Treatment of early onset spinal deformities with magnetically controlled growing rods: a single centre experience of 30 cases.

PURPOSE: The treatment of early onset scoliosis continues to be a major challenge, even when using motorized growth-sparing implants. We report on 30 cases operated on with magnetically controlled growing rods (MCGRs) at our institution, analyzing radiological parameters and complications, comparing our results with the literature and presenting a special implant fixation technique. A separate focus highlights the challenges of conversion from previous non-motorized implants. METHODS: Consecutive case series. The nature and effects of complications were recorded for all patients. Radiographic evaluations were performed for patients with a minimum follow-up of two years. Separate analyses were carried out for patients who were previously treated with non-motorized growth-sparing implants. RESULTS: There were 12 documented complications in 11/30 (37%) patients leading to 13 unplanned returns to the operating room. In all, 18/30 patients had a minimum follow-up of two years. Major curve and main kyphosis, as well as T1 to T12 and T1 to S1 distances significantly improved with MCGR implantation, however, less in patients converted from previous growth-sparing surgical treatment. While the achieved correction of the major curve was maintained, there was a loss of kyphosis correction with subsequent implant lengthening. Gain in implant length decreased with increasing number of extensions. CONCLUSION: Despite improved patient's comfort, MCGR show a considerable complication rate. Coronal plane deformities can be well controlled, but diminished implant lengthening is already apparent within two years after MCGR implantation. Central databases should help to clarify unresolved aspects and optimize the treatment of these young patients. LEVEL OF EVIDENCE: IV.

[Treatment of early onset scoliosis : How far can we go?]. / Behandlung von frühkindlichen Skoliosen : Wo liegen die Grenzen?

BACKGROUND: Recently, inconsistent definitions of early onset scoliosis (EOS) and a wide variety of treatment options have been observed. OBJECTIVES: To clearly define the term EOS, to depict non-operative and operative treatment options, and to present the limitations of the boundaries of these techniques. METHODS: Review of the literature, including conference presentations and expert opinions, in addition to personal experiences. RESULTS: Early onset scoliosis (EOS) refers to spine deformity that is present before 10 years of age, regardless of etiology. All existing operative treatment options share a high risk of complications. Therefore, non-operative treatment should act as a time-buying approach to postpone surgery. DISCUSSION: Awareness of treatment options and their specific indications, in addition to respecting each patient's individual needs and feasibilities, are crucial for the optimal outcome.

[Intramedullary motorized nail for equalization of posttraumatic leg length discrepancies]. / Ausgleich posttraumatischer Beinverkürzungen mit einem motorisierten intramedullären Nagel.

BACKGROUND: Fractures in childhood may result in a significant leg length discrepancy (LLD). The common correction method of LLD and deformities is callotasis with external fixation. This is often associated with pain, pin site infection, muscle tethering and reduced range of movement (ROM). PATIENTS AND METHODS: Between 2006 and 2008 a total of 11 cases of posttraumatic LLD (range 2.4-4.3 cm) were treated with a fully implanted motorized lengthening device (Fitbone®). Hospitalization time, leg equalization, rehabilitation time and complications compared to external fixation were recorded. RESULTS: Leg lengthening was successfully performed in all cases, in five combined with angular and/or rotatory corrections. The mean distraction index was 1.03 mm/day (range 0.6-1.2 mm/day) and the mean consolidation index was 40 days/cm (range 25.2-50.9 days/cm). The average hospital stay was 9.8 days (range 8-20 days). Bone or soft tissue infections were not observed, nor were the complications commonly associated with external fixation. Functional results were excellent as the preoperative knee ROM was regained in all cases and with improved ROM in three cases. CONCLUSION: The Fitbone® nail is a valuable alternative to conventional methods which reduces complications commonly associated with external fixation.

Ilizarov hip reconstruction without external fixation: a new technique.

PURPOSE: The Ilizarov hip reconstruction is a well accepted but complication-prone operative salvage procedure in chronically dislocated hips, not least due to the long-term application of external fixation. Although the advantages of fully implantable devices are well known in limb lengthening and are described consistently, until now, external fixation has been used exclusively to perform the Ilizarov hip reconstruction procedure. We present a new technique of Ilizarov hip reconstruction with purely internal implants. METHODS: A 14-year-old girl with a history of spina bifida presented with a 4-cm-short right leg, a Trendelenburg gait and a complex neurological disease expression. Because of refusal of external fixation by the patient and significantly lower complication rates, an Ilizarov hip reconstruction without external fixation was performed. A locking compression plate was applied to fix the proximal femoral valgus-extension osteotomy and a motorised intramedullary distraction nail was used for the distal, lengthening-varisation osteotomy. RESULTS: A healing index of 33 days/cm and full weight bearing after 6 months were noted. At the 1 year follow-up, the patient showed an improvement of the Trendelenburg gait, as well as successful leg equalisation. Satisfaction to a high degree was additionally noted by factors such as reduced pain, the ability to wear workaday clothes and cosmetically appealing scars. No complications were recorded. CONCLUSION: The exclusive use of internal implants for Ilizarov hip reconstruction is a feasible and patient-friendly alternative to traditional methods. Their use, however, may be restricted by geometric preconditions.

Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option.

INTRODUCTION: Despite the increasing use of flexible intramedullary nailing for the treatment of femoral shaft fractures during growth, the use of acute or delayed plaster fixation is still a widely practised alternative in preschool children. The purpose of this retrospective study was to analyse outcome following acute casting in preschool children with a focus on acceptable initial leg length discrepancy and angulation. MATERIAL AND METHODS: A retrospective study was performed of 46 children with femoral shaft fractures treated conservatively. It was possible to verify the outcome in 22 children with an average follow-up time of 7.5 years. We compared initial shortening and mal-angulation to radiographic data at the time of consolidation and clinical outcome. RESULTS: Most children sustained their fracture by falling out of bed or from their parent's arm. A hip spica including the foot of the injured side, a pelvic ring and the thigh of the uninjured leg was applied under sedation and manual traction. Mean time of hospital stay was 1.4 days (range, 2 h-20 days). The average immobilisation time was 16.7 days (range, 0-30 days). At follow-up, on average 7.5 years after trauma, only one patient showed a leg length discrepancy greater than 2 cm. One patient showed a minor valgus and rotational deformity. CONCLUSION: The long-term outcome for conservatively treated femoral shaft fractures in preschool children is very good, even in severely dislocated fractures. Our data show that even initial shortening of up to 2.5 cm can be treated successfully with a spica cast.

[Partial rupture of the quadriceps tendon in a 6-year-old boy]. / Partielle Quadrizepssehnenruptur bei einem sechsjährigen Jungen.

In children, avulsion fractures of the patella are observed more frequently than ruptures of the quadriceps tendon. In cases of suspected lesions of the quadriceps tendon, conventional x-ray imaging and ultrasound comparison of both patellae is recommended. Arthroscopy is helpful for diagnosing concomitant intra-articular knee lesions and permits evacuation of the hemarthrosis.

Open reduction, ulnar osteotomy and external fixation for chronic anterior dislocation of the head of the radius.

We reviewed 15 patients, nine girls and six boys, with chronic anterior dislocation of the radial head which was treated by ulnar osteotomy, external fixation and open reconstruction of the elbow joint but without repair of the annular ligament. Their mean age was 9.5 years (5 to 15) and the mean interval between the injury and reconstruction was 22 months (2 months to 7 years). All radial heads remained reduced at a mean follow-up of 20 months (6 months to 5 years). Normal ranges of movement for flexion, extension, pronation and supination were unchanged in 96.1% (49/51) and worse in 3.9% (2/51). Limited ranges of movement were improved in 77.8% (7/9), unchanged in 11% (1/9) and further decreased in 11% (1/9).There were two superficial pin-track infections and two cases of delayed union but with no serious complications. Reconstruction of the radiocapitellar joint is easier using external fixation since accurate correction of the ulna can be determined empirically and active functional exercises started immediately. Only patients with a radial head of normal shape were selected for treatment by this method.

Prevention of growth disturbances after fractures of the lateral humeral condyle in children.

Growth disturbances after fractures of the lateral condyle of the distal humerus in children present mostly as transient stimulation of the lateral physis. Clinically lateral condylar overgrowth leads to a radial bony prominence and varisation of the elbow. From 1974 to 1994, 66 fractures were prospectively diagnosed with standard roentgenograms and treated by open reduction and internal fixation with a metaphyseal lag screw in case of displacement. Fifty-four patients (82%) were reviewed with an average length of follow-up of 10 years (range, 2-22 years) to assess all sequelae of growth disturbances. Screw osteoynthesis led to anatomical union, symmetric carrying angles and full range of motion in all 27 operated cases, and proved to prevent stimulating growth disturbances contrary to the common but relatively unstable fixation with Kirschner wires.

[Pathophysiology of posttraumatic deformities of the lower limbs during growth]. / Pathophysiologie posttraumatischer Deformitäten der unteren Extremität im Wachstumsalter.

Posttraumatic deformities after pediatric fractures are either the result of incomplete or failed remodeling, complete or partial stimulation of the growth plates, or complete or partial closure of a growth plate. In contrast to fractures of the upper extremities, spontaneous remodeling should not be intentionally integrated in the treatment algorithm. Thus, stimulative growth disturbances with subsequent changes of the leg length can be prevented. Therefore, one should strive for anatomical alignment and rotation without shortening. The latter provokes remodeling, with activation of the adjacent physis. Growth disturbances with partial stimulation typically occur after metaphyseal bending fractures of the proximal tibia. If minimal valgization is overlooked, growth disturbances will lead to a progressive valgus deformity. Partial closure of a growth plate is still inevitable after epiphyseal fractures (Salter-Harris type III and IV) as well as after simple epiphysiolysis (Salter-Harris-type I, II). The resulting deformity depends on the size of the physeal closure, its localization, and on the remaining growth. A "waterproof" reduction and osteosynthesis of type III and IV fractures may well diminish the risk of a partial physeal closure but will not reliably prevent it. It will occur in about 35% after physeal fractures at the distal femur, in 30% at the proximal and 20% at the distal tibia. Based on this knowledge patients and parents should be informed correspondingly and follow-up should be continued until skeletal maturity.

[Leg length inequality. Indications for treatment and importance of shortening procedures]. / Beinlängendifferenzen. Behandlungsbedürftigkeit und Bedeutung von verkürzenden Operationen.

Real leg length discrepancies may be cosmetically disturbing and lead to gait abnormalities, pelvic obliquity with subsequent lumbar scoliosis as well as functional disturbances of hip, knee and ankle joint. During the growth period even discrepancies of more than 1 cm should be treated by simple conservative means in order to prevent a compensatory lumbar scoliosis. In adults, inequalities up to 2 cm are tolerable. As an alternative to cosmetically often unaccepted shoe lifts for discrepancies of 2 to 6 cm, lengthening and shortening procedures should be considered. The latter involve lower costs and fewer complications. However, reduced final height may be an issue. In cases of an open physis, shortening can be achieved by Blount stapling or percutaneous epiphysiodesis. Considering the minimal number of incisions, simple technique and a low complication rate percutaneous epiphysiodesis is the first choice. The key problem, though, is the correct timing of the procedure. Age, anticipated leg length discrepancy at skeletal maturity, calculated loss of length of the longer leg and growth potential of the shorter leg have to be considered. More complex problems require repeated assessment and documentation of the lengths of both legs in order to find out the individual developmental pattern of the leg length discrepancy, which is primarily associated with the underlying pathology. After skeletal maturity, precise shortening may be achieved by osteotomies with resection of up to 6 cm of bone of the femur and up to 3 cm of the tibia. More shortening is limited by muscle insufficiency, as well as relative increase of soft tissues and risk of compartment syndrome in the lower leg.

Femoral neck lengthening osteotomy after growth disturbance of the proximal femur.

Treatment of congenital dislocation of the hip, Perthes disease, bacterial coxitis, or fractures in childhood may be complicated by vascular insufficiency and subsequent growth disturbance of the proximal femur. The resulting deformity, with a high-standing greater trochanter and a short femoral neck, causes leg length shortening and insufficiency of the hip abductors with a positive Trendelenburg sign and limp. Normal anatomy and biomechanics of the hip joint can be restored by lengthening the femoral neck after two parallel osteotomies of the femur at the the upper and lower border of the femoral neck, followed by distalization the greater trochanter. This femoral neck lengthening osteotomy was first described by the senior author (EM) in 1980. This retrospective study of 37 operated patients with a mean follow-up of 8 years shows good results in 32 patients with little or no preexisting osteoarthritis. Four of five patients with marked degenerative changes underwent a total hip replacement within 1 to 9 years after the osteotomy.