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Objective:To investigate the efficacy of open exploration, ulnar osteotomy and annular ligament reduction (three-in-one surgery) in the treatment of chronic Monteggia fracture in children.Methods:The data were analyzed retrospectively of the 35 children with chronic Monteggia fracture who had been admitted to Department of Pediatric Orthopaedics, Tianjin University from June 2017 to September 2021. There were 22 boys and 13 girls, and 19 left and 16 right sides, with an age of (6.8±2.5) years. Anterolateral dislocation of the radial head occurred in 30 cases and anterolateral dislocation in 5 ones. The time from injury to operation was (17.9±9.9) months. All patients were treated with three-in-one surgery. The elbow flexion and extension, forearm rotation and The Hospital for Special Surgery (HSS) elbow score were measured and compared in all patients at 12 months after operation. Their complications were also recorded.Results:All children were followed up for 12 months. The osteotomy ends of the ulna achieved bony union 1.5 to 4.0 months after operation. The elbow extension (-1.0°±5.9°) and flexion (128.5°±4.9°) at 12 months after operation were significantly improved compared with those before operation (-9.3°±18.0° and 108.4°±17.3°) ( P<0.05). The forearm pronation (61.5°±19.4°) at 12 months after operation was significantly limited compared with that before operation (72.7°±22.4°) ( P<0.05). There was no significant difference between the forearm supination (86.7°±4.5°) at 12 months after operation and that before operation (81.0°±17.4°) ( P>0.05). The HSS elbow score at 12 months after operation (93.5±5.2) was significantly higher than that (80.6±9.3) before operation ( P<0.05). The efficacy evaluated by the HSS elbow score at 12 months after operation was excellent in 21 cases, good in 12 cases, and fair in 2 cases, giving an excellent and good rate of 94.3% (33/35). Postoperative re-subluxation was observed in one patient. Conclusion:Open exploration, ulnar osteotomy and annular ligament reduction are a safe and effective three-in-one surgery for chronic Monteggia fracture in children, because it may lead to significantly improved elbow flexion and extension after operation, though the forearm pronation may be limited.
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Objective:To explore the clinical efficacy of composite pin-rod external fixation in the treatment of open tibial fractures in children.Methods:The clinical data were retrospectively analyzed of the 21 pediatric patients with open tibial fracture who had been treated at Department of Pediatric Orthopeadics, Tianjin University by composite pin-rod external fixation from January 2019 to December 2021. There were 15 boys and 6 girls, and 9 left sides and 12 right sides. The age at the time of operation was (8.6±4.1) months. According to the Gustilo-Anderson classification, there were 3 cases of type Ⅰ, 12 cases of type Ⅱ, 3 cases of type ⅢA, 1 case of type ⅢB, and 2 cases of type ⅢC. Twenty cases had a concomitant fibular fracture, 3 cases multiple injuries, and 3 cases a segmental fracture. All the operations were performed at the emergency department. After debridement, the fractures were reduced and immobilized with a triangle external fixation of composite pin-rod system. In the patients whose conditions permitted, the wounds were closed at one stage, and no other external fixation was added after operation. Wound healing, fracture healing, frame time, knee and ankle functional results and complications were evaluated.Results:All patients were followed up for (20.7±15.8) months. Primary wound closure was achieved in 18 cases; the wound was covered by vacuum sealing drainage after debridement and reverse skin removal in the other 3 cases, of which 2 healed smoothly, and 1 was complicated with superficial infection of Gustilo type ⅢC treated eventually by an anterolateral thigh flap. Fractures healed satisfactorily in 20 cases, with a frame time of (4.5±1.7) months. At the last follow-up, there was no significant difference in the range of motion of the knee and ankle joints on the affected side compared with the uninjured side ( P>0.05). According to the Johner-Wruhs evaluation criteria, the functional recovery was excellent in 16 cases and good in 4 cases. Fracture nonunion happened in one child after skin flap operation, but fracture occurred again after reoperation for fracture, yielding a poor Johner-Wruhs evaluation. Needle tract infection was found in 9 cases but responded to therapy with no other complications. Conclusions:In the treatment of open tibial fractures in children, the composite pin-rod external fixation may lead to satisfactory clinical outcomes. It is easy in operation, provides stable fixation, and allows early rehabilitation after surgery. It can be used as a terminal treatment for wounds that can be closed at one stage.
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Objective:To investigate the Graf classification results and risk factors of infants for developmental dysplasia of the hip (DDH) by B-ultrasound screening in Tianjin.Methods:A retrospective analysis was conducted from January 2013 to December 2020 using the three-tier maternal and child health care management and the Tianjin maternal and child health information system for the early B-ultrasound screening data of 6-8 weeks old infants. The "2+1" screening model of "primary screening-re-screening-diagnostic treatment" was applied. The positive screening rate and age of infants at the time of referral for treatment in different years and different Graf classifications were analyzed, and the differences in positive infants with different sex, parity, fetal position, mode of production, gestational age, birth weight, and family history were compared. Binary logistic regression was used to analyze risk factors for DDH.Results:A total of 807 889 babies were screened, and 2 039 children (2 841 hips) were detected with B-ultrasound Graf classification count IIa and above, with the positive rate was 2.52‰ (2 039/807 889). Among the abnormal hips, 685 were type IIa(+) hips, 959 were type IIa(-) hips, 367 were type IIb hips, 262 were type IIc hips, 227 were type D hips, 265 were type III hips, and 76 were type IV hips. Type IIa(-) was the most common, accounting for 33.76% (959/2 841), type IIa(+) accounted for 24.11% (685/2 841), type D and above was 19.99%(568/2 841). The abnormality rate of the left hip was 2.02‰ (1 632/807 889), which was greater than 1.50‰ (1 209/807 889) of the right side, and the difference is statistically significant (χ 2=63.09, P<0.001). The rate of hip abnormalities in female infants was 3.27‰ (2 541/777 272), greater than 0.36‰ (300/838 506) in male infants, which the difference between the sexes had statistically significant (χ 2=1 947.871, P<0.001). The positive rate of DDH in male infants was 0.50‰ (209/419 253), and that in female infants was 4.71‰ (1 830/388 636). The detection ratio of male to female infants was 1∶8.76, and the difference in the positive rate of DDH between the sexes was statistically significant (χ 2=1 420.102, P<0.001). Different fetal position (cephalic position/breech presentation), delivery method (normal delivery/cesarean section), birth weight (normal/low weight), family history (with DDH/without DDH) showed statistically significant differences in the positive rate of DDH ( P<0.05), whereas there was no significant difference in the positive rate of DDH at different parity (first/second and above) and gestational age (term/premature) ( P>0.05). Logistic regression analysis showed that gender ( OR=10.50, P<0.001) and fetal position ( OR=3.40, P<0.001) were independent risk factors for DDH, and gestational age ( OR=0.91, P<0.001) was a protective factor for DDH. Differences in referral age of infants with different B-ultrasound Graf classification from year to year were statistically significant ( P<0.05). Conclusion:Through the "2+1" screening model of "primary screening-re-screening-diagnostic treatment", the DDH positive rate in 6-8 weeks old infants in Tianjin was 2.52‰, and the positive rate of DDH in female infants and left hip was higher. The more severe the Graf classification of B-ultrasound was, the younger the age of referral was. Women and infants with breech presentation had a higher risk of developing DDH, and the risk of DDH in preterm infants was lower.
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Objective:To evaluate the feasibility of CT volume rendering technology in the assessment of the physeal bar in children.Methods:A retrospective analysis of the relevant CT data of 20 patients with physeal bar from January 2019 to December 2021, 13 boys and 7 girls, age 9.94±2.91 years. The etiology included 17 cases of trauma, 1 cases of tumor, and 2 cases of unknown. The affected sites included 9 cases of distal femur, 5 cases of proximal tibia, 3 cases of distal tibia, and 3 cases of distal radius. Evaluate using volume rendering technology and traditional surface reconstruction technology respectively and the index include the size and type of physeal bar.Results:All the children were successfully examined at one time, and none of them required sedation. The average exposure time was 3.81±0.83 s. During scanning, only low-dose radiation was performed on the affected joints, and routine radiation protection was performed. Using volume rendering technology to evaluate the proportion of the physeal bar, the results obtained by the three testers were 25.36%±15.36%, 24.75%±16.18%, 26.70%±17.72%, and the intraclass correlation coefficient value ( ICC) was 0.976, the three repeated measurements by one tester were 25.36%±15.36%, 25.41%±15.20%, 25.74%±16.00% ( ICC=0.990). Compared with the traditional curved planar reconstruction technical evaluation, the results obtained by the three testers were 28.36%±16.74%, 23.66%±19.87%, 35.25%±15.92% ( ICC=0.737), the three repeated measurement results by one tester were 28.36%±16.74%, 31.66%±13.06%, 30.89%±12.52% ( ICC=0.875). The volume rendering technology was better than the curved planar reconstruction technique. Paired t test was performed on the measurement results of three evaluators and the three repeated measurements of the same evaluator, and the differences were statistically significant ( P<0.05). The same results were acquired by using volume rendering technology to evaluate the type of phseal bar with three testers; but there were 18 cases had the same results by using curved planar reconstruction technology and 2 cases had differences, showing the volume rendering technology was more accurate. Conclusion:Low-dose CT scanning volume rendering technology is an effective method to evaluate the physeal bar in children. It can more intuitively and accurately evaluate the proportion and type of the bar while reducing the radiation exposure of children. The consistency with inter-group and intra-group is better than traditional curved planar reconstruction technique with good reproducibility and clinical significance.
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Legg-Calvé-Perthes disease (LCPD) is an idiopathic necrosis of the femoral head in childhood, the deformities of the femoral head occurring in the progress of disease could result in osteoarthritis. Treatment can be surgical or nonsurgical, but the timing and indications remain unclear. Understanding of the prognostic factors of LCPD is helpful to predict the outcome and guide the clinical management. This study reviewed the literatures about the prognosis of LCPD since 2000, the prognostic factors were summarized from three categoriesas general factors, disease factors and intervention factors. The general factors were the characteristic information of patient that can be obtained at the first time clinically. The age of onset is the most definite prognostic factor, the younger the age, the better the prognosis, and 6-8 years is an important watershed. Disease factors refer to the disease characteristic information obtained through evaluation. The modified Waldenstr?m stage of the disease needs to be confirmed first, early treatment can ensure better prognosis. Then the severity was evaluated, including the involvement of necrosis, morphological changes and extrusion of the femoral head. The more severe the disease, the worse the prognosis. Most predicters, such as Catterall grading and Herring lateral column typing, have to be used in late-stage of LCPD. The degree of femoral head perfusion evaluated in enhanced MRI or DWI-MRI is an early predictor of LCPD, but it is still in the preliminary exploratory. Intervention factors are the effects of different methods of treatment on prognosis, including the comparison of surgery or non-surgery, different non-surgical and different surgical methods. The determination of surgical or non-surgical treatment mainly depends on the age of onset and severity of disease, and the younger and milder cases tend to be non-surgical treatment, but the specific indications are still controversial.
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Objective:To retrospectively analyze and evaluate the effect of interlocking intramedullary nail in the treatment of proximalfemoral fibrous dysplasia (FD) and to discuss its application techniques and treatment strategies.Methods:The patients with proximal femoral FD who received treatment with interlocking intramedullary nail in our department from April 2014 to August 2018 were retrospectively reviewed. The inclusion criteria included having complete data with more than 3 years follow-up. A total of 31 cases with 32 thighs were included in the present study. Among them, there were 24 males and 7 females. The mean age at operation was 11.4±2.3 years. The mean follow-up duration was 3.9±1.1 years. The surgical methods were osteotomy or in situ interlocking intramedullary nailing, and femoral neck reconstruction nails pass through the epiphyseal plate in some cases. Preoperative, postoperative and final follow-up radiographic changes, including femoral neck shaft angle, proximal femoral diaphyseal deformity, and femoral alignment were compared. Univariate analysis of the influencing factors of postoperative femoral neck shaft angle loss.Results:In this group, 13 patients had coxa varus deformity, and the angle of the neck shaft was 107.3±7.1°, and 23 patients had the bending deformity of the proximal femur, and angled 29.5°±9.1°. 10 cases of coxa varus combined with proximal femoral diaphyseal deformity received double osteotomy and internal fixation, 17cases of simple coxa varus or diaphyseal deformity received single osteotomy and internal fixation, and 5 cases had no significant deformity, underwent in situ intramedullary nailing due to pathological fractures and pain. Postoperative femoral neck shaft angle was 133.2°±5.2°. Complete correction of proximal femoral flexion deformity was obtained and the diaphyseal axis was within the normal range. At the last follow-up, the neck shaft angle of 7 patients (21.9%, 7/32) decreased from 133.6°±3.9° to 125.7°±3.4°. Univariate analysis showed that the proportion of neck shaft angle loss in cases with proximal femoral locking nails passing through the epiphyseal plate was significantly lower than that in the cases without (0 vs. 43.8%, χ 2=6.58, P=0.010). Conclusion:The application of interlocking intramedullary nails in the treatment of proximal femoral fibrous dysplasia can achieve good results, according to the situation of coxa varus or diaphysis bending deformity, single or double osteotomy can be performed. There is a risk of femoral neck shaft angle loss after surgery, which can be avoided by femoral neck reconstruction locking screw fixation crossing epiphyseal plate.
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Objective:To utilize MRI and plain films to observe the changes of soft tissue structures in patients with developmental dysplasia of the hip (DDH) after closed reduction, and explore the concentric reduction rate, the "docking" rate and the femoral head necrosis rate after reduction.Methods:Retrospective analysis of unilateral completely dislocated DDH patients with closed reduction and spica casting in our hospital from October 2012 to July 2018. MRI was performed on the day of closed reduction and every 2-3 months after operation. Pelvic plain films were performed before operation and follow-up. The labro-chondral complex (LCC) of the hip was divided into 4 types on MRI images, and the reliability and repeatability of LCC classification were evaluated by intra-class correlation coefficient. Trend chi-square test or Fisher exact probability method was used to analyze the variation of thickening rate of ligamentum teres, transverse ligaments and pulvinar during MRI follow-up, and the difference of cartilaginous acetabular head index was evaluated by analysis of variance of repeated measurements or Mann-Whitney U test. The concentric reduction rate of the femoral head after performing closed reduction, the "docking" rate of the femoral headwhen the cast was changed for the last time were analyzed, and the necrosis rate of the femoral head were followed up for 18 months or more after reduction.Results:A total of 63 DDH patients (63 hips) with closed reduction were included. Intra-class correlation coefficient of LCC classification was 0.84 between observers (95%CI: 0.74-0.91) and 0.94 within observers (95%CI: 0.90-0.97) . Most LCC classifications were type 4 on the day of CR (93.7%, 59/63) , and return to normal (type 1 classifications) at the second follow-up (50.9%, 28/55). ligamentum teres, transverse ligaments and pulvinar were hypertrophic (94.5%-100%) on the day of CR, and decreased to 10.9%-12.7% at the second follow-up, which had statistically differences ( χ2=88.6; χ2=86.4; χ2=97.9, P<0.05). The cartilaginous acetabular head index was 68.1±12.1 on the day of CR, and increased to 84.4±7.0 at the second follow-up, which had statistically difference ( Z=-3.15, P=0.002). 58.7% femoral heads were "docking", 8.6% femoral head had necrosis. Conclusion:The abnormal soft tissue structures in the hip joint mostly recovered gradually after closed reduction, and 60% femoral heads could be docked, the short-term risk of the femoral head necrosis was low.
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Objective:Course of evolution observed relatively early Perthes disease in children surgically treated and conservative, explore the significance of early surgical treatment of Perthes disease.Methods:From January 1997 to December 2017, 632 children with Perthes disease were admitted. According to the inclusion and exclusion criteria, a total of 67 children were included in this study. Surgical group: 35 cases, 32 males and 3 females, age ranged from 7.0 to 11.8 years, with an average 8.3±1.0 years old, 21 cases on the left side and 14 cases on the right side. Conservative group: 32 cases, 24 males and 8 females, age ranged from 7.1 to 12.0 years old, with an average of 8.4±1.4 years old, 22 cases on the left side and 10 cases on the right side. The pelvic orthosis and frog position were taken every 3 months, and the evolution of Perthes disease was evaluated by referring to the modified Waldenstr?m staging. In the series of observations, no modified Waldenstr?m IIb stage was found to skip the fragmentation stage. After the healing period, the pelvic orthosis and frog position were evaluated according to the Stulburg classification results, and the ratio of the width of the metaphyseal end of the affected side to the contralateral side and the height of the femoral head epiphysis were measured.Results:The time required to enter stage IIIa, surgical group: range from 0.1 to 1.5 years, with an average of 0.58±0.33 years, conservative group: range from 0.4 to 1.8 years, with an average of 0.96±0.30 years, it takes both to enter the repair phase The time difference was statistically significant ( t=5.259, P<0.05); children whose disease course skipped the fragmentation stage, surgical group: 11 cases (31%), conservative group: 5 cases (16%), the difference is statistically significant ( χ2=22.626, P<0.05). The ratio of the affected side to the uninfected side of the metaphysis: surgical group: range 101%-123%, with an average of 108.0%±6.0%. Conservative group: range 101%-148%, with an average of 115.8%±11.2%. The difference in the ratio between the affected side and the healthy side of the metaphysis was statistically significant ( t=3.450, P<0.05). The ratio of the affected side to the healthy side of the height of the femoral head epiphysis: surgical group: range 61%-96%, with an average of 82.5%±8.2%. Conservative group: range 33%-92%, with an average of 74.7%±1.3%. There was a statistically significant difference in the ratio of the height of the femoral head epiphysis between the affected side and the healthy side ( t=2.921, P<0.05). Stulberg classification, surgical group: Type I hip joints 29 hips, Type II hip joints 6 hips, Type III hips 0 hips; conservative group: Type I hips 16 hips, Type II hips 10 hips, Type III hips 6 hips. There was a statistically significant difference in the Stulberg classification after the two entered stage IV ( Z=3.386, P<0.05). Conclusion:Early surgery changed the natural evolution of Perthes disease. Early surgical treatment shortens the fragmentation period of Perthes disease, so that it enters the repair phase ear-lier, and has the opportunity to skip the late fragmentation period and change its natural course. After healing, the morphological change of the proximal femur is closer to normal.
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Objective:To analyze the risk factors of avascular necrosis (AVN) after closed reduction and spcia casting in treating developmental dysplaisa of the hip (DDH).Methods:The patients with DDH who received closed reduction in our department from January 2016 to December 2017 were retrospectively reviewed. The inclusion criteria included aged at reduction ≥6 months, achieving successful reduction, having complete data with more than 2 years follow-up. A total of 48 cases with 54 hips were included in the present study. Among them, there were 2 males and 46 females, 41 unilateral hips and 13 bilateral hips. The mean age at closed reduction was 16.4±3.8 months (range 6-24 months). The mean follow-up duration was 2.9±1.8 years (range 2.3-4.1 years). Closed reduction was conducted under general anesthesia followed with a spcia cast immobilization. The abduction angle of the cast was recorded. The stability of reduction was evaluated by Ramsey safety zone. The maximum abduction and re-dislocation abduction were recorded. The quality of reduction was evaluated by the medial gap and femoral head coverage on intraoperative arthrography and post-reduction MRI. AVN was diagnosed according to Salter criteria. The risk factors of AVN were analyzed by univariate and binary logistic regression analysis.Results:AVN occurred in 12 hips (22.2%) of 54 hips. International Hip Dysplasia Institute (IHDI) grade and the difference between maximum abduction and cast abduction (Max-Cast abduction) were related to the occurrence of AVN in univariate analysis. The incidence of AVN in hips of IHDI grade 4 (42.9%, 9/21) was significantly higher than that in hips of IHDI grade 3 (9.7%, 3/31) (χ 2=6.007, P=0.018). However, the hips of IHDI grade 3 and 2 (0%, 0/2) presented a similar incidence of AVN (χ 2=0.000, P=1.000). The Max-Cast abduction was -0.7°±5.9° in the AVN group and 6.1°±7.6° in the AVN group ( t=2.125, P=0.038). Finally, IHDI grade ( OR=8.256, P=0.015) and Max-Cast abduction ( OR=0.832, P=0.047) were both independent factors of AVN in multivariate analysis. Conclusion:Most of the hips with AVN are IHDI grade 4 after closed reduction for DDH. The abduction angle in a spica cast could not be significantly related to the occurrence of AVN. However, the risk of AVN might be increased when the cast abduction is close to or beyond the maximum abduction. Safe abduction in the cast should be 5 to 10 degrees less than maximum abduction at least.
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Objective:Comparing with the external fixator technique, investigate the clinical effect of fixator-assisted plating technique for treatment distal femoral valgus deformity in adolescent.Methods:A retrospective analysis of the relevant data of 22 patients (25 limbs) with acute correction of distal femoral valgus deformities from July 2015 to June 2019, according to the difference of the final fixation, they were divided two groups. The fixator-assisted plating group, including 8 patients (9 limbs), 5 boys and 3 girls, 5 left and 2 right, 1 bilateral, the physis were closed in 4 cases and opened in 4 cases, age 14.04±1.99 years (11.7-18 years). The external fixator group, including 14 patients (16 limbs), 6 boys and 8 girls, 8 left and 4 right, 2 bilateral, the physis were closed in 9 cases and opened in 5 cases, age 13.33±1.88 years (10.1-16.5 years). Measuring the mechanical axis deviation (MAD) and the mechanical lateral distal femur angle (mLDFA) in full length standing AP view X-ray of the lower limb pre and post operation. Recording the changed of limb length discrepancy (LLD) before and after surgery and the knee range of motion at 6 weeks, 3 months, 6 months and the last follow up post operation. The Kolcaba comfort status scale was used to evaluate the comfort of two groups at 2 weeks, 6 weeks, 3 months, 6 months and the last follow up. Meanwhile recorded the healing time of osteotomy sites and the complications.Results:The difference in general information between the two groups was not statistically significant. The fixator-assisted plating group followed up mean 26 months (range, 12-40 months), the healing time were 4.00±0.66 months, the mLDFA mean 73.33°±4.12° before surgery and 87.89°±1.69° after surgery and there was significant difference ( t=10.582, P<0.05). The external fixator group followed up mean 36 months (range, 22-42 months), the healing time were 4.00±0.66 months, the mLDFA mean 73.31°±3.95° before surgery and 87.31°±1.54° after surgery and there was significant difference ( t=14.118, P<0.05). The MAD were in the normal range in all patients after surgery, and there were no significant difference about healing time of the osteotomy sites and postoperative mLDFA between the two groups ( t=1.514, P=0.150; t=0.845, P=0.411). Comparing with the knee function, the fixator-assisted plating group was better at 6 weeks, 3 months, 6 months after surgery but there was no difference at the last follow up. Also, the fixator-assisted plating group felt more comfortable at 2 weeks, 6 weeks, 3 months, 6 months and there was no difference at the last follow up. All the patients with external fixator have mild pin sites infection and there were no obvious complications in patients with plate. Conclusion:The fixator-assisted plating technique can accurately correct the valgus deformity with satisfactory healing of the osteotomy in distal femoral compare with the external fixator technique, but the patients feel more comfortable and the knee joint function recovers faster and no risk of pin site infection, the clinical results was satisfactory with fewer complication.
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Objective@#To investigate the reproducibility of the femoral head perfusion index by enhanced MRI and the predictive value of the Herring lateral pillar classification after the progression of early stage of Perthes disease (X-ray modified Waldenström stage Ia, Ib, IIa) to stage IIb.@*Methods@#From October 2016 to November 2018, a total of 30 children with early stage of Perthes disease were enrolled, including 29 males and 1 female, aged 7.5±1.0 years (range 6.3 to 9.5 years). All patients were evolved by unilateral with left 24 cases and 6 cases on the right side. There were 1 case in stage Ia, 16 cases in stage Ib and 13 cases in stage IIa. At the initial evaluation, X-ray films and enhanced MRI were performed. Three observers measured the femoral head perfusion index on the enhanced MRI. The ratio of the pixels in the affected ossified nucleus perfusion area to the pixels in the contralateral femoral skull nucleus was recorded. A total of 30 cases were measured with repeated evaluation at intervals of 1 to 2 weeks. The second measurement was independent of the first measurement results. The average of the two measurements was regarded as the final measurement results. At 3 months follow-up, anteroposterior and Lauenstein frog-lateral radiographs were taken. The follow-up duration was end at the stage IIb progression. The Herring lateral pillar of the femoral head was determined on the X-ray films. The differences in the early MRI femoral head perfusion index were compared between the different lateral column types.@*Results@#The ICC values of the femoral head perfusion index between the three observers were 0.876. The ICC values measured by the 1/3 perfusion index of the lateral femoral head were 0.729. The ICC values of the femoral head perfusion index measured by the same observer at different times were 0.932. The ICC values measured by the 1/3 perfusion index of the lateral femoral head were 0.805. A total of 30 children were followed to stage IIb at 6.49±5.12 months (range 2.3 to 22.1 months). There were 13 cases of type A and type B and 17 cases of type C. The sputum perfusion index of type A and type B was 59.77%±17.12% (range 25%-85%), and that of group C was 13.47%±10.65% (range 2%-23%). The difference between groups was statistically significant (t=8.563, P=0.000). The 1/3 perfusion index of the lateral femoral head of the A and B groups was 75.62%±15.03% (range 50%-95%), while the C type was 22.24%±12.28% (range 5%-45%) with significant difference (t=10.621, P=0.000).@*Conclusion@#The measurement of femoral head perfusion index on enhanced MRI has almost perfect agreement between and within observers across multiple rounds of study. In children with early Perthes disease, enhanced MRI has predictive effect on the Herring lateral pillar classification after progression to stage IIb.
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Objective To compare the difference of X-ray film and MRI in evaluating the degree of early femoral head protrusion of Perthes disease.Methods Data of 38 cases with unilateral modified Waldenstr(o)m necrosis and fragmentation stage from January 2005 to August 2016 were retrospectively analyzed.There were 35 males and 3 females with an average age of 7.2±1.4 years old.There are 21 cases at lefi side,and 17 at right side.14 cases were at necrosis stage,with an average age of 6.9±1.5 years.While 24 cases were at fragmentation stage,with an average age of 7.4±1.4 years old.Both side X-ray films and MRI femoral head extrusion index (X-ray:femoral head bony protruding acetabular part of the outer edge of the bones/femoral skull margin maximum diameter× 100％;MRI:outer edge of bony cartilage protrudes the part of the rim of the acetabular cartilage/the maximum transverse diameter of the cartilage of the femoral head× 100％) were collected.Results The femoral head extrusion index of healthy side was measured on X-ray films and showed an average value of 11.6％±8.2％,and the mean value of affected side was 19.3％±9.8％.The difference between the two sides was statistically significant (t=1 1.550,P=0.000).The femoral head extrusion index of the healthy side was measured on MRI and showed an average value of 20.1％±5.5％,and the mean value of affected side was 27.8％±5.8％.The difference between the two sides was statistically significant (t=5.172,P=0.000).The mean femoral head extrusion index of affected side in necrosis stage of X-ray film was 16.3％± 10.2％,but there were no significant difference compared with the healthy side (13.0％±9.0％) (t=0.369,P=0.719).The mean value of extrusion index of affected side in fragmentation stage was 21.3％±8.8％,while there was 10.8％±1.6％ at the healthy side.The difference was statistically significant (t=4.756,P=0.000).The mean extrusion index of affected side of necrosis stage in MRI was 27.9％± 19.6％,and there was significant difference compared with the healthy side (21.6％± 1.4％) (t=2.651,P=0.018).The mean extrusion index of affected side of disintegration period was 27.8％±5.4％,which was significantly lower than that of healthy side (19.6％± 1.1％).There was statistical significance (t=4.622,P=0.000).There were 17 cases (70.8％) and 22 cases (91.7％) of MRI showed positive sign,and the difference had no statistically significance (P=0.137).Conclusion No significant increasement in femoral head extrusion was observed on the X-ray at necrosis stage in Perthes disease,while MRI showed prominent femoral head extrusion at the acetabular rim.MRI evaluation for evaluating early femoral head extrusion of Perthes disease has better clinical significance.
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Objective To observe the natural outcomes of Graf type Ⅱ a hip dysplasia aged 6 weeks to 3 months,and to explore the indications of treatment.Methods A prospective study was conducted to collect children aged from 6 to 12 weeks with Graf type Ⅱ a dysplasia (50°≤α angle＜60°) but clinically stable hips according to the Early Screening of Developmental Dysplasia of the Hip in Tianjin project from July 2012 to July 2014.Those hips with history of treatment or neuromuscular disorders were excluded.All infants had no treatment initially following with ultrasound surveillance each 2 weeks and radiograph evaluation each at 3,4.5 and 6 months of age.Patients received Pavlik harness or abduction brace treatment if hip dysplasia turned to be type Graf Ⅱ c or worse,or clinical unstable before 6 months;also if hip dysplasia was persistent in radiograph at 6 months.All infants were routinely followed up at 12 and 24 months of age to detect the late cases.The difference of initial α angle,hip abduction,acetabulum index and acetabulum margin morphology (sharp,round or defect) in the pelvic radiograph at 3 month were compared between the treated and untreated groups.Results A total of 238 children (285 hips) were enrolled in the present study,of which there were 25 males and 213 females,193 left and 92 right hips.The average age was 9 weeks (range 6 to 12 weeks).No hip turned to be type Ⅱ c or worse,or clinically unstable.One hundred patients (120 hips) received treatment for persistent dysplasia at 6 months.There had statistically significant difference in initial α angle between the treated and untreated groups (respectively 54.5°±3.3° and 55.6°±2.9°,t=-2.749,P=0.004).In the treated group,there were 47 hips (39.2％,47/120) with limited abduction initially,and 52 hips (43.3％,52/120) with poor acetabular morphology at 3 months.The differences were statistically significant comparing with the untreated group (x2=4.010,P=0.045;x2=14.143,P=0.000).Logistic multivariate regression analysis showed that patients with Graf Ⅱ a-hips (OR=2.908) and poor acetabular morphology hips (OR=2.822) were more likely to receive treatment.Thirty-eight patients (47 hips) received treatment among Graf Ⅱ a+ hips (α angle ≥55°),of which 21 hips (44.7％,21/47)had limited abduction and 31 hips (66.0％,31/47) poor acetabular morphology.The differences were statistically significant comparing with untreated cases (x2=12.073,P=0.001;x2=35.879,P=0.000).Logistic multivariate regression analysis showed that Graf Ⅱ a+ hips with limited hip abduction (OR=4.145) and poor acetabular morphology (OR=10.117) were more likely to receive treatment.Conclusion Graf Ⅱ a dysplasia with clinically stable hips should be treated if α angle ＜55° at 6 weeks or if α angle ≥55° with limited hip abduction or poor acetabular morphology (round or defect) at 3 months.
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Objective To retrospectively analysis the clinical effect of temporary hemiepiphysiodesis for treatment of genu varus and valgus with pathologic physis in children.Methods All of 31 children (52 knees) were included in the study from January 2008 to December 2014,20 boys and 11 girls,the age at the time of surgery from 2 year 4 month to 13 year 4 month,mean 6 year 5 month.12 varus and 19 valgus,10 unilateral and 21 bilateral,41 femurs and 44 tibias.The Mechanichal Axis Deviation (MAD) was evaluated and the mechanical lateral distal femur angle (mLDFA) and medial proximal tibia angle (mMPTA) pre-operation and post-surgery was measured.Judging the efficacy with zone system for assessing mechanical axis based on Stevens,we think the results was satisfactory if the mechanical axis falls in zone ± 1 when removed the eightplate and other was unsatisfactory.We made statistical analysis of children who were corrected satisfactory and observed the change of the width and appearance of the physis.We also made the univariate analysis and Logistical multivariate regression analysis about sex,unilateral or bilateral,surgery age,femur or tibia,varus or valgus and severity of deformity to judge the influencing factors between satisfactory and unsatisfactory.We recorded the knee function and deformity recurrence at last follow up.Results The follow-up period was 2 year 6 month to 9 year 5 month,mean 4 year 1 month,44 knees (84.6％) were corrected satisfactory.The mean value of MAD at pre-surgery and at the time when the plate was removed were (-33.3t7.2) mm and (2.1 ±4.3) mm,mean mLDFA were 102.9°±4.9° and 85.3°±3.8°,mean mMPTA were 81.2°±3.4° and 90.5° ±4.4° in genu varus (21 knees);The meam value of MAD at pre-surgery and at the time when the plate was removed were 29.3±6.8 mm and-4.1±6.5 mm,and the mean mLDFA were 79.5o±5.7° and 88.1°±3.5°,mean mMPTA was 97.0°±4.3° and 87.1°±5.2° in genu valgus (23 knees),which were significant difference.There were 28 knees with physis width asymmetry in the 44 knees pre-operation and improved obviously after-surgery and the appearance became normally.8 knees corrected unsatisfactory included 2 varus and 6 valgus.The severity of deformity was a risk factor that affects efficacy with univariate analysis(t=5.124,P=0.000).Regarding the range of the age,we also did the logistic multivariate regression analysis with results showing that surgery age (OR=1.032) and se verity of deformity (OR=1.335) were related to the outcome.There were 8 knees in the 44 knees which had deformity recurrence and the rate was 19.5％ (8/41,3 knees excluded due to doing the limb lengthening surgery when removing the plate) at last follow up,and the knees function were normal.Conclusion Temporary hemiepiphysiodesis is a minimally invasive and effective method for treatment of genu varus or valgus with pathologic physis in children and could improve the appearance of the physis.The age at surgery and severity of deformity are the risk factors that affect efficacy.The pathological changes persisted could cause complication and deformity recurrence which need follow-up after removal of the plate.
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Objective To evaluate the outcome of Titanium Elatic Intramedullary Nail (TEINs) for treatment of lengthunstable femoral shaft fracture of children.Methods Retrospectively analyze the data of total of 21 children with length-unstable femoral shaft fractures,from December 2011 to June 2014,were treated with TEINs and end caps.This study involved 15 boys and 6 girls,with age ranged from 5 years and 6 months to 10 years and 10 months,whose average age was 7 years and 5 months.Firstly children were treated with traction for 3-7 days,with traction weight of 1/4 to 1/6 of the weight.After that,shortening and angular deformity were significantly corrected.Then surgeries of close reduction and internal fixation with TEINs were done in general anesthesia.TEINs were supported with double nail C shape.The lateral tip of TEIN located near the epiphyseal plate of greater trochanter,and the medial tip near the epiphyseal plate of femur head.Cut the tail of TEINs,set and screw the end caps into cortex,keeping the tail of TEINs and fracture fixed.Spica casting was used for 4 weeks after operation.The last follow-up time was 2 years,and the follow up results were analyzed.Results 21 children were followed up ranged from 22 to 26 months,with the mean follow up 23.4 months.Remove the spica casting and bear loading at 4 weeks after operation.All fractures healed,with healing time of 5 to 8 weeks (an average of 6.2 weeks).At the last follow-up,the limb force line was good with no angular deformity.Femur overgrew 4.2-21.1 mm,with an average of 6.1 mm.At the last follow-up,the patients were evaluated with Harris score,and the excellent and good rate was 100％.No case of TEINs push-out,limited hip mobility,fracture nonunion,delayed healing or other complications was found.Only 1 case got a mild lameness.All parents were satisfied with their outcome.Conclution TEINs and end caps are effective methods for the length-unstable femoral shaft fracture in children.These results indicated that the risk of TEINs push-out can be reduced.
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Objective To compare the early treatment results of Pavlik harness and closed reduction plus spica cast?ing in treating developmental dislocation of the hips (DDH). Methods The patients with GrafⅢ/Ⅳtype DDH diagnosed by ul?trasound in our hospital were analyzed retrospectively from January 2009 to December 2013. The subjects with intact clinical and radiologic data and more than 2 years follow?up were included. The present study included 257 patients (298 hips), 31 male and 226 female, with the average age of 74.1±39.2 d (from 30 to 159 d). Pavlik harness underwent in 190, while 67 cases were treated with closed reduction plus spica casting. Acetabular index (AI), Wiberg OE angle (point O was the middle point of proximal me?taphyseal border) and Smith instability index (SI, SI?c:the lateral displacement index, SI?h:the vertical displacement index) on the pelvic X?ray film at 2-3 years of age after successful early treatment were recorded. Femoral head avascular necrosis (AVN) was diagnosed according to the Salter criteria. Results The success rate of reduction of closed reduction was significantly higher than Pavlik harness (97.5% vs. 69.9%, χ2=0.353, P=0.000). There was no significant difference in the incidence of AVN be?tween the closed reduction and Pavlik harness (6.6% vs. 4.6%, χ2=0.106, P=0.745). For GrafⅢ type DDH, the success rate of reduction of Pavlik harness and closed reduction were 80.7% and 98.4% respectively (χ2=11.248, P=0.001), while the Pavlik harness group had significantly worse results of AI, OE and SI?c at the age of 2-3 years (Pavlik harness: 22.9°±3.7°, 16.5°± 6.3° and 0.74 ± 0.06; closed reduction: 21.4° ± 3.4° , 18.9° ± 3.6° and 0.72 ± 0.03; P<0.05). For GrafⅣ type DDH, the success rate of reduction of Pavlik harness was much less than closed reduction (25.6% vs. 94.4%, χ2=24.231, P=0.001), with signifi?cantly worse results of OE at the age of 2-3 years (16.0°±4.1° vs. 18.6°±4.5°, t=-2.141, P=0.038). Conclusion Pavlik har?ness has limitations in treating GrafⅢ/Ⅳtype DDH, with lower success rate of reduction for GrafⅣtype DDH. Closed reduction plus spica casting has better clinical results than Pavlik harness in success rate of reduction and subsequent hip development with? out the additional risk of AVN.
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Objective To retrospectively review long?term results of developmental dislocation of the hip patients treated with open reduction and Salter pelvic osteotomy, and to analyze the potential risk factors. Methods Sixty?eight developmental dislocation of the hip cases (81 hips) were treated with open reduction and Salter pelvic osteotomy from September 1992 to Octo?ber 2002, 45 cases (52 hips) were followed up to skeletal maturity. None had undergone other treatment before the key surgery. Some cases received skeleton traction before surgery. The radiographic and functional results were assessed at last follow?up. The possible relevant factors for unsatisfactory outcome were analyzed. The correlation between type ⅡAVN and the coverage rate of the femoral head were evaluated. Results The mean age at surgery was 2.5 years (ranged from 1.4 to 5.3 years). At last follow?up, 44 hips (84.6%) had excellent or good functional results. 23 hips (44.2%) had avascular necrosis of varying severity, of which 16 hips were typeⅡ. There was significant relevance between the AVN severity and the Severin classification result (P=0.018). Theover correctionhips, that were overcorrected during surgery, were more likely to get severe type AVN ( P=0.037). There was no correlation between TypeⅡAVN with uncoverage according to CE angle and Reimers index (P=0.457, 0.308 respectively). Con?clusion 1) Satisfactory functional and radiographic results could be expected in developmental dislocation of the hip cases with?out AVN;2) High risk of AVN existed in the late diagnosised hips that underwent open reduction and Salter pelvic osteotomy, typeⅡwas the most common type;3) TypeⅡAVN was not a predictor for progressive femoral head coverage deficiency;4)Over cor?rectionin Salter pelvic osteotomy was related with severe type AVN which should be avoided.
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Objective To analyze the natural development of the residual subluxation after early close reduction for developmental dislocation of the hip,and to seek the early surgical timing and indication.Methods The research included 36 patients (48 hips) born before January 2000 who showed residual subluxation after close reduction in one year.All of patients had serial X-ray radiographs at every follow-up point.The radiographs were assessed using acetabular index (AI),Reimers index,center edge (CE) angle and the orientation of the sourcil of the acetabulum.The last follow-up results were evaluated according to the Severin classification,and Severin grade Ⅰ and Ⅱ were defined as satisfactory group and Severin grade Ⅲ and Ⅳ as unsatisfactory group.Then we compared and analyzed the serial radiological parameters between satisfactory and unsatisfactory groups.Results The mean age at close reduction was 1.6 years.At the last follow-up,the mean age was 13.8 years.The satisfactory group comprised 18 hips (37％),whereas the unsatisfactory group comprised 30 hips (63％).At the age of three to four years,there was a significant difference between the two groups in the Reimers index (34.4％±4.5％ vs.43.0％±4.6％,P ＜ 0.05).And at four to five years old,there were significant differences for both Reimers index and CE angle (29.3％ ±7.2％ vs.40.0％±6.2％,P ＜ 0.05; 21.0°±5.5° vs.10.6°±5.2°,P ＜ 0.05).When the Reimers index ＞38％ at the age of three to four years,18 of 18 hips fell into the unsatisfactory group.And when Reimers index ＞33％ at the age of four to five years,26 of 30 hips had unsatisfactory result,and in addition to that the sourcil orientation was upward,26 of 26 hips fell into the unsatisfactory group.Conclusion To avoid early osteoarthritis,surgical correction for residual subluxation was recommended if the Reimers index ＞38％ at the age of three to four years or the Reimers index ＞33％ with the sourcil upward at the age of four to five years.
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Objective To evaluate the effect of greater trochanteric transfer for the treatment of coxa brevis in children and adolescents.Methods From August 2005 to January 2011,twenty patients (22 hips)with coxa brevis underwent greater trochanteric transfer.Among them 18 patients (20 hips) were available for evaluation,including 4 boys and 14 girls,with an average age of 11.4 years (range,7.5-15.0 years) at operation.Five cases (6 hips) were caused by Perthes disease,and 13 cases (14 hips) were caused by developmental dysplasia of hip.Four patients (4 hips) had undergone greater trochanteric epiphyseodesis ever before.All patients were fixed with tension screw after the deformity was corrected during the operation.After operation,the human plaster spica was used for 6 weeks in all patients.Results All patients were followed up for 14 to 79 months (average,31 months).At the last follow-up,fatigue or pain in the hips disappeared or improved in 13 patients.Sixteen patients had limping and positive Trendelenburg sign preoperatively,at the last follow-up 9 patients got improvement.Twelve patients (13 hips) had limitation of abduction of the hip,the average range of abduction was 25.38°±1.20°,which was improved to 45.38°±1.05° at the last follow-up.The average articulotrochanteric distance and ratio of the distance from the greater trochanter tip to femoral head center and the radius of the femoral head at the last follow-up was (17.47+3.14)mm and 2.10±0.21,respectively,there were statistical differences compared with those before operation [(-2.89±4.62) mm and 1.59±0.22,respectiovely].The average leg-length discrepancy at the last follow-up was (0.78t±0.26) cm,which had on statistical differences compared with that [(0.83 ±0.33) cm]before operation.Conclusion Greater trochanteric transfer for the treatment of coxa brevis in children and adolescents could improve the clinical symptom,recover the normal anatomy of the proximal femoral,restore the hip biomechanics environment,but could uot improve the leg-length discrepancy.
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ObjectiveTo evaluate and compare the outcomes of missed Monteggia fractures in children treated with ulnar angulation-distraction osteotomy and plate fixation or external fixation.Methods Nineteen patients,including 11 boys and 8 girls who presented with missed Monteggia fracture,were reviewed from July 2005 to June 2011.Twelve children (Group A) were treated with ulna angulation osteotomy and plate fixation,and 7 eases(Group B) with ulna angulation-distraction osteotomy and external fixator.Thirteen patients were classified as type Bado Ⅰ,and six as type Bado Ⅲ.The age,the delay from injury to surgery,complications,elbow and forearm function,and the healing time of the osteotomy were compared.ResultsAll 19 patients were followed up.The duration of missed dislocation was from 6 to 36 months (mean,10 months).Redislocation of the radiocapitellar joint occurred after surgery in one case in group A.Forearm compartment syndrome occurred in one case after surgery in group B.All patients,except one,regained full elbow flexion in group A and B,various forearm pronation limitation were noted in all patients (mean,15°).The average healing of osteotomy of group A and B was 8 weeks(6-15 weeks) and 22 weeks (10-44 weeks).ConclusionThe ulnar angulation-distraction osteotomy could correct the ulnar deformity in children of missed Monteggia fractures,which is the key issue to be corrected.Both of the fixation strategies can obtain the same treatment results.Preoperative assessment is most important,plate internal fixation was recommended for young age and short delay cases,on the contrary,we prefer to choose external fixator.