Role of proximal tibiofibular fixation in leg lengthening with the Ilizarov method in the achondroplastic patient.

The role of proximal tibiofibular joint (TFJ) transfixion during Ilizarov tibial lengthening is still debated in the literature. The aim of this study was to show that TFJ transfixion can be avoided with no impact on patient outcome. All achondroplastic patients undergoing tibia lengthening from 1999 to 2018 were included. Patients were divided in two groups: group A (11 patients) submitted to proximal TFJ transfixion and group B (22 patients) not submitted to TFJ transfixion. The results showed a statistically significant difference in proximal fibular migration (PFM) between the two groups of patients, with a mean PFM of 9.2 mm (range, 1-20 mm) and of 21 mm (range, 2.7-76 mm) in group A and in group B, respectively. We can state that PFM up to 41 mm in our series did not affect joint function and stability. There are no statistically significant differences in the other radiological parameters. Analysis of functional scores (Knee Society, Tegner-Lhysolm, Association for the Study and Application of Methods of Ilizarov) did not reveal significant differences between the groups. The scores of the Achondroplasia Personal Life Experience Scale were also similar in the two groups, demonstrating a good quality of life. There are no differences between the two groups in terms of clinical-functional outcome of the knee, radiographic results, and quality of life. Transfixion of proximal TFJ may not be necessary, but it is important to avoid premature consolidation of the fibular osteotomy.

Clinical results and complication rates of lower limb lengthening in paediatric patients using the PRECICE 2 intramedullary magnetic nail: a multicentre study.

Implantable intramedullary nail lengthening devices (e.g., PRECICE 2 system) have been proposed as alternative method to external fixation for lower limb lengthening surgery. The aim of this study was to analyse our outcomes and complications using the PRECICE 2 (P2) nail system and review them in light of the existing literature. A retrospective multicentre study was conducted on patients <18 years, who were treated for limb lengthening using the P2 system. The inclusion criteria were a limb length discrepancy ≥ 30 mm and a follow-up ≥6 months after the end of treatment. A total of 26 (15 males) patients were included, average age was 14.7 ± 2.3 years; 26 nails (21 femur, 5 tibia) were implanted. The average goal lengthening was 49.4 ± 12.4 mm, while average achieved lengthening was 44.4 ± 11.6 mm. Average distraction and consolidation indexes were 11.9 ± 2.1 days/cm and 25.1 ± 8.1 days/cm, respectively. Nail accuracy and reliability were 91.1% and 88.5%, respectively. A total of five problems (joint contractures), one obstacle (femur fracture) and three complications (hip joint subluxation, deep infection and nail running back) were encountered. The P2 nail system is a valid alternative to external fixator for limb lengthening in young patients with no significant angular or rotation deformities. Our study confirms a favourable complication rate and available evidence from literature suggests a lower complication rate than external fixator systems. Nevertheless, surgeons should keep a watchful eye on risk of joint subluxation and mechanical complications with intramedullary lengthening.

Treatment of complex foot deformities with hexapod external fixator in growing children and young adult patients.

BACKGROUND: Treatment of complex foot deformities in growing children and young adult patients is challenging. The traditional approach consists of extensive soft tissues releases, osteotomies and/or arthrodesis. More recently, distraction osteogenesis has been proposed as an alternative strategy. The aim of this study was to describe our treatment strategy and report clinical outcomes of the patients affected from complex foot deformities treated by distraction osteogenesis and hexapod external fixator. MATERIALS AND METHODS: We retrospectively reviewed 10 consecutive patients with complex foot and ankle deformities treated from 2014 to 2016 at our unit. A TrueLok external fixator system was used in all patients. Final outcome was classified as good, fair and poor according to the criteria indicated by Paley and Ferreira. The results were also evaluated by the pre-operative and post operative American Orthopedic Foot and Ankle Score (AOFAS) and The Manchester-Oxford Foot Questionnaire (MOXFQ). RESULTS: A plantigrade foot was obtained in eight patients at the end of treatment, while in two patients a recurrence of the deformity was noted. Result was classified as good in 6 patients, fair in 2 patients, and poor in 2 patients. The AOFAS score improved from 33.9±21.2 pre-operatively to 67.25±15.1 post-operatively (p=0.005). A statistically significant improvement was observed for the MOXFQ score as well (from 60.6±23.3 to 33.0±25.2, p=0.020). CONCLUSIONS: Our study shows that the TrueLok hexapod external fixator is a safe and effective tool in treatment of complex rigid foot deformities. Nevertheless, deformity recurrence can be observed in some cases and treatment remains challenging. Distraction osteogenesis should be reserved as a salvage solution for particularly complex cases and should be performed at dedicated specialized centers.

Correction of complex lower limb angular deformities with or without length discrepancy in children using the TL-HEX hexapod system: comparison of clinical and radiographical results.

The aim of this study was to compare clinical and radiographical results for treatment of lower limb multiaxial deformities±limb length discrepancy (LLD) of at least 2 cm with the Truelok hexapod fixator system (TL-HEX). All consecutive cases of lower limb multiaxial deformities were included. Patients were divided in two groups: group 1, lower limb angular deformity+LLD less than 2 cm, and group 2, lower limb angular deformity+LLD of at least 2 cm. Only patients with age younger than or equal to 20 years and follow-up of 6 months after removal of the external fixator were included. A total of 27 (six femur and 39 tibia treated) and 20 patients (12 femur and 19 tibia) were enrolled in groups 1 and 2, respectively. Complete correction of the deformity was achieved in 90 and 96% of the patients in groups 1 and 2, respectively. There were no differences in terms of external fixator, maturation, and distraction indexes between the two groups and between different anatomical sites. Good to excellent functional results (ASAMI score) were obtained in 93% of patients in group 1 and 75% in group 2 (P=0.01). Complication rate was similar between the two groups (7.4 vs. 10%, respectively). Average follow-up after removal of the external fixator was 25.6 (range: 7.0-54.0) months. The TL-HEX external fixator system allows a predictable correction of complex lower limb deformities regardless of the presence of LLD. Although complication rate is similar between the two groups, lower functional outcomes can be expected in patients with significant preoperative LLD.

Diaphyseal femoral fractures below the age of six years: Results of plaster application and long term followup.

BACKGROUND: In children less than 6 years, the treatment of femoral shaft fracture is often non surgical, using closed reduction and casting. The literature reports many experience about this type of trauma but none of these has a long term followup. We present a retrospective study on a group of femoral diaphyseal fractures treated nonsurgically in children up to 6 years of age, with a minimum of 10 year followup. MATERIALS AND METHODS: 48 cases (36 males/12 females) with femoral diaphyseal fractures treated between January 1988 and December 1998 were reviewed. Patients with fractures due to obstetrical trauma and pathologic fractures were excluded. The mean age of the patients was 3.3 ± 1.1 years (range 5 months-6 years). Right side was involved in 21 cases (44%), and left side in 27 cases (56%). In 34 cases (71%), closed reduction was performed and hip spica was applied with the hip and knee flexed to 45°. In 8 cases (17%), skeletal traction was applied to perform fracture reduction and the traction pin was embedded in plaster while in the remaining 6 cases (12%), the Delitala pressure apparatus was applied after casting. RESULTS: All fractures healed in our study. There were no complications (infection or vascular nervous issues, axial deviations, consolidation delays, or pseudoarthrosis). In 13 cases (27%), followup examinations showed mean lengthening of 1.3 ± 0.75 (range 0.5-2.5 cm) of the fractured lower limb. All these patients were treated with skin traction before treatment and presented with 2.08 ± 0.28 cm mean initial femoral shortening. In 1 case (2%) with 2.5 cm lengthening, epiphysiodesis of the ipsilateral knee was performed. No patients showed prolonged difficulty with gait disorders. CONCLUSION: On the basis of our results conservative treatment of femoral shaft fractures in children can be considered less invasive and safe procedure.

Agreement among musculoskeletal pediatric specialists in the assessment of radiographic joint damage in juvenile idiopathic arthritis.

OBJECTIVE: To evaluate agreement among musculoskeletal pediatric specialists in assessing radiographic joint damage in juvenile idiopathic arthritis (JIA). METHODS: Two pediatric rheumatologists, 2 pediatric radiologists, and 2 pediatric orthopedic surgeons evaluated independently 60 radiographs of both wrists and hands of children with polyarticular-course JIA. Films were scored using an adapted and simplified version of the Larsen score, ranging from 0-5. Study radiographs were selected from 568 films used in a previous study aimed to validate an adapted pediatric version of the Sharp/van der Heijde (SHS) score. To enable comparison of specialists' scores with the adapted SHS score, the 60 radiographs were divided into 6 classes of severity of damage based on quintiles of the adapted SHS score. Agreement was evaluated in terms of absolute agreement and through weighted kappa statistics. RESULTS: The pediatric radiologists tended to assign lower scores and to provide more frequently scores of 0 than did the other specialists. Weighted kappa for the 3 pairs of specialists ranged from 0.67-0.69, indicating substantial agreement. Absolute agreement ranged from 51.3-55.7%, depending on the pair of specialists examined. Both absolute and weighted kappa concordance between specialists' scores and the adapted SHS score were poorer for the pediatric radiologist than for the other specialists. CONCLUSION: We observed fair agreement in the assessment of radiographic damage among pediatric specialists involved in the care of children with JIA. The radiologists tended to be more reserved than the rheumatologists and orthopedic surgeons in labeling radiographs as damaged or in considering changes as important.

Use of the eight-Plate for angular correction of knee deformities due to idiopathic and pathologic physis: initiating treatment according to etiology.

PURPOSE: Angular deformities of the knee resulting from idiopathic, congenital, or acquired causes are commonly encountered in pediatric orthopedics. Whereas physiological deformities should be treated expectantly, the remaining often progress enough to warrant operative treatment, despite attempted bracing. Historical methods of surgical treatment (e.g., epiphysiodesis and stapling) have yielded to the increasingly popular method of reversible guided growth using the eight-Plate. METHODS: We studied 58 patients with knee angular deformities managed with eight-Plate guided growth. All etiologies except physiological deformities and those with very slow growth rate were included. Each patient was under appropriate medical management during the entire duration of treatment and after plate removal. RESULTS: In the dysplasia/syndrome group, we noted complete correction in 22 patients (78.5%), partial correction in 5 (17.9%), and no correction in 1 patient (3.6%). All cases of idiopathic deformities resolved. Patients with osteochondral dysplasias and genetic syndromes underwent earlier intervention and slower correction than those with idiopathic genu varum or valgum. The time difference in reaching a neutral mechanical axis between the two groups (11 months in idiopathic versus 18 months in pathological physis) could be explained by a significant difference in growth speeds (P = 0.003). CONCLUSION: Results indicate that early intervention is advisable for patients with osteochondral dysplasias/syndromes as subsequent correction takes longer. If rebound growth causing recurrent deformity occurs, guided growth can be safely repeated. Additionally, complications reported with other techniques such as hardware failure, physeal violation by the implant, premature physeal closure, and overcorrection were not reported while using the eight-Plate.