Surgical management of moderate adolescent idiopathic scoliosis with ApiFix®: a short peri- apical fixation followed by post-operative curve reduction with exercises.

Surgery in adolescent idiopathic scoliosis (AIS) is a major operative intervention where 10-12 vertebrae are instrumented and fused. A smaller motion preserving surgery would be more desirable for these otherwise healthy adolescents. The ApiFix® system is a novel less invasive short segment pedicle screw based instrumentation inserted around the apex of the main curve. The system has a ratchet mechanism that enables gradual postoperative device elongation and curve correction. The ratchet is activated by performing specific spinal exercises. The unique features of the device allow curve correction without fusion. The system which has a CE approval was employed in adolescents with main thoracic curves. More than a dozen of ApiFix surgeries have been performed so far. The preoperative Cobb angle was 45° ± 8, and 25° ± 8 at final follow up. The following is a report on three adolescent females aged 13-16 years with curves between 43°-53° and Risser sign of 1-4 who underwent surgery with ApiFix®. Two pedicle screws were inserted around the curve apex and the ratchet based device with polyaxial ring connectors was attached to the screws. No fusion attempt was made. Operative time was around one hour. Two weeks after surgery the patients were instructed to perform Schroth like daily exercises with the aim of rod elongation and gradual curve correction. Patients were followed between 6 months to 2 years. Curves were reduced and maintained between 22- 33°. Patients were pain free and were able to perform their spinal exercises. Postoperative gradual elongation of the device was observed. No screw loosening or rod breakage were observed. No adding on or curve progression was seen. Three factors may contribute to the ApiFix® success: polyaxial connections that prevent mechanical failure, gradual curve correction by spinal motion and spinal growth modulation. The ApiFix® system allows managing moderate AIS with a simple and minor surgical intervention. Recovery is rapid with negligible motion loss. It allows gradual and safe curve correction with high patient satisfaction. It may also serve as an internal brace for AIS.

Diastematomyelia in congenital scoliosis: a report of two cases.

INTRODUCTION: Even if diastematomyelia is a rare condition, it always has to be identified in case of diagnosing and treating a case of congenital scoliosis. The consequence of missing the diagnosis of such a malformation may be devastating to the involved patient. This paper wants once again to make aware the physicians of the eventual presence of a spinal dysraphic malformation when dealing with a congenital spinal malformation. METHODS: The presence of diastematomyelia was noticed in two of our cases, one with congenital scoliosis and another with congenital kyphoscoliosis. First of all in these cases, we performed the resection of the bony septum, followed by spinal fusion in a single-stage surgical procedure. We noticed no complications during and after surgery related to the resection of the bony septum. RESULTS: In both patients, we obtained partial correction and stabilization of the congenital spinal malformation after a safe excision of the bony septum. CONCLUSIONS: Diastematomyelia is a rare condition. It has to be taken into consideration when dealing with a congenital scoliosis. The first step in the surgical procedure has to be the resection of the diastematomyelic septum. In case of a scoliosis ranging up to 30° and not presenting a progressive potential, the expectative-evaluation attitude is a correct one.

The therapeutic attitude in distal radial Salter and Harris type I and II fractures in children.

INTRODUCTION: Salter Harris Fractures type, especially type I and II are treated by orthopedic reduction in the emergency room or operating room, under general anesthesia, followed by plaster immobilization. Neglected or incorrectly treated fractures, leading to malunion and radiocarpal subluxations which require surgical procedure. PURPOSE: This paper proposes to evaluate the correctly applied orthopedic treatment and the expose of an original surgical technique in case of neglected and incorrectly treated fractures, leading to mal-unions and impediments in the radiocarpal mobility and aesthetics. MATERIAL AND METHOD: we studied a group of 238 children with Salter Harris fractures type I and II, treated in "M.S. Curie" Emergency Hospital for Children, Bucharest. Out of the studied group, 200 children were treated by orthopedic reduction and immobilization in a plaster device. Malunions present within 38 children due to neglected or mistreated fractures, underwent open reduction with internal osteosynthesis by a technique that avoids violating the growth cartilage. This technique involves making an internal fixation with the radial joint surface in a normal position. RESULTS: Children receiving proper orthopedic reduction and immobilization in plaster device, 200 patients, were cured after 30-45 days of immobilization, depending on age and joint mobility which were within normal range. The 38 children with malunions underwent surgery to rectify the position of the radial joint surface. Postoperative results were good, proper position of the radiocarpal joint were made during the surgical procedure. The intemal fixation is ensured by a transepiphyseal wire and after 30 days of immobilization in a plaster device the patients started the recovery treatment. Radiocarpal joint mobility returned to normal after a variable period of 3 to 6 months, depending on the patient's age. CONCLUSIONS: Salter Harris I and II fractures are absolute indication for orthopedic treatment, in a matter of emergency, preferably in the operating room under general anesthesia. Verification is necessary between the 7th and 14th day after orthopedic reduction, to avoid malunions. Malunited fractures require surgical intervention after a special technique, avoiding damage to the growth cartilage and radial epiphysis.

Diagnosis and complications of renovascular hypertension in children: literature data and clinical observations.

INTRODUCTION: Renovascular hypertension in children is a very rare illness. It occurs as a result of the imbalance between hypotensive and hypertensive systems. Renal ischaemia (95% of the cases) and the shortening of hipotensive factors (5% of the cases) are responsible for the production mechanism of renovascular hypertension in children. In order to make an early diagnosis regarding the renovascular hypertension in all children suffering from renovascular illnesses, blood pressure must be taken correctly and repeatedly. MATERIALS AND METHODS: This paper is a case study on 19 children with renovascular hypertension, aged between 2 and 15 years old. Most cases were divided into two groups: subjects aged 4-7 years old and subjects aged 8-12 years old. Each group represents 34.2% of all cases. The diagnosis of renovascular hypertension in those 19 children was established after correctly taking the blood pressure and comparing it with the normal values for each age. Hypertension was diagnosed before knowing its cause in 8 neglected cases. The blood pressure was repeatedly taken in the other 11 children suffering from renovascular illnesses and the diagnosis of hypertension was early established when blood pressure values increased. Previously, blood pressure was normal in these 11 cases. RESULTS: The etiopathogenical diagnosis showed parenchymal diseases in 12 cases--63.1%. Seven patients suffered from renovascular lesions--36.9%. Laboratory exams, radiology, imagistic exams, arteriography and scintigraphy were steps taken in order to establish the etiopathogenical diagnosis. These exams showed the next direct causes of renovascular hypertension: bilateral chronic pyelonephritis in 4 cases--21.4%, hydronephrosis in 3 cases--16.2%, congenital renal hypoplasia in 2 cases--10.4% and doubled kidney in 2 cases--10.4%. The other 8 cases presented acute glomerulonephritis, unilateral renal agenesis, horseshoe kidney, unilateral pyelonephritis, renal artery agenesis, renal trauma, renal abcess and Wilms tumor, one case of each illness--5.2%. The major complications were: retinopathy, chronic renal failure and stroke. CONCLUSIONS: Laboratory data are just a hint in diagnosing renovascular hypertension. However, radiology, imagistic exams, arteriography and scintigraphy are compulsory in the renourinary status and etiopathogenical diagnosis.

Osteoarticular reconstructive surgery in malignant bone tumors: the importance of external fixators.

This paper is a retrospective study on 8 patients admitted and treated in Paediatric Surgery and Orthopaedics Clinic of "M. S. Curie" Hospital Bucharest between 1997 and 2007. The patients with malignant bone tumors (table 1.) were studied by sex, tumor type, location, age at the moment of diagnosis, age at the moment of the last evaluation, type of surgery, external fixator implanted, complications, results and survival period. We also considered for each patient the extent of the tumor to diaphysis, soft tissue involvement, involvement of physis and epiphyseal invasion, articular extent, vessels and nerves invasion, presence of metastases and local skin invasion. The certain diagnosis was based on pathological anatomy exam, because clinical and imagistic data were not decisive in each case. There were studied only those patients who received external fixators, the only method to achieve oncological safe resection and osteoarticular recontruction. We used monoplanar or circular fixators, in adjustable or mixed mountings. The postoperative complications were not fatal. The survival period has been between 6 months and 18 years. Only two patients, who have survived 6 months and respectively 18 months, were not able to return to prior activities. The other six were reinserted in social activities. Nowadays, there is made a great effort to save the affected limbs. The conservative treatment is preferred to the amputation, which is being used in very few cases. The development of reconstructive bone surgery is sustained by the possibility to delineate the tumor by diagnosis based on imaging and by the possibility to use modern preoperative and postoperative chemotherapy and radiotherapy. Limb conservation was possible only in aggressive benign tumors up to 1970. Since then the same treatment was preferred also in malignant bone tumors, because the relapse appeared as frequent as in cases with amputation but the physical and psychological comfort made the patients to accept it readily. The goal of malignant bone tumors treatment is to save the life of the patient, to preserve the affected limb, to maintain the length and function of the limb. Oncologic surgery consists of "en bloc" tumor resection followed by bone reconstruction or modular prosthetic replacement. Modular prosthetic replacement leads to the loss of at least one growing cartilage. The use of radiotherapy in some cases may also affect other growing cartilages, leading to limb length discrepancies.