Ultrasonic Evaluation of the Achilles Tendon in Patients Treated for Congenital Clubfoot: Comparison between Patients Treated with Plaster Alone, Achilles Tenotomy, and Z-Plasty Lengthening.

BACKGROUND: Clubfoot is a common congenital deformity. The Ponseti technique, involving early corrective manipulations followed by applying long leg casts and Achilles tenotomy, is widely accepted as the preferred treatment. Rapid tendon healing after surgery has been documented, but the aspect regarding long-term tendon structure and properties is not known. Three cases of Achilles tendon rupture in adolescents previously treated for clubfoot have been described in the literature. As rupture is a rare event in this age group, a possible correlation with previous surgery has been hypothesized. The primary aim of the study was to compare the ultrasound findings of the Achilles tendon in patients treated for clubfoot, between patients treated with casting alone and with patients who underwent surgery (percutaneous tenotomy or Z-plasty lengthening). METHODS: There were 22 asymptomatic patients (34 feet) with a median age of 12 years, previously treated for clubfoot, that were recruited for this study; the patients underwent an Achilles tendon ultrasound examination during a follow-up outpatient visit. RESULTS: A greater thickness and increased number of structural alterations with the presence of hypoechoic areas of the operated tendons compared with those treated with plaster alone were observed (p-value: 0.0498 and <0.001, respectively). These ultrasound findings were indicative of tendon suffering, as seen in tendinopathies. CONCLUSIONS: The presence of ultrasound alterations in asymptomatic patients operated on for clubfoot requires careful control of the extrinsic factors of tendinopathy in order to reduce the risk of subcutaneous rupture.

Achilles tendon surgery in clubfoot: Are long term sequelae predictable?

Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.

Acute Effects of Self-Correction on Spine Deviation and Balance in Adolescent Girls with Idiopathic Scoliosis.

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of spine and trunk with a higher incidence in girls. AIS alters and reduces postural control and balance. Self-correction movement (SCM) is a well-known non-invasive approach to ameliorate spine curve in AIS subjects. We aimed to evaluate the effects of SCM on the spine and on the balance of adolescents with AIS with a new non-invasive instrumentation. Methods: A total of 38 girls with AIS were recruited. To evaluate the acute effects of SCM and the oscillations of center of pressure (COP), we used LiDAR technology combined with a stabilometric platform to evaluate both changes in spinal curves and balance at the same time. Two tests were carried out simultaneously using the two instruments: before the execution of SCM, in the spontaneously assumed position of each subject (SP) and after the execution of SCM, during the achieved position (SC). Sway area, COP medio-lateral and antero-posterior directions, eccentricity of the ellipse and vertebral lateral deviation were recorded. The two conditions were compared with a Wilcoxon signed-rank test. Results: In general, all measures showed lower values in SC condition (p < 0.05), except the variation along the Y axis. Conclusions: Thanks to objective measured data, the therapists observed real-time changes during the performance of SCM, appreciating its efficacy on curve correction.

Displacement of Centre of Pressure during Rehabilitation Exercise in Adolescent Idiopathic Scoliosis Patients.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is included into the category of pathologies that could affect postural control. Rarely AIS shows symptoms but often compromises the normal positioning of the head, trunk and, more generally, of the limbs in the space. We used a stabilometric platform to evaluate the motor control outcomes during a self-elongation in girls with AIS. METHODS: In 10 girls with AIS, we evaluated the center of pressure (COP) modifications on a baropodometric platform in a standing position and after a self-elongation correction. RESULTS: All the outcomes (except the eccentricity) showed an increasement during the self-elongation exercise even if the significant differences were not found. CONCLUSION: SE correction contributes to ameliorate the COP symmetry with a better repercussion on the balance management. This highlights the importance of repetitions during all activities of daily life.

Congenital Dislocation of the Patella - Surgical Treatment Rationale and Literature Review.

INTRODUCTION: Congenital dislocation of the patella (CDP) is a rare condition and its treatment is not well defined. In CDP, patella is dislocated on the lateral aspect of the distal femur, laterally from the trochlear groove, it cannot be reduced manually and it is almost always associated with genu valgum, lateral torsion of the proximal tibia, and flexion contracture of the knee. This condition is present at birth, but the clinical findings can be subtle at birth due to the size and character of the structures being examined; early diagnosis is essential, but it may be delayed to late childhood or adulthood. If CDP is not promptly treated, the disability increases during growth, so surgical correction should be planned as soon as the diagnosis is confirmed. CASE REPORT: We report a case of bilateral CDP associated with bilateral proximal radioulnar joint stiffness; the patient at the age of diagnosis was 11 years old and underwent a bilateral delayed surgical procedure; the 4-year follow-up results are satisfactory. Surgical treatment rationale and literature are reviewed. CONCLUSION: Surgical correction for CDP is generally recommended, but there is no agreement in literature on the ideal treatment and in some cases, with mild impairment of the knee function, observation alone has been suggested. The decision about a surgical treatment can be difficult and depends on the degree of disability of the patient.

The Effects of Insole-Based Visual Feedback on Weight-Bearing in Patients Undergoing Total Hip Replacement.

This study aimed to investigate the visual biofeedback effect of a sensorized system for plantar pressure dynamic evaluation of in patients with a total hip replacement. Experimental group followed the rehabilitation training wearing sensorized insoles that provided images on three monitors. The control group followed the verbal instructions of physiotherapists during training. Weight bearing percentage healthy limb (WBPH), weight bearing percentage surgical limb (WBPS), swing healthy limb (SWH) and swing surgical limb (SWS) improved significantly more in the experimental group. The results underline the effectiveness of visual biofeedback based on sensorized system with dynamic evaluation of the plantar pressure.

Interpreting neonatal hip sonography: intraobserver and interobserver variability.

The purpose of this study is to state the reliability of neonatal hip ultrasound interpretation, defining the intra and interoperator variability in the evaluation of the scans. We considered a sample of 2071 scans (coming from 798 patients who attended the screening programme for hip dysplasia), which were interpreted by the operator who obtained and read the images at the screening time and then by a different operator who saw the images for the first time. Both the intra and interoperator variability of α and ß angles' values resulted statistically not significative (intraclass correlation coefficient > 0.8) and determining a class shift (according to the Graf's classification) in a nonstatistically significative number of cases (agreement percentage >91% and Cohen's κ >0.8). Hip sonography can reliably detect hip dysplasia and the intra and interoperator variability in the interpretation of the exam is NS when the examination is correctly executed.

Proposal of an innovative casting technique for correction of clubfoot according to Ponseti method: a pilot study.

A total of 70 clubfeet were treated by a posterior above-knee cast (pressure points on the talus and on the first metatarsal) according to Ponseti method. At diagnosis, average Pirani score was 4.44, and mean time of treatment was 50.32 days. Overall, 27 (38.6%) clubfeet had only conservative treatment (5.29 casts) and 43 (61.4%) also had Achilles tenotomy (6.38 casts). At the end 61/70 feet (87.14%) had Pirani score 0; 10/70 feet (5.71%) had Pirani score 0.5. The Pirani score gain/cast was ß=-0.432 (P<0.001). This new casting technique is safe and effective at avoiding some adverse issues related to the removal of the conventional cast.

Pseudoarthrosis of second metatarsal fracture.

Metatarsal fractures make up the greatest portion of foot fractures in children. Most of them are treated with closed reduction and non-weightbearing cast immobilization.Usually, these fractures heal uneventfully and delay union and pseudoarthrosis are rare. We report a case of a 10-year-old child with non-union of the second metatarsal following a traumatic fracture, caused by an accident 10 months before, and treated successfully by osteosynthesis with plate and screws. Good clinical outcome was achieved at 2 years follow-up.

Transient femoral nerve palsy in spica cast treatment for developmental dysplasia of the hip.

A 4 months and half female child come to our attention for congenital dislocation of the left hip, previously treated in another hospital with abduction bracing, without satisfactory results. After progressive longitudinal bilateral traction, closed reduction under general anesthesia was performed and a spica cast was applied in the so-called human position. The patients remained in the spica cast for 6 weeks and then the plaster cast was renewed in narcosis for another 6 weeks. Once the second cast has been removed left femoral nerve palsy was detected. Orthopaedic treatment was interrupted and in 3 months the nerve completely recovered, while the hip was still stable. We followed the child regularly since then, she is now five years old, she is totally asymptomatic, X-rays shows a residual acetabular dysplasia, with no sign of avascular necrosis.

Bone disorders in children and adolescents with chronic HCV infection.

BACKGROUND AND AIMS: Although several studies have demonstrated a higher incidence of bone disorders in HCV-infected adults, the bone turnover alterations occurring in children and adolescents with chronic hepatitis C has not been thoroughly focused yet. We performed a study on a cohort of 30 HCV infected caucasian children and adolescents to assess the prevalence of osteodystrophy and evaluate a possible prophylactic and therapeutic approach. METHODS: Data regarding biochemical markers of bone metabolism were collected. Moreover, results of ultra-sonographic bone densitometry yearly performed were evaluated in comparison with data obtained from more than 500 healthy children and adolescents. RESULTS: Osteocalcin and telopeptide of the collagen molecule type-1, CTX, appeared higher than normal in 8/30 and in 7/30 cases respectively; the 25OH vitamin D values were normal in 25/28 cases. By densitometry osteoporosis was detected in 2 patients and osteopenia in other 5. After stratification of cases by age groups, the incidence of osteopenia/osteoporosis appeared higher among children than among adolescents. Osteocalcin levels tended to be higher in cases where hepatic fibrosis were not detected. CONCLUSIONS: The higher number of cases of osteopenia/osteoporosis in children than in adolescents is worthy of note, although not statistically significant. Ultrasound densitometry confirmed its important early diagnostic role in asymptomatic HCV infected children; moreover, also the increase in serum levels of osteocalcin may be considered as early marker of osteodystrophy of complementary value. Larger studies will be needed to confirm the efficacy and safety of antiviral and supportive care in these patients.

Revision of 120 tibial infected non-unions with bone and soft tissue loss treated with epidermato-fascial osteoplasty according to Umiarov.

Treatment of tibial infected non-unions with bone and soft tissue loss has to solve three problems: infection, lack of bone continuity and lack of skin coverage. The aims of treatment are infection healing, bone consolidation with preservation of limb length and soft tissue reconstruction. The most important stage in the planning is an accurate débridement. Soft tissue reconstruction can be achieved using plastic surgery, and bone reconstruction is accomplished with bone grafts or induced membrane technique, but these methods may present disadvantages and risks. Epidermato-fascial osteoplasty is a modified procedure of compression-distraction osteosynthesis that was first described by Umiarov in 1982. This procedure offers the advantages of exactly classifying the phases of simultaneous bone and soft tissue regeneration, and of eliminating large tissue losses without previous closure of soft tissues or use of grafts, because the transported fragment takes fascia and skin along during the transport and closes the edges of the soft tissue gap until the epidermic and fascial reconstruction is complete. A total of 120 patients underwent this kind of surgery between 1986 and 2010 and were followed up for 2-26 years. Average age was 34 years (range 21-57 years). Cultures were positive for Staphylococcus in all cases, and for Pseudomonas in 27 cases. Adequate antibiotic therapy was administered in collaboration with the Infectious Diseases Specialist. Tibial bone resection was from 6 to 18cm (average 9.5cm). The Ilizarov apparatus was used with the oblique wire technique for bone transport in all patients. No intraoperative complications were observed. One patient died 40 days after the operation because of pulmonary embolism. The duration of treatment for the remaining 119 patients was 7-18 months. In all cases, infection eradication, healing of regenerate bone, consolidation at the docking site (with the aid of an autoplastic bone graft in only 11 patients), and epidermic and fascial reconstruction were observed, and functional results were very good. These techniques are particularly demanding for the patient and for the surgical team, but our results demonstrate that they can provide excellent outcomes in the management of difficult cases of infected non-unions.

Evaluation of bone density in infancy and adolescence. Review of medical literature and personal experience.

The evolution of medical and surgical therapies allows the increased survival rate of a growing number of children affected by rare pathologies. In this light osteoporotic disease is also of orthopaedic interest as it is sometimes the outward manifestation of serious pathologies (i.e. osteogenesis imperfecta). Sometimes, even in infancy and adolescence, osteoporosis is associated with complications due to fractures; in other cases it seems to have no immediate consequence. Nevertheless it must be considered as a fracture risk factor in adulthood as it negatively affects the achievement of peak bone mass. The evaluation of variations in bone mass that take place during growth is thus of particular importance in order to guarantee a level of bone health suitable for the next phase. These remarks compose the premise of a study on bone resistance carried out on a study population of between 6 and 18 years of age in the city of Pavia. To determine the resistance of the bone an ultrasound device was employed (Omnisense™ , Sunlight Medical Ltd, Tel Aviv, Israel) in two skeletal sites, distal radius and midshaft of tibia. The analysis of our results and a review of the relevant literature indicate that the median values of normality, against which we compare the measurements of the patients under examination, depend not only on age, sex, skeletal sites, race, and even ethnic group. The introduction of this new parameter, to be kept in mind when interpreting the results, invites us to be very prudent in determining the diagnostic threshold values in paediatric age. As with anthropometric data (weight, height, cranial circumference) it is possible to suggest an interpretation of the patient's SOS values comparing them with the 'centile curves' typical to the region the child belongs to. Of course, further studies are required to understand what are the variables involved and to determine the extension of the geographical area to be examined to obtain suitable reference curves.