Optimizing the vertical position of the brace thoracic pad: Apical rib or apical vertebra?

INTRODUCTION: The vertical position of the thoracic pad is a subject of controversy in brace design. Traditional recommendations dictate a maximal force applied at the level of the apical rib, about 2 levels below the apical vertebra. We sought to evaluate the optimal vertical position of the brace thoracic pad using fulcrum bending radiographs. HYPOTHESIS: A lateral force applied at the apical vertebra of a thoracic curve is more efficient at correcting coronal deformity than a force placed the apical rib. PATIENTS AND METHODS: In this prospective study, we recruited patients presenting with adolescent idiopathic scoliosis (AIS) and Risser stage 0-2 over a period of 12 months. Patients with a history of spine or thoracic surgery were excluded. Two fulcrum bending radiographs were performed for each patient: one with the center of the fulcrum placed under the most lateral part of the apical rib and another with the fulcrum centered below the apical vertebra. Cobb angles were measured on each fulcrum radiograph and compared using a paired t test. RESULTS: Fifty-two patients were included, with a mean age of 12.4 years and mean thoracic Cobb angle of 39.4˚. Placing a fulcrum under the apical vertebra reduced the Cobb angle to a mean of 11.5˚, which was significantly lower than a fulcrum placed under the apical rib (14.3˚, p=0.001). This corresponded to a 20% relative loss in the absolute correction angle when placing the fulcrum under the apical rib. The difference between the 2 Cobb angles was not significantly correlated to patient age (p=0.896) or curve apex (p=0.813). DISCUSSION: This is the first clinical study addressing the vertical position of the thoracic pad in braces for AIS. A lateral force applied at the level of the apical vertebra was significantly more efficient at reducing thoracic curve deformities than one applied at the apical rib. Our results provide clinical support to finite element studies that refute traditional recommendations of brace design, advocating for a revision of these guidelines to optimize non-operative treatment of AIS. LEVEL OF EVIDENCE: II, prospective comparative study.

Pediatric avulsion fractures of pelvis: current concepts.

PURPOSE OF REVIEW: Provide the reader with an evidence-based update on the importance of accurate diagnosis of commonly missed avulsion fractures of pelvis apophyses, the necessary imaging studies, the feared complications and the recent treatment recommendations. RECENT FINDINGS: Accurate diagnosis of avulsion fractures of pelvis apophyses is high yield as misdiagnosis leads to improper treatment. They should be differentiated from muscle strain and apophysitis. These fractures are usually associated with good outcomes; however, missed diagnosis can lead to further displacement, nonunion, functional limitation, femoroacetabular impingement and infection. A/P and frog lateral pelvis radiograph show the fracture and its displacement in the majority of cases. Conservative treatment, consisting of a short period of rest and immobilization followed by passive stretching then progressive resisted activity before return to sports, is recommended in minimally displaced avulsions. Surgical treatment is favored in displaced fractures (>15 mm), as it is associated with quicker return to sports. SUMMARY: Treating physicians should keep a high index of suspicion in pediatric and adolescent patients presenting with typical clinical exam findings. Pelvic Anteroposterior and frog leg radiographs are often diagnostic. Missed diagnosis can aggravate the prognosis of a usually benign condition. Adequate medical or surgical treatment should then be administered.

Preliminary Results of the Induced Membrane Technique for the Reconstruction of Large Bone Defects.

BACKGROUND: During past decades, gradual bone transplant using external fixators and vascularized fibular or rib transplants widely contributed to solve difficult problems related to the reconstruction of large bone defects in children. However, these surgeries are time consuming and require specialized surgical skills, not always available in a general hospital setting, mainly in rural areas. PURPOSE: To report the preliminary results of the more recently described induced membrane technique in a consecutive series of 8 children and to identify some factors related to the procedure's success. METHODS: Nine consecutive children with bone defects ranging from 5 to 14 cm were included in the study. The age at surgery ranged from 3 to 16 years. There were 3 congenital pseudarthrosis (CP) of the fibula, 1 CP of the tibia, 1 Ewing sarcoma of the tibia, 1 Ewing sarcoma of the ulna, 1 tibial osteosarcoma, 1 fibular osteosarcoma, and 1 chronic diffuse tibial osteomyelitis. The procedure was performed according to the original Masquelet's description in 2 stages. Follow-up ranged from 1 to 7 years. RESULTS: The child with tibial osteosarcoma died 3 months after the surgery from complications related to chemotherapy. Among the 8 remaining children, 6 healed uneventfully, and 2 required revision with additional grafting and/or better internal fixation, one with Ewing sarcoma of the tibia and a 13-cm bone defect and the second with CP of the fibula. Both of them had suboptimal internal stabilization. CONCLUSIONS: The induced membrane technique is a useful, efficient, and simple alternative to highly specialized surgical procedures used for the reconstruction of large bone defects in children. Risk factors for failure include chemotherapy, suboptimal bone fixation, and persistent axial malalignment. LEVEL OF EVIDENCE: Level IV.

Orthopedic complications related to growth hormone therapy in a pediatric population.

Since the introduction of recombinant growth hormone, its use has diversified and multiplied. Growth hormone is now the recommended therapy for a growing indication to all forms of short stature because of its direct and indirect role on bone growth. Hereby, we discuss the orthopedic complications associated with growth hormone treatment in pediatric patients. These complications include carpal tunnel syndrome, Legg-Calve-Perthes' disease, scoliosis, and slipped capital femoral epiphysis. Their incidence rates recorded in several growth hormone therapy-related pharmacovigilance studies will be summarized in this study with focused discussion on their occurrence in the pediatric and adolescent age groups. The pathogenesis of these complications is also reviewed.

Percutaneous radiofrequency coagulation of osteoid osteoma of the "Neural Spinal Ring".

STUDY DESIGN: Three cases of osteoid osteomas of the spine, adjacent to neural elements, were treated with CT-guided thermal coagulation. OBJECTIVE: To present an alternative method to conventional treatment of spinal osteoid osteoma. SUMMARY OF BACKGROUND DATA: Percutaneous CT-guided radiofrequency coagulation has been successfully used for osteoid osteoma of the extremities. The conventional management of spinal osteoid osteoma is by surgical resection. METHOD: Three patients with osteoid osteoma of the spine, adjacent to neural structures, were treated by percutaneous radiofrequency ablation. The procedure was performed in the CT room under general anesthesia and CT guidance. The thermocoagulation electrode was heated at 90 degrees C for 4 min. RESULTS: Two patients left the hospital the same day; the third one was kept 24 h for observation. All of them had total pain relief within 48 h following the procedure. No complications were recorded. There was no evidence of recurrence after a mean follow-up period of 17 months. CONCLUSION: Osteoid osteoma of the spine, adjacent to neural structures, can effectively and safely be treated by minimally invasive percutaneous CT guided radiofrequency coagulation.

Rib fixation for humeral lengthening following interscapulothoracic resection for malignant tumor.

We report a case of humeral lengthening in an adolescent, 6.5 years after interscapulothoracic resection for an osteosarcoma of the scapula. The lengthening external fixator was augmented by ipsilateral rib fixation in order to prevent cephalad migration of the proximal fragment. At a 3-year follow-up, the patient was satisfied, with an improved cosmesis and function of his limb.

"Perthes-like" changes in a free riding untreated congenital dislocated hip.

The development of avascular necrosis of the femoral head (AVN) after the treatment of congenital dislocation of the hip (CDH) is a well-known complication, but the coexistence in an old child of untreated CDH and ischemic changes of the femoral head has not been reported. Many authors and several years of clinical observation have shown that Perthes-like changes do not occur unless the two sides of the joint are in contact. The purpose of this paper was to report a case of Perthes-like disease that occurred in an untreated CDH, and to discuss the possible pathogenesis. The patient is an 8-year-old African American girl, who presented with a leg length discrepancy, and very mild complaints at the left hip. Physical examination revealed left hip stiffness with a positive Galeazzi sign. Pelvic radiographs showed a complete high riding dislocation of the left hip, with a small and dense femoral head. MRI showed a decreased signal of the entire femoral head. Hematologic and metabolic work-up was normal. Although the vascular theory seems to be well accepted in the pathogenesis of Perthes disease, it does not seem that the contact between the femoral head and the acetabulum is necessary to produce ischemic changes of the femoral epiphysis.