Treatment of reflex sympathetic dystrophy in children using a prostacyclin analog: preliminary results.

UNLABELLED: The aim of our study was to evaluate Iloprost, a prostacyclin analog, for treatment of reflex sympathetic dystrophy in children not responsive to conservative treatment. Seven female patients with a mean age of 9 years (range, 6-11 years) diagnosed with reflex sympathetic dystrophy Stage II were treated with infusions of Iloprost given on three consecutive days. Additionally, all patients had physiotherapy and were offered psychologic consultation. One day after the final infusion, all seven patients were free of pain and achieved full weightbearing. The side effects of Iloprost were headache in all patients and vomiting in two patients. Two patients experienced relapse--one patient at 3 months and the other patient 5 months after primary treatment--but both were free of pain by 5 days after a second series of infusions. During a mean followup of 30 months all patients remained asymptomatic. Our preliminary results suggest that temporary sympathicolysis with Iloprost, physiotherapy, and psychologic counseling is a safe and an effective treatment of reflex sympathetic dystrophy in children with a long history of symptoms or in those who do not respond to conservative treatment. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Instructions for Authors for a complete description of levels of evidence.

Pathomorphology and treatment of congenital anterolateral bowing of the tibia associated with duplication of the hallux.

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.

Iloprost for the treatment of bone marrow edema in the hindfoot.

The parenteral application of the vasoactive drug, iloprost, might be a viable option for the treatment of BMES of different origins, especially ischemic ones. In edema that is secondary to osteoarthrosis or stress, the effect of therapy with iloprost depends on the grade of the basic disease. The natural course of the disease, as well as the normalization of the signal pattern of the MRI, seem to be accelerated.

Juvenile bone-marrow oedema of the acetabulum treated by iloprost.

The bone-marrow oedema syndrome is associated with local vascular disturbances and may be treated either conservatively or by core decompression after which recovery may take several weeks. We describe a 15-year-old girl with bone-marrow oedema of the left acetabulum which was confirmed by MRI. She presented with a four-week history of severe constant pain. Routine blood tests and plain radiographs were normal. She was treated with intravenous infusions of iloprost on five consecutive days (20 microg administered in 500 ml of sodium chloride). Iloprost causes vasodilatation with reduction of capillary permeability and it inhibits platelet aggregation. She had relief from pain at rest after three days of treatment and was completely free from symptoms after two weeks. MRI after six weeks showed almost complete resolution of the marrow oedema and was normal after four months. This is the first report of the pharmacological treatment of the bone-marrow oedema syndrome in children.

Treatment of bone-marrow oedema of the talus with the prostacyclin analogue iloprost. An MRI-controlled investigation of a new method.

Bone marrow oedema syndrome of the talus is a rare cause of pain in the foot, with limited options for treatment. We reviewed six patients who had been treated with five infusions of 50 microg of iloprost given over six hours on five consecutive days. Full weight-bearing was allowed as tolerated. The foot score as described by Mazur et al was used to assess function before and at one, three and six months after treatment. The mean score improved from 58 to 93 points. Plain radiographs were graded according to the Mont score and showed grade-I lesions before and after treatment, indicating that no subchondral fracture or collapse had occurred. MRI showed complete resolution of the oedema within three months. We conclude that the parenteral administration of iloprost may be used in the treatment of this syndrome.

[Congenital pseudarthrosis of the tibia]. / Die kongenitale Tibiapseudarthrose.

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging conditions in paediatric orthopaedics. The history of CPT treatment is characterised by repeatedly ineffective surgical interventions with the inevitable outcome of severe disability. Most procedures failed to account for the complexity of the problem. The past two decades have witnessed more experience having been gained with the Ilizarov technique. This method provides a comprehensive approach to all aspects of CPT problem, allowing the surgeon to simultaneously address the problems of union as well as those of deformity, length discrepancy joint function, ankle valgus and weight bearing. It appears that the goal to achieve stable fusion before the child begins school is attainable. In the pre-pseudoarthrotic stage, bracing should be preferred to surgery until the patient is in an older age group. This study reports on the results of 19 patients: 15 have finished treatment, and 14 of them with a stable fusion at follow-up. The results were highly encouraging in reaching the ultimate goal of avoiding amputation and achieving a well-functioning limb.

Reflex sympathetic dystrophy in children.

This report presents the case of an 8-year-old boy who underwent a second clubfoot operation following early-stage reflex sympathetic dystrophy (RSD). After other conditions had been ruled out, the patient was submitted to physiotherapy supported by antiphlogistic and analgesic drugs as well as a partial immobilisation of the affected extremity. He remained asymptomatic during the following 4 weeks. RSD in children is not a well-recognised entity. This case of early-stage RSD illustrates the need to be aware of this possible complications after operation in the differential diagnosis of local pain and swelling of a limb.

Radiographic evaluation of the acromion in impingement syndrome: comparison with arthroscopic findings in 147 shoulders.

We analyzed standardized scapulolateral and anteroposterior view radiographs in 147 patients with impingement syndrome to detect a subacromial osteophyte or spur, which should be of value in those patients who require surgical treatment. Standard anteroposterior view radiographs with a fixed tube angulation, 0 and 30 degrees, were compared to anteroposterior view radiographs with individual tube angulation (the radiograph beam was tilted caudally, depending on the slope of the acromion). In all patients, we identified an acromion bony overhang on the anteroposterior view radiographs with individual tube angulation having an average thickness of 5 mm, which correlated well with the intraoperative findings at arthroscopic acromioplasty. In only 35% of the patients did we detect a subacromial osteophyte or spur on radiographs with a fixed tube at 0 degrees angulation and in 92%, we found a false impression of a spur on the 30-degree views because of overexposure. We conclude that, anteroposterior view radiographs with an individual caudally-tilted X-ray beam, depending on the acromion slope, can show the whole spur and/ or size of the osteophyte, on the anterior margin of the acromion.

Stress fracture of the tibia after total knee arthroplasty.

We present a case of total knee arthroplasty in which the patient suffered a transverse stress fracture of the tibia 2 weeks after replacement without significant injury. Plain radiographs were obtained on event presentation. Later radiographic examination showed the fracture and a periosteal reaction. The fracture healed after immobilising the limb in a cast for 2 months. This case illustrates well an insufficiency fracture to the occurrence of stress risers in a weakened bone when subjected to repetitive loading as a complication following total knee arthroplasty.

Radiographic analysis of metatarsus primus varus. 45 feet followed 15 months after distal metatarsal osteotomy and lateral soft-tissue release.

We analyzed standardized radiographs of 45 feet in 41 patients with symptomatic hallux valgus and an intermetatarsal angle of 17 (15-23) degrees 15 (9-24) months after distal metatarsal osteotomy and lateral soft-tissue releases. A mean reduction in the II-intermetatarsal angle of 12 degrees and hallux valgus angle of 24 degrees was found. On average, the metatarsus primus varus angle improved by 4 degrees, the I-intermetatarsal angle by 3 degrees and the inclination angle of the first cuneiform by 4 degrees. We conclude that this operation corrects the metatarsus primus varus, without substantially altering the alignment of the long axis of the first metatarsal.

[Mobile flatfoot as a sequela of dislocation injury of the Lisfranc joint. A retrospective analysis of 13 patients]. / Der mobile Plattfuss als Spätfolge einer Subluxationsverletzung im Lisfranc-Gelenk. Eine retrospektive Analyse von 13 Patienten.

In this retrospective study, 13 patients with subtle Lisfranc joint injuries were examined after a mean period of 23 months using clinical assessment, radiography and dynamic pedographic gait analysis. The aims were to identify the factors leading to a mobile flatfoot deformity, evaluate the functional and clinical outcome of these injuries, and draw practical conclusions for initial management and subsequent intervention. All patients showed a mobile flatfoot deformity, increased motion in the subtalar joint, increased load on the hindfoot, decreased load on the forefoot, and a prolonged contact phase during the stance phase. Radiographs revealed progressive osteoarthrosis in the joint and a residual displacement of the medial Lisfranc joint. An unstable medial Lisfranc joint results in the development of a mobile flatfoot. Initial treatment of a subtly displaced Lisfranc joint should consist of exact anatomical reduction and additional maintenance of the longitudinal arch of the foot. After failed initial treatment, early arthrodesis of the midfoot is recommended as a salvage procedure for the foot.

Arthrodesis for traumatic flat foot. Tarsometatarsal and medial longitudinal arch fusion by inlay grafting, 11 feet followed for 1.5 years.

We examined 11 feet, 18 (11-30) months after simultaneous tarsometatarsal and medial longitudinal arch fusion to stabilize a residual mobile flat foot resulting from an injury. All had solid fusion and the surgical correction of the flat foot deformity was maintained. At the follow-up, we rated 6 feet as excellent and 5 as good. Mechanically, simultaneous arthrodesis of the tarsometatarsal joint and the longitudinal arch of the foot seem better than isolated arthrodesis of the tarsometatarsal joints.

[Gait analysis after intra-articular calcaneus fractures]. / Ganganalyse nach intraartikulären Fersenbeinfrakturen.

We retrospectively compared 20 patients with displaced intra-articular calcaneal fractures by clinical assessment and dynamic pedography. Eleven were treated operatively, 9 conservatively. The purpose was to identify differences in post-traumatic gait performance and to correlate the pedographic data to a clinical score to show its reliability. Twenty individuals without a history of foot injuries were used as a control group. Both groups had restricted motion in the subtalar joint, increased hindfoot and midfoot loading and decreased forefoot loading. Furthermore, they showed prolonged contact phases and an impaired ability to speed up gait during the toe-off phase. Load transfer from the hindfoot to the forefoot showed typical distribution patterns. The operatively treated group showed better functional results with fewer subjective complaints.