Cervical rib--preliminary data on diagnosis by ultrasound.

AIM: To determine whether ultrasound is useful in detecting cervical rib. Ultrasound was used to diagnose cervical rib in five patients with neck pain and the findings were compared to those from plain radiography. MATERIALS AND METHODS: Ultrasound was used in 34 patients with pain and stiffness in the neck region. The area concerned was scanned sonographically in both longitudinal and transverse planes. In the sitting position, plain radiographs were obtained after ultrasound examination for comparison and verification. The contralateral side of the neck was used as control. RESULTS: Sonography revealed abnormalities in five patients. Sonography and X-ray confirmed the diagnosis of cervical rib in six patients, whereas one patient had a lipoma of the neck. CONCLUSION: Sonography is an additional and easily available diagnostic modality for the detection of cervical rib in cases of pain and stiffness in the neck region.

Ultrasonographic findings in patients with olecranon bursitis.

BACKGROUND: Musculoskeletal ultrasonography (U.S.) is an important imaging technique in the diagnosis of olecranon bursitis, especially for early manifestation. It allows sensitive detection of small fluid collections as well as for differentiation between soft tissue and bone lesions. U.S. examination allows detection of effusions, synovial proliferation, calcifications, loose bodies, rheumatoid nodules, gout tophi and septic processes. AIM: To assess the role of ultrasonography in the diagnosis and management of patients with olecranon bursitis. METHODS: Ultrasound was used in 34 patients with swelling above the olecranon. The opposite asymptomatic side served as a control group. RESULTS: 20 patients demonstrated increased fluid collection in the olecranon bursa. 5 had synovial proliferation, 2 cases showed loose body, 5 patients revealed markedly increased blood flow consistent with inflammation, 2 patients had triceps tendonitis with calcifications. CONCLUSIONS: Sonography is an extremely effective tool for the diagnosis of soft tissue lesions in the olecranon area.

Sonographic imaging of mallet finger.

UNLABELLED: Mallet finger is a flexion deformity of the distal interphalangeal joint (DIPJ) caused by a disruption of the extensor mechanism. The deformity can b e caused by active trauma, minor trauma or other conditions like rheumatoid arthritis or osteoarthritis. AIM: To describe the sonographic findings in mallet finger. METHOD: We performed sonographic examination on thirty patients with traumatic mallet finger, on thirty control patients where we examined the same finger in the opposite hand (,) and thirty patients with rheumatoid arthritis or osteoarthritis and flexion deformity. RESULTS: We found four criteria for traumatic mallet finger which included: discontinuity of the extensor tendon with partial or complete tear, avulsion fracture, no real time movements of the extensor tendon, and fluid in the region of insertion of the extensor tendon. CONCLUSION: Sonographic examination of patients with traumatic mallet finger is an important diagnostic tool and can differentiate between traumatic mallet finger and flexion deformity of rheumatoid arthritis or osteoarthritis.

Total hip arthroplasty in patients younger than 30 years of age following developmental dysplasia of hip (DDH) in infancy.

Total hip arthroplasty (THA) in young patients is a controversial subject, due to the high failure rates reported in the literature, and even more so in patients with a history of developmental dysplasia of the hip (DDH). A group of 11 patients, all under the age of 30 years at the time of surgery, underwent THA due to congenital dislocation of the hip. Mean age at the time of operation was 23.3 years (range 16-30 years). The mean follow-up period was 9 years (range 3-14 years). The mean preoperative Harris' hip score (HHS) was 56.9 compared with the postoperative HHS of 90.6. Due to aseptic loosening of the cup, 4 patients underwent successful revision arthroplasty. These encouraging medium-term results in our patients suggest that THA may be a good solution for young patients suffering from coxarthrosis due to DDH, at least temporarily, especially when other alternatives, such as arthrodesis or resection arthroplasty, are considered.

Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature.

Sonographic examination of the knee has been proposed by several authors in the past as a simple and reliable method to diagnose Osgood-Schlatter disease (OSD). Ultrasound was used to compare the knees of 25 boys and 10 girls with typical OSD with 35 symptom-free knees of an aged-matched group of children. Based on recorded data, patients were categorized (one affected knee in each individual) according to the classification system proposed by De Flaviis et al. in 1989. The results included the following pathological findings: pretibial swelling, fragmentation of the ossification center, insertional thickening of the patellar tendon, and excessive fluid collection in the infrapatellar bursa. Of our patients, 26% fell into the type 1 category, 43% were type 2, 20% type 3, and 11% type 4. This distribution of cases was found to be statistically similar to the initial findings reported by De Flaviis and colleagues. This study therefore supports the validity and reproducibility of their classification method for the ultrasonographic evaluation of children with OSD. This is only the first step, and further assessment of this classification is still required to elucidate its clinical as well as its prognostic value.

Achilles tendon pain and related pathologies: diagnosis by ultrasonography.

BACKGROUND: When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays. OBJECTIVES: To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon. METHODS: We conducted a retrospective review of patients presenting at our orthopedic clinics. RESULTS: Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions; a complete rupture in two patients (5%); a partial rupture of the Achilles tendon in 3 (7%); various degrees of calcification of the tendon in 7 (17%); and peritendinous lesions discerned by the tendon's hypoechoic regions with disorganized arrangement of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +/- 2.7 mm, while normal tendons measured 5.2 +/- 0.8 mm (P < 0.001). CONCLUSION: As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.

Ultrasonography: an imaging modality enabling the diagnosis of bipartite patella.

Ultrasound was used to diagnose bipartite patella in seven adolescents with anterior knee pain, and the findings were compared to those from plain radiography and to those of a group of asymptomatic subjects. In all affected individuals the quadriceps and patellar tendons appeared normal on ultrasound. Sonographic examination of the patella demonstrated an irregularity of the bony contour with occurrence of a cleft between the main part of the patellar body and the large superolateral accessory ossicle. The signal detected in the interface between bones was less echogenic than bone reflecting its fibrocartilaginous nature. The correlation with conventional radiography was absolute, as was the inter- and intraobserver reliability. Ultrasound is thus proposed as a simple and reliable imaging modality in bipartite patella. We do not believe that it should replace the initial radiographic, but it can be used to evaluate the contralateral knee for bilaterality and as an adjunct to therapeutic procedures such as local injections to increase the accuracy of treatment.

Hemichondrodiastasis for the treatment of genu varum deformity associated with bone dysplasias.

Hemichondrodiastasis has been reported for treatment of angular deformities in children close to skeletal maturity. The use of distraction through the physis in younger children was not recommended. The authors report three children 3 to 7 years of age who underwent bilateral proximal tibial hemichondrodiastasis for correction of genu varum due to bone dysplasia. Ilizarov external fixators were applied in all cases. The patients underwent gradual angular correction at a rate of 0.5 mm/d. Distraction was continued until a normal mechanical axis was achieved. Normal alignment was achieved in two patients and slight overcorrection in the third. The patients were followed for 3 to 11 years, and no adverse affects on the physis were identified. This is the first report of physeal distraction in patients this young. Our results are good, and we believe that hemichondrodiastasis can be safely used for correction of angular deformities in young children.

Total hip arthroplasty after childhood septic hip in patients younger than 25 years of age.

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14-25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.

Prenatal diagnosis of distal arthrogryposis type 1.

A 23-year-old woman, gravida 1 parity 0, was referred for routine ultrasound examination at 23 weeks gestation. Fetal anatomy was normal. However, both hands demonstrated clasped thumbs without extension. Repeated ultrasound examination verified the bilateral hands posture. The position of the hands did not change following sound stimulation. The child was diagnosed as distal arthrogryposis type 1. Prenatal counselling by the pediatric orthopedic surgeon, geneticist and gynecologist, was provided, to inform the parents on the probable outcome of the fetus and the hands. The parents were advised to continue with the pregnancy. A 1,975-g healthy boy was delivered by spontaneous vaginal delivery. Neonatal examination confirmed the prenatal diagnosis of arthrogryposis type 1. Following reconstructive surgery the child functions well with both his hands.

Effect of proximal phalangeal epiphysiodesis in the treatment of macrodactyly.

The recommended treatment for macrodactyly of the foot will often include epiphysiodesis of the proximal phalanx in an attempt to halt further longitudinal growth of the toe. Nine patients who underwent open epiphysiodesis and debulking of the excess soft tissues involving 11 toes were reviewed to evaluate the effectiveness of this procedure. In 9 of 11 toes, overall length of the proximal phalanx did not change after surgery. Two toes demonstrated continued growth; one of these toes underwent a repeat epiphysiodesis of the phalanx, and the other foot underwent epiphysiodesis of the affected metatarsal. Overall, this surgical approach led to radiographic results that satisfied the surgical goals.

[Leg-lengthening for length inequality].

32 patients (age range 1.5-22 years) were treated for leg-length discrepancy. 39 lengthening procedures were performed of which 36 involved gradual distraction, in 2 cases chondrodiasthesis was used, and 1 had 1-step elongation. Gradual distraction was done according to Ilizarov, including corticotomy and a 1-week delay before the initiation of distraction. In 33 cases Wagner's external fixator was used, in 2 Ilizarov frame and in 1 an orthofix fixator. There was complete clinical and radiologic union in all but 1 case. Significant correction of leg-length discrepancy and equalization of leg-length was achieved in most patients. In some growing patients over-correction was successfully achieved. The most prevalent complications were pin-site problems, axis deviation, joint subluxation and joint contractures. At latest follow-up most of these complications had disappeared. 91% of the patients either functioned normal or were only mildly limited.

Orthopaedic long term aspects of bladder exstrophy.

This study evaluates long term orthopaedic aspects of children with bladder exstrophy who were operated on using different techniques and at different ages. Data were accumulated from 20 patients with an age range of 2 to 29 years (average, 13 years). Fourteen patients underwent pelvic osteotomy. Interviews and physical examinations confirmed that, in the long term, children with classical bladder exstrophy do not have significant orthopaedic problems or disability, whether or not they underwent pelvic osteotomy. Radiographic imaging showed normal hip joint configuration with marked pubic diastasis. There were no clinical problems associated with the diastasis. Pelvic computed tomography studies in 7 patients showed marked remodeling of the femora and acetabula. Radiographs of the spine showed a curve in 7 (47%) of the patients, but in only 3 cases was the curve larger than 10 degrees. Pelvic osteotomy is indicated during surgical correction of bladder exstrophy to facilitate closure of the abdominal wall to prevent postoperative wound dehiscence and possibly achieve better urinary control in older age. However, there is no clear indication for pelvic osteotomy from an orthopaedic point of view.

Fresh osteochondral allografts at the knee joint: good functional results in a follow-up study of more than 15 years.

The treatment of deep chondral defects at the knee joint poses major difficulties and challenges to the orthopaedic surgeon, particularly in young patients for whom solutions like total or hemi-joint arthroplasty are not recommended, because of their limited durability. Biological resurfacing with materials such as perichondrium, periosteal allografts, and cultured chondrocytes is still at the experimental stage and there has been limited clinical validation. Since 1978, we have successfully used fresh osteochondral ('shell') allografts for the treatment of selected patients with a chondral defect at the knee joint. These grafts, implanted mainly in young patients, have proved durable and have provided good functional results for more than 15 years, as shown by an average of 84.6 in the Hospital for Special Surgery (HSS) Knee Score. The operative technique and results of long-term follow-up of patients receiving fresh, osteochondral ('shell') allografts are presented and discussed.