.
The Antero-posterior approach for Latissimus Dorsi & Teres Major transfer to the rotator cuff in Obstetrical Brachial Plexus Palsy reconstruction surgery
Franklin Lokiec , Eitan Segev , Shlomo Wientroub
Dep. of Pediatric Orthopedic Surgery
Dana Children`s Hospital, Tel Aviv Medical Center, Israel
The traditional axillary approach (Hoffer`s technique) has been used for many years in our department, for the transfer of the Latissimus Dorsi and Teres Major tendon to the Rotator Cuff in the reconstruction of abduction and external rotation movements of the shoulder in children with impaired function after obstetrical brachial plexus palsy. Using the traditional approach, through a small axillary incision the tendons of the L.D and T. M. were exposed and reinserted into their new position in the humerus. Suturing the tendons through the axillary exposure was frequently difficult and the optimal reinsertion point in the rotator cuff was sometimes missed resulting in sub-optimal function and poor
Results:In other cases adequate tension of the transfer was not obtained resulting in inefficient functional power. In the last three years we have been using a new technique performing an additional small postero -superior incision allowing exposure of the postero-superior lateral corner of the rotator cuff, pulling out the tendons for adequate tendon reinsertion and obtaining optimal tension of the transfer. In this presentation we describe the technique, the surgical tips and the preliminary results based on the experience in 12 cases. In conclusion, we observed better functional results based on the Mallet score in patients where this technique was used, the surgical procedure was much more simple than the classical approach and surgical time was considerably reduced.
The mid-term effectiveness of Single Event Multi-Level (SEML) surgery, in children with spastic Cerebral palsy in their motor function
Dr.S.Venkataramanan
Purpose / aim:The mid-term effectiveness of Single Event Multi-Level (SEML) surgery, in children with spastic Cerebral palsy in their motor function.
Materials and Methods:35 patients suffering from spastic cerebral palsy underwent Single Event Multi-Level surgery and were evaluated after a minimum of 2 years to note the changes in their motor function. Hemiplegics, diplegics and quadriplegics were 3, 23, and 9 in numbers respectively. All patients underwent contracture releases including osteotomies as per their clinical findings at the hip, knee, foot or ankle and gait observations. It was ensured that all patients were placed on an adequate postoperative therapy programme done /guided by a trained therapist.
Results:Patients were evaluated at 3, 6, 12 and 24 months. Most patients / parents felt gratifying improvement in gait/ posture / sitting ability or reduction in pain. Complications were: 1 death, 2 post-op infections, and 1 recurrence of contracture.
Conclusion:SEML surgeries are very effective in improving motor function, general development, reduction in pain, and ease in therapy and the effects are maintained well in the mid term. Identification of the multiple contractures and deformities involves detailed and possibly repeat clinical examinations and gait observations. Such surgeries are, however, prolonged and involve good pre- and post-operative care to avoid serious complications.
Tibial Osteotomy and Deformity Correction with the Taylor Spatial Frame The Afula Experience
Noam Bor
Orthoedic department and Pediatric orthopedic unit.
Haemek Central Hospital
Afula Israel
The Taylor Spatial Frame (T.S.F) is a unique external fixation system, can correct in conjuction with a software program, the simplest to the most complex skeletal deformity utilizing the same frame. The TSF is an evolution of the classicl Ilizarov frame, the computer program clculates a schedule for gradual strut and frame adjustment, simultaneously correct multiple aspects of deformity around a virtual hinge without the need for complicated frame modification.Since January 2004 the TSF has been adopted in our hospital. The pupose of this study is to evaluate our first experince on 17 patients treated for different aspects of Tibial deformity.
Material and Methods:
The TSF was used in the Total Residual Deformity Correction mode.
Since January 2004 to date forty patients were treated in our department with the TSF, for various etiologies. 17 out of these patients - twelve males and 5 females - underwent correction for tibial deformity.
The mean age of the patients was 34 years (range 8 – 67 years).
The etiologies for the tibial deformity are the following: Malunion into varus, or valgus – 4 patients, late onset tibia vara – 3 patients, medial compartment osteoarthritis of the knee (MCOA) – 5 patients. Two patients suffered from lateral compartment osteoarthritis, and renal rickets. Three patients had proximal physeal tibial damage at childhood resulted in recurvatum (2 patients) and varus (1 patient).
The mean follow up is 19 months (range 7 – 36 months).
The tibial deformity was calculated on patella-forewad AP and lateral tibia views using the method of Paley. The following parameters were calculated: Pre and postoperative MPTA (medial proximal tibial angle), PPTA (proximal posterior tibial angle), LDFA (lateral distal femoral angle), PDFA (posterior distal femoral angle), the angle of the deformity and the LLD (leg length discrepancy). Rotation was assessed clinically.
The tibial osteotomy was performed with the Gigly saw in 11 patients, and with the technique of low enenrgy osteotomy, in the other six.
The fibula was osteotomized in all patients. Either a syndesmosis screw, (11 patients) or an Ilizarov fibular wire (6 patients) were inserted in all patients in order to prevent the fibula from dislocating out of the ankle mortise. In 4 patients additional procedures were performed at the time of the main surgery: Removal of an old intramedullary nail via osteotomy of the tibial tuberosoty, anterior compartment fasciotomy, and femoral osteotomy (2 patients).
The duration of frame fixation from the time of application to the time of removal averaged 5.1 months (range 3.5 – 13 months).
One patient had a multiplanar deformity included varus, recurvarum, postero-medial translation, and internal tibial torsion which was corrected to normal aligment. The average preoperative MPTA in 12 patients suffered from varus deformity was 79 degrees (range 66 – 86) and 90.3 degrees at the latest follow up (range 89 – 92). The average preop PPTA in 5 patients with recurvatum deformity was 97.2 degrees (range 87 -110), and 82 degrees (range 82 – 84) postoperatively. Preoperative MPTA in 3 patients suffered from valgus deformity was 103 degrees (range 100 – 110), and an average of 91 degrees was achieved (range 90 -96) at the latest follow up. Three patients had combined varus and recurvatum deformity.
The average preoperative angular deformity in all patients was 10.8 degrees (range 5 – 24). At the latest follow up all deformities were corrected to within the normal range or according to the preoperative planning. For example: for the patients suffered from MCOA the preoperative plane was to overcorrect the deformity into valgus.
Limb length discrepancy was corrected in 6 patients, an average of 3.3 cm of tibial lengthening was avhieved (range 2 – 6 cm).
Intenal tibial torsion of between 10 to 15 degrees was corrected in 3 patients.
The following 5 complications were noticed: 1 patient had subcapital fracture during treatment at the ipsilateral limb due to disuse osteoporpsis, she underwent at the end of the TSF treatment total hip replacement. One patient is still suffering from nonunion of the tibial osteotomy. In him carcinoma of the colon was diagnosed few weeks after the TSF removal, currently is under chemotherpy treatment.
Knee flextion contracture of 40 degrees was developed in one 9 years old girl. She origenally underwent double femoral and tibial osterotomy contemporarly, and currently waiting for EUA (examination under anesthesia) and eventually contracture release.
One patient post valgus osteotomy for MCOA, is still suffering from pain in her knee, candidate for unicondylar knee replacement.
One patient 67 years old, with an original valgus deformity, partial lost of the correction achieved during treatment, was noticed at her latest followup.
Most patients experienced at least one episode of pin tract infection, all resolved with oral antibiotics.
Based in our results, the TSF allows safe gradual correction and is accurate and well tolerated. The gradual correction of the deformity, as opposed to acute correction, allows for confirmation of the mechanical axis and joint line correction during treatment. Residual correction is easily performed reutilizing the computer program during treatment, and no return to the operating room is required.
Treatment of Congenital Pseudarthrosis of Tibia by Ilizarov Method
Amol patel, Dr G.S Kulkarni, Dr R.M Kulkarni
Author: Dr Amol Patel
Co-Author: Dr G.S Kulkarni, Dr R.M Kulkarni
Institute: Post Graduate institute Of Swasthiyog Prathisthan, Miraj.
Key Words: Congenital pseudarthrosis tibia, Ilizarov
Congenital Pseudarthrosis of Tibia (CPT) is one of the most challenging conditions in pediatric Orthopaedics. Ilizarov method gives a comprehensive approach to all aspects of CPT, allowing the surgeon to address the problems of union, deformity, leg length disperancy, ankle Valgus and weight bearing.
Material and Methods:In our institute total of 37 cases were operated with a follow up till 13 years. Out of these 12 dysplastc type, 8 cystic type, 5 late type, 1club foot type and 11 with anterior angulation type were present. In four cases surgery was done in (<)4 years and all failed. Average age of patient at the time of first surgery was 10 years. (3 – 40). In all resecting of the pseudarthrosis and the surrounding pathological periosteum was done. Acute shortening and compression at the resection site and simultaneous lengthening of the proximal tibia was done. Bone grafting and periosteal graft was also done. Ilizarov external Fixator was kept till consolidation.
Result:Of the 37 cases 34 united after an average of >2 surgeries. The Fixator time was an average of 8 months .Additional bone grafting was required in 9 cases. Refracture occurred in 30% of our cases, Non – union persisted in 2 cases. One case is undergoing treatment, with presently 4 months post.
Conclusion:Ilizarov Fixator is an efficient solution for CPT .Union is achieved by maintaining the pseudarthrosis ends in opposition to each other. It helps in correction of the angulation and also the leg length disperancy. Helps in early weight bearing and in the end avoids amputation and gives a well functioning limb.
Treatment of Residual Clubfoot Deformities with the Taylor Spatial Frame Using a Ponseti Sequence
Mark Eidelman(1), Alexander Katzman(1), Noam Bor(2), Bradley Michael Lamm(3), and John Eric Herzenberg(3)
1.Rambam Medical Center, Haifa,Israel
2.Emek Hospital,Afula, Israel
3.Rubun Istitute for Advanced Orthopedics, Sinai Hospital, Baltimore, USA
Type of Presentation: Oral, E-poster, Poster
Category: Clubfoot
Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external fixator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external fixator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation first and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a final phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method.
Methods:During a five-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, five had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with fibular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program.
Results:All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superficial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the first metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases.
Conclusions:We believe that the Ponseti sequence of correction can be applied to older children with residual clubfoot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed.
Significance:The Ponseti-inspired method of residual clubfoot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures. Ultrasoune evaluation of clubfoot correction during pnseti treatment. Alaric Aroojis.
Ultrasound Evaluation Of Clubfoot Correction During Ponseti Treatment
Dr Alaric Aroojis
AUTHOR: Dr. Alaric Aroojis, Paediatric Orthopaedic Surgeon
INSTITUTION: Bai Jerbai Wadia Hospital for Children & Holy Family Hospital, Mumbai
ADDRESS: 8/424 Church View, 14th Road, T.P.S. III, Bandra, Mumbai – 400050
Tel: (022) 26004334, 9820684402 Email: aaroojis@vsnl.net, aaroojis@gmail.com
The Ponseti method is used widely in the treatment of clubfoot and long term results have been well documented. There is no method to document serial correction or to predict if spurious correction occurs. Radiographs are not useful to monitor treatment as the feet are small and the bones are cartilaginous. We report our experience using sonography as a tool to evaluate correction during the Ponseti maneuver. The goal of the study was to use serial ultrasound to assess and monitor correction of the forefoot during Ponseti method of manipulation, and to detect the incidence of spurious correction.
PATIENTS & METHODS:26 patients (12 days – 3 months) with 32 affected feet were included (6 bilateral). All feet were scored at presentation and serially using the International Clubfoot Study Group (ICFSG) criteria and the Pirani scoring system. All feet underwent three serial ultrasound evaluations with the forefoot at rest (static measurement) and using the simulated Ponseti maneuver (forefoot abduction with counter pressure over the head of the talus). The following measurements were made: Distance between tip of medial malleolus and medial end of navicular in mm (MMN) and Talo-cuneiform angle in degrees (TC).
RESULTS:Study population was divided into 2 groups: Group I - age < 6 weeks and Group II – age > 6 weeks at start of treatment. In 20 normal feet (controls), the mean medial malleolus to navicular measurement was 6.45 – 9.88 mm and the mean talo-cuneiform angle was -4.3 to -3.7 degrees. In 32 clubfeet, the mean medial malleolus to navicular distance was 4.5 – 6.44 mm pre-treatment and 6.9 – 9.1mm post-treatment. The mean talo-cuneiform angle was 26.5 to 21.7 degrees pre-treatment and -4.5 to -4.0 degrees at the end of treatment. 5 feet underwent a spurious correction, with normalization of talo-cuneiform angles but minimum change in medial malleolus to navicular distance, indicating that the break had occurred in the naviculocuneiform joint.
DISCUSSION:This is the first such study from India showing the use of Ultrasound in monitoring clubfoot correction. Normative data have been established and accurate realignment of the talonavicular and calcaneocuboid joints can be demonstrated during Ponseti correction. In our study, 5 feet out of 32 (15.6%) underwent a spurious correction which could be documented sonographically. Sonographic evaluation is a relatively simple, non-invasive and widely available procedure. It is a promising technique for assessing and monitoring of clubfeet during treatment and should be a part of the neonatal assessment of clubfoot. Use Of Taylor Spatial Frame In Children - Kings College Hospital Experience
Use Of Taylor Spatial Frame In Children - Kings College Hospital Experience
Mr O Lahoti
Consultant Orthopaedic Surgeon
Kings College Hospital
London
The Taylor spatial frame is unique circular frame fixator for correction of deformities and lenthening. Since its introduction in 1994, it has gained immense popularity and is used in various clinical situations. Our aim is to evaluate our early experience with this relatively new technique.
Methods:We have applied 52 frames since January 2005, out of which eight were paediatric patients. The aetiology of deformity included Blount’s disease (3), limb length discrepancy due to osteomyelitis and unknown aetilogy(2) and post polio deformities (3). Patients were regularly followed up for clinical and radiological examination (when appropriate).
Results:We achieved excellent correction and target length in all. There were three episodes of superficial infection and one of severe pin track infection.
Conclusions:We found that TSF, achieves accurate correction with less hardware on the limb when compared to traditional Ilizarov method. However, there are cost and learning curve implications.
Mr O Lahotiwill present this paper
Contact details: omlahoti@mac.com
Hip Joint Reconstruction for the Treatment of Severe Spastic Hip Disease
Uri Givon M.D.(1,2), Nir Sher-Lurie M.D.(1), Amos Schindler M.D.(1)
(1) Pediatric Orthopaedic Unit, Safra Hospital for Children, Sheba Medical Center, Tel Hashomer, Israel
(2) Motion Analysis Laboratory, Sheba Medical Center, Tel Hashomer, Israel
Objective: To review our results with hip joint reconstruction in severe spastic hip disease.
Design: Descriptive case series.
Setting: A tertiary referral medical center.
All the patients who underwent a hip reconstruction procedure because of SHD were retrospectively evaluated. Twenty-five patients with 32 involved femoral necks were treated between 1997 and 2003. All of the patients had a migration index greater than 40% with 8 of them having a migration index of over 65%. 15 patients had total involvement type CP and 10 patients had diplegic type CP.
Intervention:Hip joint reconstruction comprised of varus derotation osteotomy and a periacetabular osteotomy such as the Dega osteotomy, and when necessary an open reposition of the hip joint was performed.
Results:Good coverage of the femoral head was achieved in 23 of the patients and in 30 of the femoral heads. There was no difference between the high migration index group and the low migration index group. In two cases progressive posterior dislocation continued following the operation, attributed to incomplete correction of the posterior acetabulum. One patient had an intra-operative fracture of the femoral neck. The results were similar in the more severe and less severe groups.
Conclusions:hip reconstruction has favorable results in all types of CP. We found no difference between the group with high migration index and the low migration index concerning complications and outcome. A high migration index should not be considered as reason not to reconstruct the hip joint. The only contraindication for this procedure is osteoarthritic changes of the hip joint.
Botulinum Toxin In Cp- Goals & Indications
Weigl Daniel MD, *Arbel Nili LPT, Katz Kalman MD, Bar- On Elhanan MD
Pediatric Orthopedics & *Rehabilitation Units
Schneider Children’s Medical Center of Israel
Botulinum injections as an adjunct to other treatment modalities have been used in our unit since 2001. Purpose: What is the correct patient selection? Who are the optimal responders? What are the best indications?
Patients and methods:Study cohort was composed of 45 patients. Inclusion criteria were children with a spastic disorder and a minimal follow-up of 4 months. Age ranged from 18 months to 22 years with a median value of 4 years. There were 59 treatment sessions, in which 78 muscle groups were injected. The Gross Motor Functional Classification Scale was used to classify patients' functional level. Treatment goals for each session were determined. A Goal Assessment Scale which evaluates the attainment of our functional goals was created, scaled from -1 (worsening) to 4 (improved GMFCS).
Results:The most common response was actually at a 1 level. Results were analyzed according to the different indications, and conclusions regarding best indication are described.
Conclusion:These treatments are a good alternative to win time until surgery for the younger patient. Improvement in sitting balance and crouched stance in the severely disabled patients can be expected. The optimal injected dose has still to be examined- we feel that higher doses can be safely used. Treatments should be given on a regular schedule, knowing that their effect lasts for about three months. Do not expect a change in the Gross Motor Function: match expectations with family and patient.
Documentation Of Gait Patterns: Suggestion For A Visual Gait Recording Format
Weigl Daniel MD; *Arbel Nili, LPT; *Keler Ayelet, LPT; Katz Kalman, MD; Becker Tali, MD; Bar- On Elhanan MD.
Pediatric Orthopedics & *Rehabilitation Units
Schneider Children’s Medical Center of Israel
Complex gait analysis laboratories are not yet generally available worldwide.
Our objective was to develop a simple gait recording format, based solely on observation of the walking patient.
Such a system has to address several requirements: 1) it should provide the most critical information regarding the patients’ gait skills, 2) it has to expose and point at critical problems that need to be treated, 3) it should be simple to use during a routine outpatient clinic visit, 4) and finally - be reliable among raters and valid compared to the golden standard of a 3D gait analysis laboratory.
The current study was designed to examine the reliability of an originally designed systematic visual gait recording format. This was designed to look at chosen sagittal, frontal and horizontal deviations, at three stages of the gait cycle.
Thirty three ambulatory children with cerebral palsy were observed by 3 different raters. Their gait patterns were recorded by using this scheme. Interrater variability was statistically examined. A high agreement percentage was found among observers in most examined fields. The validity of the system has yet to be examined by comparison with a 3D gait analysis laboratory.