Preoperative and Postoperative, Three-dimensional Gait Analysis in Surgically Treated Patients With High-grade Spondylolisthesis.

BACKGROUND: High-grade spondylolisthesis (HGS) (Myerding grade III-V) in adolescents can lead to a marked alteration of gait pattern and maybe the presenting symptom in these patients. This characteristic gait pattern in patients with HGS has been referred to as the "pelvic waddle." Modern 3-dimensional (3D) gait analysis serves an important tool to objectively analyze the different components of this characteristic gait preoperatively and postoperatively and is an objective measure of postoperative improvement.This study demonstrates the use of 3D gait analysis preoperatively and postoperatively in a cohort of 4 consecutive patients with HGS treated surgically at a single tertiary referral center and utilize this to objectively evaluate outcome of surgical treatment in these patients. This has not been reported previously in a cohort of patients. METHODS: This is a prospective analysis of patients with HGS who underwent surgical intervention for spondylolisthesis at a single institution. Patient demographics, clinical, and radiologic assessment were recorded, and all patients underwent 3D gait analysis before and after surgical intervention. Kinetic, kinematic, and spatial parameters were recorded preoperatively and postoperatively for all patients. This allowed the outcome of change in gait deviation index, before and after surgical treatment, to be evaluated. RESULTS: We were able to review complete records of 4 adolescent patients who underwent surgical treatment for HGS. Mean age at surgery was 13.5 years with a minimum follow-up of 2.5 years postoperatively (average 40 mo). Preoperative gait analysis revealed marked posterior pelvic tilt in 2 patients, reduced hip and knee extension in all 4 patients and external foot progression in 3 of the 4 patients. Along with an observed improvement in gait, there was an objective improvement in gait parameters postoperatively in all 4 patients. Gait deviation index score improved significantly from 78.9 to 101.3 (mean). CONCLUSIONS: Preoperative gait abnormalities exist in HGS and can be objectively analyzed with gait analysis. Surgical intervention may successfully resolve these gait abnormalities and gait analysis is a useful tool to assess the outcome of surgery and quantify an otherwise intangible benefit of surgical intervention. LEVEL OF EVIDENCE: Level IV-case series.

Stability-based assessment of Monteggia-type injuries predicts failure of treatment.

Paediatric Monteggia-type injuries are complicated by treatment failure and posterior interosseous nerve palsy, without reliable predictive indicators. Outcome is considered to be good, with little patient-reported evidence. We propose novel radiographic parameters. A total of 33 Monteggia-type injuries were analysed. Posterior interosseous nerve palsy was strongly predicted by the Radial Head Displacement Index. The presence of two or more of three novel instability markers was associated strongly with treatment failure. Patient-reported outcome measures were almost uniformly excellent. We advocate the use of a new, inclusive, stability-based classification of Monteggia-type injuries to predict patients who require accurate internal fixation.

The height-to-width index for the assessment of femoral head deformity following osteonecrosis in the treatment of developmental dysplasia.

BACKGROUND: The principal complications that follow the treatment of developmental dysplasia of the hip are redislocation and growth disturbance of the femoral head and neck as a result of osteonecrosis of the femoral epiphysis. Growth disturbance secondary to osteonecrosis is difficult to determine until long after the treatment episode has passed. Consequently, the treating surgeon has little early feedback regarding the long-term consequences of management interventions. We therefore sought to devise a quantitative method to identify early evidence of growth disturbance related to osteonecrosis. METHODS: The width and height of the epiphyses were measured on anteroposterior radiographs of the pelvis made twelve to eighteen months after successful closed reduction and on the latest available radiograph for each patient (mean age, 8.6 years). The epiphyseal index was calculated by dividing the height by the width. The radiographs were also scored for osteonecrosis with use of the Kalamchi and MacEwen classification system and were also assessed for sphericity with use of Mose rings. RESULTS: Forty-seven patients with late-presenting developmental dysplasia of the hip who subsequently underwent successful closed reduction were included. An index of <0.357 on the twelve to eighteen-month post-treatment radiograph strongly predicted the development of a nonspherical femoral head on the latest radiograph (sensitivity, 0.83; specificity, 0.95; positive predictive value, 0.55; and negative predictive value, 0.99). CONCLUSIONS: The height-to-width index appears to be a simple and quantifiable measurement of the severity of growth disturbance as a consequence of osteonecrosis following treatment for developmental dysplasia of the hip. It is predictive of asphericity at the time of intermediate-term follow-up and appears likely to predict asphericity at maturity, but this must be confirmed with follow-up to maturity. Unlike the currently used methods of assessing osteonecrosis, the index allows for the quantifiable evaluation of growth disturbance within a few years after the corrective procedure.

Long-term follow-up of Ethibloc injection in aneurysmal bone cysts.

The aim of this study is to assess the long-term results of Ethibloc injection in aneurysmal bone cysts (ABC). Thirty-three patients with ABC were treated with computed tomography-guided percutaneous injection of Ethibloc into the cyst cavity. Twenty-two patients had Ethibloc injection as primary treatment and 11 patients had presented to us with recurrence after previous procedures including steroid injection, bone marrow injection, curettage bone grafting and various other surgical procedures. The mean follow-up was 54 (22-90) months. Symptoms were relieved in all patients. Two patients were lost to follow-up. Eighteen (58%) of the 31 patients followed, had complete resolution of the lesion, 11 (35.5%) patients had partial healing (asymptomatic residual nonprogressive lytic areas). Two (6.5%) patients showed recurrence in the proximal humerus during the follow-up. They are under follow-up but asymptomatic and another two patients encountered more significant complications after the procedure. Ethibloc injection is a relatively simple, minimally invasive alternative procedure for the treatment of ABC, and makes open operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of ABC's excluding spinal lesions as shown by our largest and longest follow-up study.

Treatment of severely displaced proximal humeral fractures in children with elastic stable intramedullary nailing.

We report on our 8-year experience of using elastic stable intramedullary nailing for severely displaced proximal humeral fractures in children. Fourteen patients (mean age 13.4 years) with seven epiphyseal and seven metaphyseal fractures underwent intramedullary nailing, using single nail fixation in 12 cases. Clinical and radiological healing was achieved at 2.4 and 3.2 months, respectively. Complications included temporary shoulder and elbow stiffness in one and four cases, respectively, one nail breakage at removal, two cases with minor humeral shortening, and two cases with minor varus deformity. At the final (14.6-month) follow up all patients had a symptom-free full range of motion. Elastic stable intramedullary nailing is a valid method of treating severely displaced proximal humeral fractures in children.