Femoral Lengthening in Children-A Comparison Between Magnetic Intramedullary Lengthening Nails and External Fixators.

BACKGROUND: Femoral lengthening can be achieved using external fixators or intramedullary lengthening nails. The purpose of this research was to compare the outcome of femoral lengthening in children using PRECICE magnetic lengthening nails with lengthening external fixators. METHODS: Retrospective analysis of 50 children who had femoral lengthening. Group A included patients who had lengthening with external fixation, patients in Group B had lengthening with PRECICE intramedullary lengthening nails. Each group included 25 patients. The sample strictly included children aged between 11 and 17 years. Patients in each group were matched according to age and indication for lengthening whether congenital or acquired conditions. The outcomes focused on the ability to achieve target length, healing index, residual malalignment, length of hospitalization following the osteotomy surgery, and encountered complications. RESULTS: Mean patient age was 14.7 years for each group. The length gain was 42±12 mm for Group A and 41.6±8 mm for Group B (P=0.84). Lengthening nails achieved the target length more accurately compared with external fixation (P=0.017). The healing index was significantly higher in group A with 53.2±19 days/cm compared with 40.2±14 days/cm in group B (P=0.03). Group A had significantly higher complications than group B (P<0.0001). There was no statistically significant difference in the final coronal malalignment between the 2 groups (P=0.2). The mean length of stay was 9.2±5.8 days for group A and 4.2±3.3 days for group B (P=0.0005). CONCLUSION: Magnetic lengthening nails are clinically effective for femoral lengthening in the pediatric population. Compared with external fixation, healing index and complications were more favorable with PRECICE nails. Further research is required to study the cost-effectiveness of this technique. LEVEL OF EVIDENCE: Level IV-case series.

Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction.

AIM AND OBJECTIVE: Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical issues from external fixators leading to reduced compliance. We present the same reconstruction procedure using only internal devices with a modification in the technique and review early results. MATERIALS AND METHODS: We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by two-stage reconstruction; stage I included femoral head resection and pelvic support osteotomy using double plating, whereas stage II comprised distal femoral osteotomy avoiding varus followed by the insertion of a retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. RESULTS: At a mean follow-up of 19 months (range, 6-36), all osteotomies healed with a bone healing index of 47 days/cm (range, 30-72). Pain improved from 8.3 (range, 7-9) to 2 (range, 0-6) while the limb length discrepancy got corrected from 4.3 cm (range, 3-5) to 1.4 cm (range, 0-2.5) at the final follow-up. Trendelenburg sign was eliminated in three patients and delayed in five patients. No examples of infection or permanent knee stiffness were noted. One patient had plate breakage due to mechanical fall, and another patient had 35 mm of lateral mechanical axis deviation (MAD) requiring corrective osteotomy. CONCLUSION: Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, although with some degree of lateral MAD. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. CLINICAL SIGNIFICANCE: Pelvic support hip reconstruction performed by internal implants is a viable alternative to Ilizarov hip reconstruction with potential benefits. HOW TO CITE THIS ARTICLE: Metikala S, Kurian BT, Madan SS, et al. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020;15(1):34-40.

Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction.

AIM AND OBJECTIVE: Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical problems from external fixators leading to reduced compliance. We present the same reconstruction utilising only internal devices with a modification in technique and aim to review early results. MATERIALS AND METHODS: We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by a two-stage reconstruction; stage 1 included femoral head resection and pelvic support osteotomy using double plating, while stage 2 comprised distal femoral osteotomy avoiding varus followed by insertion of retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. RESULTS: At mean follow-up of 19 months (range 6-36), all osteotomies healed with bone healing index of 47 days/cm (range 30-72). Pain improved from 8.3 (range 7-9) to 2 (range 0-6), while limb length discrepancy got corrected from 4.3 cm (range 3-5) to 1.4 cm (range 0-2.5) at final follow-up. Trendelenburg sign was eliminated in three and delayed in five. No examples of infection or permanent knee stiffness were noted. One patient had plates breakage due to mechanical fall and one had 35 mm of lateral mechanical axis deviation requiring corrective osteotomy. CONCLUSION: Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, albeit with some degree of lateral mechanical axis deviation. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. CLINICAL SIGNIFICANCE: Pelvic support hip reconstruction performed by internal implants is a viable alternative to IHR with potential benefits. HOW TO CITE THIS ARTICLE: Metikala S, Kurian BT, Madan SS, et al. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction. Strategies Trauma Limb Reconstr 2020;15(2):91-97.

Extra-articular deformity correction using Taylor spatial frame prior to total knee arthroplasty.

A good long-term outcome following a total knee arthroplasty relies on restoration of the mechanical axis and effective soft tissue balancing of the prosthetic knee. Arthroplasty surgery in patients with secondary osteoarthritis of the knee with an extra-articular tibial deformity is a complex and challenging procedure. The correction of mal-alignment of the mechanical axis is associated with unpredictable result and with higher revision rates. Single-staged deformity correction and replacement surgery often result in the use of constraint implants. We describe our experience with staged correction of deformity using a Taylor Spatial Frame (TSF) followed by total knee arthroplasty in these patients and highlight the advantage of staged approach. The use of TSF fixator for deformity correction prior to a primary total knee arthroplasty has not been described in the literature. We describe three cases of secondary osteoarthritis of the knee associated with multiplanar tibial deformity treated effectively with a total knee arthroplasty following deformity correction and union using a TSF. All patients had an improved Knee Society score and Oxford Knee score postoperatively and were satisfied with their replacement outcome. Staged deformity correction followed by arthroplasty allows the use of standard primary arthroplasty implants with predicable results and flexible aftercare. This approach may also provide significant improvement of patient symptoms following correction of deformity resulting in deferment of the arthroplasty surgery.

Management of paediatric tibial fractures using two types of circular external fixator: Taylor spatial frame and Ilizarov circular fixator.

BACKGROUND: The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management. METHOD: A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months. RESULTS: Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group. CONCLUSION: In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter. LEVEL OF EVIDENCE: Level II-comparative study.

The oblique plane deformity in slipped capital femoral epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is commonly treated with in situ pinning. However, a severe slip may not be suitable for in situ pinning because the required screw trajectory is such that it risks perforating the posterior cortex and damaging the remaining blood supply to the capital epiphysis. In such cases, an anteriorly placed screw may also cause impingement. It is also possible to underestimate the severity of the slip using conventional radiographs. The aim of this study was to describe and evaluate a novel method for calculating the true deformity in SCFE and to assess the interobserver and intraobserver reliability of this technique. METHODS: We selected 20 patients with varying severity of SCFE who presented to our institution. Cross-sectional imaging [either axial computed tomography (CT) scans or magnetic resonance imaging (MRI) scans] and anteroposterior (AP) pelvis radiographs were assessed by four reviewers with varying levels of experience on two occasions. The degree of slip on the axial image and on the AP pelvis radiographs were measured and, from this, the oblique plane deformity was calculated using the method as popularised by Paley. The intraclass correlation coefficient (ICC) was calculated to determine the interobserver and intraobserver reliabilities between and amongst the raters. RESULTS: The interobserver reliability for the calculated oblique plane deformity in SCFE ICC was 0.947 [95 % confidence interval (CI) 0.90-0.98] and the intraobserver reliability for the calculated oblique plane deformity of individual raters ranged from 0.81 to 0.94. The deformity in the oblique plane was always greater than the deformity measured in the axial or the coronal plane alone. CONCLUSION: This method for calculating the true deformity in SCFE has excellent interobserver and intraobserver reliability and can be used to guide treatment options. This technique is a reliable and reproducible method for assessing the degree of deformity in SCFE. It may help orthopaedic surgeons with varying degrees of experience to identify which hips are suitable for in situ pinning and those which require surgical dislocation and anatomical reduction, given that plain radiographs in a single plane will underestimate the true deformity in the oblique plane. LEVEL OF EVIDENCE: Level II diagnostic study.

Outcomes of hip arthroscopy. A prospective analysis and comparison between patients under 25 and over 25 years of age.

OBJECTIVE: To compare the results of hip arthroscopy in patients under the age of 25 with those over 25 years. DESIGN: From March 2006 until May 2010, data were collected on all patients who underwent hip arthroscopy for symptomatic intra-articular hip pathology. The patients were divided into two groups based on age (less than 25 years and over 25 years). Patients completed the modified Harris hip score (MHHS), non-arthritic hip score (NAHS) and hip dysfunction and osteoarthritis outcome score (HOOS) questionnaires at baseline then at 6 weeks, 6 months, 12 months and at latest follow-up. PARTICIPANTS: 88 patients who underwent 94 hip arthroscopies by the senior author. Mean age was 24.3 (range 11-57 years). RESULTS: The mean NAHS and HOOS subscales for pain and activities of daily living were worse at baseline in over 25 groups. Follow-up ranged from 9 to 68 months. 45 hips had greater than 3 year follow-up. The MHHS improved in both groups with a mean difference in the under-25 group of 16.22, and 20.88 in the over 25s. Improvements in the NAHS and HOOS subscales were also of a similar magnitude. There was no statistically significant difference between outcome scores of the two groups at the latest follow-up visit. CONCLUSIONS: We found a comparable improvement in outcome between those patients under 25 years and those over 25 years. We propose that hip arthroscopy is of potential benefit to patients with symptoms of femoroacetabular impingement regardless of age.

Complications of Elastic Stable Intramedullary Nailing for treating paediatric long bone fractures.

This study reports the complications observed in children with long bone fractures treated using Elastic Stable Intramedullary Nailing (ESIN). One hundred and sixty-four (n = 164) fractures in 160 patients under the age of 16 years formed the basis of our review. This included 108 boys and 52 girls with the median age of 11 years and median follow up of 7.5 months. The analysis included fractures of the radius/ulna, humerus, femur and tibia. All pathological fractures were excluded. In this series 54 patients (34%) had complications however majority of these were minor complications with irritation due to prominent nail ends being the commonest complication. No long-term sequelae were encountered in our patients.

Pelvic osteotomy techniques and comparative effects on biomechanics of the hip: a kinematic study.

Dysplasia of the hip is characterized by malpositioning of the proximal femur in a shallow acetabulum, providing deficient femoral head coverage. This abnormal relationship leads to altered biomechanics of the hip joint, as predicted by measurement of kinematic parameters such as increased load over reduced acetabular weight-bearing area, leading to increased joint contact stresses, which subsequently results in secondary osteoarthrosis, pain, and disability. To prevent these sequelae, particularly in children and younger adults, various osteotomies have been performed with varying degrees of success. The goal of this study was to devise a simple and reproducible laboratory method to perform a kinematic analysis of the individual and comparative effects of 5 commonly performed pelvic osteotomy techniques: Chiari pelvic osteotomy, Salter innominate bone wedge osteotomy, Steel triple pelvic osteotomy, Tönnis triple pelvic osteotomy, and Ganz periacetabular pelvic osteotomy. The aim was to determine which of the osteotomy techniques caused greater correction in most of the kinematic parameters used to estimate changes in the biomechanics of the hip joint. Our hypothesis was that pelvic osteotomies such as Chiari and Salter produced favorable changes and were relatively easily reproducible, but that more biomechanical correction in all planes would be achieved by the relatively more complex triple innominate bone and Ganz osteotomy.

Ischial spine projection into the pelvis : a new sign for acetabular retroversion.

Femoroacetabular impingement may occur in patients with so-called acetabular retroversion, which is seen as the crossover sign on standard radiographs. We noticed when a crossover sign was present the ischial spine commonly projected into the pelvic cavity on an anteroposterior pelvic radiograph. To confirm this finding, we reviewed the anteroposterior pelvic radiographs of 1010 patients. Nonstandardized radiographs were excluded, leaving 149 radiographs (298 hips) for analysis. The crossover sign and the prominence of the ischial spine into the pelvis were recorded and measured. Interobserver and intraobserver variabilities were assessed. The presence of a prominent ischial spine projecting into the pelvis as diagnostic of acetabular retroversion had a sensitivity of 91% (95% confidence interval, 0.85%-0.95%), a specificity of 98% (0.94%-1.00%), a positive predictive value of 98% (0.94%-1.00%), and a negative predictive value of 92% (0.87%-0.96%). Greater prominence of the ischial spine was associated with a longer acetabular roof to crossover sign distance. The high correlation between the prominence of the ischial spine and the crossover sign shows retroversion is not just a periacetabular phenomenon. The affected inferior hemipelvis is retroverted entirely. Retroversion is not caused by a hypoplastic posterior wall or a prominence of the anterior wall only and this finding may influence management of acetabular disorders.

Accuracy of correction of tibia vara: acute versus gradual correction.

The purpose was to assess the accuracy of deformity correction achieved in patients with tibia vara using acute intraoperative correction compared with gradual postoperative correction. Acute correction (AC) group consisted of 14 patients (14 tibiae) with a mean age of 11.4 years and whose tibia vara was corrected acutely and held using an EBI external fixator. Gradual correction (GC) group consisted of 18 patients (18 tibiae) with a mean age of 10.2 years and whose tibia vara was corrected gradually using 6-axis deformity analysis and Taylor Spatial Frame. Deformity measurements were compared preoperatively, postoperatively, and at latest follow-up. At latest follow-up, medial proximal tibial angle deviation from normal was similar for the 2 groups; posterior proximal tibial angle was significantly greater in the AC group (5.6 degrees) than in the GC group (1.9 degrees). Mechanical axis deviation was significantly greater in the AC group (17.1 mm) than in the GC group (3.1 mm). Postoperatively, frequency of accurate translation corrections (achieved translation within 5 mm of preoperative required translation) was significantly greater in the GC group (18/18) than in the AC group (7/14). Frequency of accurate angulation corrections (medial proximal tibial angle within 3 degrees of normal and posterior proximal tibial angle within 5 degrees of normal) was significantly greater in the GC group (17/18) than in the AC group (7/14). For both groups, all tibiae with preoperative internal rotation deformity had accurate rotation correction. Correction of preoperative limb-length inequality was achieved in 5 of the 7 patients in the AC group and 11 of the 11 patients in the GC group. Gradual deformity correction is a more accurate treatment method of tibia vara than acute correction.

Evaluation of an algorithmic approach to pediatric back pain.

Pediatric patients require a systematic approach to treating back pain that minimizes the number of diagnostic studies without missing specific diagnoses. This study reviews an algorithm for the evaluation of pediatric back pain and assesses critical factors in the history and physical examination that are predictive of specific diagnoses. Eighty-seven pediatric patients with thoracic and/or lumbar back pain were treated utilizing after this algorithm. If initial plain radiographs were positive, patients were considered to have a specific diagnosis. If negative, patients with constant pain, night pain, radicular pain, and/or an abnormal neurological examination obtained a follow-up magnetic resonance imaging. Patients with negative radiographs and intermittent pain were diagnosed with nonspecific back pain. Twenty-one (24%) of 87 patients had positive radiographs and were treated for their specific diagnoses. Nineteen (29%) of 66 patients with negative radiographs had constant pain, night pain, radicular pain, and/or an abnormal neurological examination. Ten of these 19 patients had a specific diagnosis determined by magnetic resonance imaging. Therefore, 31 (36%) of 87 patients had a specific diagnosis. Back pain of other 56 patients was of a nonspecific nature. No specific diagnoses were missed at latest follow-up. Specificity for determining a specific diagnosis was very high for radicular pain (100%), abnormal neurological examination (100%), and night pain (95%). Radicular pain and an abnormal neurological examination also had high positive predictive value (100%). Lumbar pain was the most sensitive (67%) and had the highest negative predictive value (75%). This algorithm seems to be an effective tool for diagnosing pediatric back pain, and this should help to reduce costs and patient/family anxiety and to avoid unnecessary radiation exposure.

Anterior dislocation of the radial head with fractures of the olecranon and radial neck in a young child: a Monteggia equivalent fracture-dislocation variant.

We present a case of a type I Monteggia equivalent lesion in a 7-year-old child consisting of anterior dislocation of the radial head, radial neck fracture, and a fracture of the olecranon without an associated fracture of the ulnar diaphysis or metaphysis. After a review of the literature, we report this fracture pattern as a rare type I Monteggia equivalent fracture-dislocation variant. This report describes delayed surgical treatment and outcome after close follow-up of a rare type I Monteggia equivalent lesion. Diagnostic challenges with and treatment options for pediatric Monteggia equivalent fracture-dislocations are discussed.

Hinged distraction of the adolescent arthritic hip.

From 1996 to 2000, 11 adolescents with hip joint arthritis secondary to osteonecrosis or idiopathic chondrolysis were treated with articulated hinged distraction arthroplasty. Indications for surgery were severe pain and limited ambulation. Charts and radiographs were reviewed. Clinical status was assessed preoperatively and at latest follow-up (mean 4.8 years after surgery) using criteria of pain, range of motion, and ambulation level. Ten patients showed improved clinical status, with seven having an excellent outcome and three a good outcome. One patient failed distraction. Mean joint space was 2.6 mm before surgery and 4.8 mm at latest follow-up. Average duration of fixator use was 4.4 months. Four patients (36.4%) had complications. Articulated hip distraction was effective in eliminating pain, improving function, and preventing progressive degenerative changes in young patients' hips. It should be considered a salvage procedure for arthritic hips and an alternative to arthrodesis in this difficult-to-treat group of patients.

Genu valgum secondary to focal fibrocartilaginous dysplasia of the distal femur.

We report a case of unilateral genu valgum secondary to focal fibrocartilaginous dysplasia (FFCD) isolated in the posterolateral cortex of the distal femur. This case is the first incidence of a discrete fibrous band occurring in conjunction with a FFCD lesion in the distal posterolateral femur treated with excision of the tether and the overlying periosteum with curettage of the cortical focal fibrocartilaginous defect. Treatment was considered successful with gradual resolution of the 30 degrees valgus deformity over 24 months, and we avoided the necessity of corrective osteotomy and its associated risks. To our knowledge, resolution of genu valgum secondary to FFCD in the distal posterolateral femur after curettage has not been previously described in the literature.

Interobserver error in interpretation of the radiographs for degeneration of the lumbar spine.

We examined 114 segments in 23 patients' lumbar spine plain radiographs affected by disc degeneration. Two consultant orthopaedic surgeons, two consultant radiologists, and one spine nurse practitioner made independent observations on the radiographs. MRI scan films of the corresponding 114 segments were used as a gold standard. Kappa coefficients were used to evaluate the interobserver error, and the error between the independent observers and the MRI scanning reports. The systematic differences between the observers for the diagnosis of the disc degeneration at each segment level was recorded. There was significant interobserver error between the independent observers. The pairwise interobserver agreement ranged from fair to substantial on the plain radiograph observations [Weighted kappa coefficient, mean: 0.517 (CI=0.388-0.646)]. The pairwise interobserver agreement between the independent observers and the MRI scan ranged from fair to moderate [Weighted kappa coefficient, mean: 0.388 (CI=0.259-0.518)]. There is significant error in interpretation of the plain radiographs for the diagnosis of lumbar disc degeneration. MRI may be more accurate in the diagnosis of lumbar disc degeneration.

Correction of tibia vara with six-axis deformity analysis and the Taylor Spatial Frame.

Operative correction for infantile and adolescent tibia vara has been described using both external and internal fixation. Gradual correction using a circular fixator offers the advantage of accurate coronal, sagittal, and axial plane correction without significant soft tissue dissection. This study evaluated the use of six-axis deformity analysis and the Taylor Spatial Frame (TSF) for the correction of tibia vara. Nineteen patients (22 tibias), 6 with infantile and 13 with adolescent tibia vara, underwent correction with TSF. On the basis of mechanical axis correction, 21 of 22 tibias were corrected within 3 degrees of normal. Using Schoenecker's criteria, all patients achieved good results (no pain, <5 degrees difference in tibial-femoral angle from the normal side). Complications included one intractable pin-site infection, two superficial pin-site infections, and one delayed union. Six-axis deformity analysis and TSF provide accurate and safe correction of infantile and adolescent tibia vara.