Does transepiphyseal drilling and closure of the greater trochanter in early Legg-Calve-Perthes disease improve natural history?

PURPOSE: There is no consensus regarding treatment of Legg-Calve-Perthes disease (LCPD). The most common sequel of the disease is coxa breva and overgrowth of the greater trochanter (GT). Our purpose was to examine the effectiveness of transepiphyseal drilling combined with closure of the GT apophysis in patients with LCPD. METHODS: During 2013-2018, we treated 16 consecutive cases of LCPD. Average age was 7.5 (range 6-10) years; nine patients were in early fragmentation, five in late fragmentation and one in reossification stages. Treatment protocol included hip arthrography, percutaneous drilling of the femoral head epiphysis, percutaneous tenotomy of adductor longus and epiphysiodesis of the GT apophysis. RESULTS: Mean follow-up was 38 months. One patient was lost to follow-up. All patients had a limp prior to surgery. However, at latest follow-up, 10/15 patients had no limp, 11 patients had substantial improvement in hip range of motion. On radiographs, nine patients had Stulberg type 1-2, one type 3 and five type 4-5. There was no change in the epiphysio-trochanteric distance in any patient. Eight out of nine patients treated in the early fragmentation stage had good clinical and radiographic outcome. Most patients treated in late fragmentation stage had Stulberg 4-5 hip and required additional procedures. CONCLUSIONS: Based on our preliminary experience, our protocol can be effective in the treatment of patients with LCPD in the initial or early fragmentation stages by improving the clinical and radiographic outcomes of the disease. This minimally invasive approach does not compromise any future treatment options. LEVEL OF EVIDENCE: IV.

Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery.

Over the past two decades, the Ponseti 'conservative' (non-surgical) method of clubfoot treatment has been almost universally adopted worldwide. As a result, the need for operative treatment for clubfoot has decreased dramatically. However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis anterior tendon transfer. Additionally, relapses are common, sometimes necessitating further surgical intervention. Relapses are recurrent deformities in previously well corrected feet. Residual deformities may be defined as persistent deformities in incompletely corrected feet. In addition, in many parts of the developing world, neglected clubfoot is still a major challenge. Many neglected feet can be treated with Ponseti principles, particularly in younger children. However, in older children and adults, surgical approaches are more likely to be needed. Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Sometimes, despite excellent treatment, and perfect adherence to the bracing protocols, there are still relapses, related to intrinsic muscle imbalance. We describe several solutions that include reinstitution of Ponseti casting and 'á la carte' operative treatment. As an alternative for particularly stubborn cases, application of a hexapod external fixator can be a powerful tool. In order to be a full-service clubfoot specialist, and not only a Ponseti practitioner, one must have in their toolbox the full gamut of adjunctive surgical options. LEVEL OF EVIDENCE: V.

Avascular necrosis of the 1st metatarsal head.

Idiopathic avascular necrosis of first metatarsophalangeal head in child is unique condition not described in literature in past exlude one case. It seems to be part of avascular bone necrosis syndromes, like Freiberg disease, Sever disease etc. and the same principles of treatment are appropriate in AVN of 1st MTT head. We describe the case of bilateral AVN of 1st MTT head treated conservatively with complete cure.

Delayed rupture of the extensor pollicis longus tendon following intramedullary nailing of a radial fracture in a child.

This case reports another cause of delayed rupture of the extensor pollicis longus tendon in children following radial fracture management, due to attrition over a protruding nail end after elastic stable intramedullary nailing using the technique recommended to allow nail removal.

Low dose-rate interstitial brachytherapy in soft tissue sarcomas.

Purpose. To assess the effectiveness of Ir-192 interstitial brachytherapy as an adjunct to wide local excision as a functionsaving strategy for soft tissue sarcomas.Subjects and methods. From September 1993 to April 1998, 20 consecutive patients diagnosed with soft tissue sarcomas were treated with a combination of wide local excision and interstitial brachytherapy. In 16 patients brachytherapy was done as an intraoperative procedure, while in four, the implant was performed post-operatively under local anesthesia. Eleven of the 20 patients also received external beam radiotherapy following the implant.Results. After a mean follow-up of 27 months (4-54) the local control rate for all 20 patients was 85% (17/20). In the 16 patients who had an intra-operative implant, local control was 94% (15/16). In the four patients who underwent a post-operative implant, local control was 50% (2/4). Actuarial 5-year survival was 90%. There were three cases (15%) of severe local complications.Conclusions. Wide local excision followed by low dose rate intersitital brachytherapy have yielded a 85% local control rate in 20 patients with soft tissue sarcomas. Local control rates were higher when the implants were done as an intra-operative procedure than as a post-operative one.

Lysosomal hydrolases are present in melanosomes and are elevated in melanizing cells.

Melanosomes, the subcellular site of melanin synthesis and deposition, may be related to the endolysosomal lineage of organelles. To determine if melanosomes contain lysosomal hydrolases, we examined the subcellular distribution of five of these enzymes in melanocytes cultured from C57BL/6J mice. Analyses of Percoll gradient density centrifugations demonstrated that beta-hexosaminidase, beta-galactosidase, beta-glucuronidase, and cathepsins B and L all co-sedimented with tyrosinase-rich densely sedimenting melanosomes. The melanosomal distribution of these enzymes was confirmed in studies of melanocytes cultured from albino mice and of melanocytes rendered amelanotic by transfection with the v-rasHa oncogene (which lack dense, melanized melanosomes). In these cells, only a less dense peak of activity for each hydrolase was present. The level of each hydrolase was elevated in black cells when compared with albino cells. Metabolic labeling studies confirmed that the increase in beta-glucuronidase in black versus albino cells resulted mainly from increased synthesis of this enzyme. The data suggest that melanosomes represent specialized lysosomes present within melanocytes, that they contain a broad array of lysosomal hydrolases, and that the levels of these hydrolases are elevated in cells actively engaged in pigment production.