Blount's disease.

Out of a total of 40 patients affected with Blount's disease treated at the Pediatric Orthopaedic Division of the Rizzoli Orthopaedic Institute between 1965 and 1996, 29 were affected with the infantile type, and 11 with the adolescent type. In the group affected with infantile Blount's disease, the mean age was 5.5 years, 11 were bilateral, for a total of 40 limbs affected, with a mean TMD angle of 24 degrees. All of the patients were treated by valgus osteotomy obtaining a percentage of poor results (insufficient correction or recurrence) equal to 25% according to Schoenecker's criteria. Mean follow-up was 3.6 years. In the group affected with adolescent Blount's disease, mean age was 12.6 years, the affection was always monolateral, the mean TMD angle was 15 degrees. All of the patients except 1 were treated by valgus osteotomy with elevation, and the results were constantly favorable. Mean follow-up was 2 years. The authors believe that the type of osteotomy used must be modulated based on the anatomopathologic findings of compromise in the proximal tibial metaepiphysis.

Femoral shaft fractures during childhood.

The treatment of femoral shaft fractures in the child is influenced by the anatomophysiological peculiarities of the bone in childhood. The authors report a personal series of 51 fractures treated surgically (Kuntschner, Rush, Kirshner, external fixator), and they analyze the most significant aspects of fractures of the diaphyseal segments during childhood: post-fracture lengthening and the ability for post-fracture malalignment to self-correct. Also considered are the different methods of treatment, emphasizing advantages and disadvantages (from an economical point of view, as well), to emphasize the authors' therapeutic orientation. Under 6-7 years: trans-skeletal traction for 5-6 days, reduction in narcosis without expecting to achieve anatomical reduction, pelvipodalic plaster. Over 10 years: surgical indications are more frequent, until they are the same as those for adults aged over 13-14 years. Between 7 and 10 years of age is a no man's land, where indications for surgery must be made based on the individual surgeon's experience.

Intra-articular deformities of the knee in congenital hypoplasias of the lower limb: an arthroscopic study.

A knowledge of the morphology of the cruciate ligaments in congenital hypoplasias of the lower limb, susceptible to treatment to even the length discrepancy, is of practical importance in the prevention of subdislocation and dislocation of the knee during the distraction phase of femoral and/or tibial lengthening. The authors report their experience with 20 arthroscopies diagnosed in 20 children affected with congenital hypoplasia of the lower limb (shoft congenital femur, longitudinal peroneal hemimelia) performed prior to assembling the Ilizarov external fixator for femoral and/or tibial lengthening. None of the patients had congenital dislocation of the knee or knee with recurvation. In the patients in our study, it is possible to demonstrate that the anatomical cause of instability of the knee in congenital hypoplasias of the lower limb may be constituted by aplasia of one or both cruciate ligaments.

Recurrent dislocation of the elbow in children: description of a case.

The authors report a case of recurrent dislocation of the elbow in a boy aged 11 years, surgically treated by reconstruction of the lateral capsuloligamentous structures. After a review of the literature, the need for a diagnostic protocol to establish the main cause of recurrent dislocation is emphasized.

The chondroepitrochlearis muscle: case report.

An extremely rare muscle disorder in the pectoral region is described. It involves a musculotendinous unit which originates from the pectoralis major and inserts onto the medial epicondyle of the humerus. The authors report a case of an 11-year-old boy, affected bilaterally, who underwent surgical treatment to lengthen the chondroepitrochlearis muscle. There was significant cosmetic and functional improvement.

The treatment of congenital hip dysplasia.

The authors take into consideration the different phases of the treatment of congenital hip dysplasia (CHD) as it is related to age and natural development. Within the first year of age three objectives must be aimed at: reduction of the epiphysis, its retention and immobilization, maturation of the hip. After three years of age, once the epiphysis has been reduced, reconstructive and stabilizing surgery must be performed (acetabuloplasty and femoral osteotomy) in order to correct the modified joint parameters. After ten years of age and until the end of growth the degree of dysplasia influences treatment, as intervention is justified (preferably with biological reconstruction of the acetabulum) in forms of severe dysplasia caused by the definite occurrence of pain at an early age. We emphasize the importance of adapting treatment to the specific phase of evolution of the hip understood to be dynamic reality.

Complications in acetabuloplasty in the treatment of CHD during the growth age.

The authors analyze the complications of acetabuloplasty in the treatment of CHD during the growth age, evaluating the incidence and the possible causes, that emerged from a review of cases at the Rizzoli Orthopaedic Institute including 238 patients treated from 1970 to 1986 using different methods. The techniques adopted were: acetabuloplasty for lowering in 100 cases, Salter osteotomy in 30 cases, triple pelvic osteotomy in 48 cases and acetabuloplasty according to the Chiari method in 50 cases. Complications of various types were observed in 9.6% of the cases after a mean follow-up of 5 years. It is the purpose of ths study to discuss the complications that are observed during each operation, and to compare them with those reported in the literature, as well as to present a pathogenetic interpretation. A study of complications influences indications and surgical technique.

Arthroscopic surgery of the discoid meniscus during childhood.

A total of 43 lateral discoid menisci in 38 patients submitted to arthroscopy between 1990 and 1995 is discussed. Age ranged from 2 to 14 years. Morphological changes of the lateral meniscus were classified according to Watanabe criteria. The features of preoperative symptoms were related to the type of meniscal lesion and to the age of the patient, and the results evaluated according to the Ikeuchi scale.

Joint fractures of the proximal end of the femur during childhood.

A total of 18 joint fractures of the proximal end of the femur in patients aged under 16 years (all treated non-surgically) are reported. Complete clinical-radiographic documentation was available for all 16 of them, with a minimum follow-up of 2 years. Results were evaluated based on the Ratliff criteria. The incidence of complications (in particular, avascular necrosis) was related to the type of fracture (Delbet classification) and to the degree of shifting of the segments (Boitzy).

Traumatic lesions of the acetabular triradiate cartilage (presentation of four cases and considerations on treatment).

Four cases of fracture of the triradiate cartilage (TC) are reported, all of which may be classified as epiphyseal detachments. Two of the patients were submitted to osteosynthesis of the posterior column: results were very satisfactory in one of the cases for which long-term follow-up was obtained. The other two cases, treated non-surgically, developed meta-traumatic actabular dysplasia probably due to association with crushing phenomena (Salter-Harris V) in the germinative area of TC. Despite the favorable results obtained in the case that was submitted to surgery, the authors believe that conservative treatment is best in this type of lesion, and that surgical reduction should be performed only in cases of instability and severe displacement, once surgical reduction has failed.

Complications of varus derotation osteotomy in the treatment of CHD during growth.

Complications of varus derotation osteotomies in the treatment of congenital hip displacement (CHD) are reported. Only "true" complications were considered, that is, those related to errors in technique, while those related to errors in indications were excluded. An analysis of 150 cases with a mean follow-up of 4.2 years revealed that "true" complications are a rare occurrence. Among these the most frequent are dysmetria (20%), and infection (2.6%). There was only one case of osteochondrosis (0.6%). The dysmetria (usually under 2 cm) rarely required further surgical treatment involving temporary epiphysiodesis of the homolateral knee, while the infection responded satisfactorily to combined conservative and surgical treatment.

External humeral condylar fracture in children. A long-term review of 30 cases operated.

Follow-up ranging from 2 to 14 years (mean 6 years) was obtained for 30 fractures of the external humeral condyle in children aged from 2 to 11 years; the patients had been submitted to reduction-osteosynthesis. Twelve patients were at the end of the growth period when followed-up. All of the patients were classified as Lagrange and Rigault grades II and III. Synthesis always involved two or three Kirschner wires bent under the skin. There were 24 perfect results and 6 good ones. Valgus equal to less than 10 degrees was present in 2 cases. Deficit in flexion-extension, present in 4 cases, did not exceed 20 degrees overall. Another case showed "fish-tail" radiographic deformity (due to epiphysiodesis) which did not interfere with function. Despite the potential danger of the lesion, the authors believe that careful surgical treatment provides very satisfactory results.

The treatment of congenital hip dislocation between the ages of 1 and 3.

A total of 81 patients (103 hips) with a diagnosis of congenital hip dislocation were reviewed, who had been treated between one and three years of age. All of the patients were initially treated with adhesive band traction prior to non-surgical reduction, which was performed under general anesthesia using gentle reduction maneuvers followed by immobilization in plaster. Non-surgical reduction was performed in 69 hips (67%), surgical in the remaining 34 (33%). A total of 91 associated surgical procedures were performed for the treatment of residual subluxation. Average follow-up was 12 years (minimum 5, maximum 19). The clinical results of the non-surgical reductions were excellent in 75% of the cases. Radiographically, 48% are hips which have a normal aspect, while 42% have a moderate degree of residual dysplasia or deformity of the femoral epiphysis and of the acetabulum. Hips that were initially classified as grade III dislocations show fair results. Hips treated non-surgically included 11 cases of avascular necrosis (16%); recovery was adequate. Hips treated surgically included 14 cases of avascular necrosis (30%), which was more accentuated in those hips that had initially been treated elsewhere, and in those classified as grade III. The clinical and radiographic results obtained for the hips treated surgically demonstrate poor results in 17% of the cases (6 out of 34), as a consequence of types III and IV osteochondrosis. It may be concluded that in this age group congenital hip dislocation is best treated by non-surgical reduction, possibly followed by surgery of the femur and acetabulum. Surgical reduction was only indicated when conservative methods failed.

Treatment of the sequelae of septic osteoarthritis of the hip during pediatric age.

A total of 69 cases (73 hips) of the sequelae of septic osteoarthritis of the hip are studied. The sequelae are classified based on whether or not the femoral epiphysis is present, and on stability of the joint according to Hunka (1982). Three of the hips were treated non-surgically. All of the others were submitted to from a minimum of 2 to maximum of 5 operations with the purpose of re-establishing joint relationships. The results were: good: 50 hips (72.5%); fair 12 (17.4%); poor: 11 (16%). The most significant sequelae were hip instability, joint function limitation, and shortening of the limb.

Glomus tumor in children (description of one case).

Glomus tumor is a lesion of the soft tissues which rarely occurs in children. One case of the disease characterized by deep localization and atypical radiographic symptoms and manifestations is described.

Post-injective quadriceps contracture.

After reviewing the literature, the authors report 19 patients affected with post-injective contracture of the quadriceps muscle observed by them between 1971 and 1983. Clinical evaluation, indications for surgery and the results of surgery are discussed.

Fractures of the intercondylar eminence of the tibia in children.

The authors review 31 cases of fracture of the intercondylar tibial eminence in children and adolescents. In view of the constant relationship observed between the initial clinical and radiological findings and the final results, they advise that a clinical examination in narcosis be done in all cases in order to ascertain the existence or otherwise of ligamentous laxity, which is the determining factor in the end result. After emphasizing the differences as compared with these fractures in adults, the principal surgical techniques are reviewed, including the role of arthroscopy.

Long term results of triradiate osteotomy of the pelvis. A follow-up study of 26 hips.

The authors reviewed 26 hips in 21 patients treated by triple osteotomy of the pelvis for the sequelae of congenital dysplasia or congenital dislocation of the hip. The minimum follow-up was 3 years, maximum 6 years. The clinical condition remained constant over this period. Pain, if present before operation, was either improved or disappeared. The Trendelenburg limp was either unchanged or improved. Reduction of range of hip movement was very rare. There was 0.5 cms lengthening of the leg compared with the pre-operative state. The post-operative radiographic parameters were unchanged over the follow-up period. These included the acetabular roof angle (C.E. angle), Hilgenreiner's roof angle, the neck/shaft angle, and anterior coverage of the femoral head. In about one third of the cases, however, there was deterioration in centralization.