Alteration in hypoplasia of the hindfoot structures during early growth in clubfeet treated using the Ponseti method.

PURPOSE: Previous reports have demonstrated diminished size of the hindfoot bones in patients with idiopathic clubfoot deformity. However, no study has quantified the percentage of hypoplasia as a function of early growth, during the brace phase of Ponseti treatment. METHODS: We measured the dimensions of ossified structures on radiographs in patients with unilateral Ponseti-treated clubfeet to determine changes in the percentage of hypoplasia between two and four years of age. RESULTS: The degree of hypoplasia varied among the osseous structures in Ponseti-treated clubfeet at age two years, with greater hypoplasia being observed in the talus (7.3%), followed by calcaneus (4.9%) and the cuboid (4.8%). Overall, the degree of hypoplasia diminished by four years, such that the degree of hypoplasia was greatest in the talus (4.2%) and the calcaneus (4.2%) followed by the cuboid (0.6%). At four years of age, the greatest degree of hypoplasia persisted in the talus and calcaneus. CONCLUSIONS: Changes occurred in the size of the ossification of hindfoot bones between two and four years of age, and the observed changes in the percentage of hypoplasia varied among the different structures. At four years of age, the greatest percentage of hypoplasia was observed in the talus and calcaneus at values similar to those previously reported in skeletally mature patients. The results suggested that the relative difference in size of the feet may be expected to remain constant in a child with a unilateral clubfoot after this age.

Quantification of the ossification of the lateral cuneiform in the feet of young children with unilateral congenital talipes equinovarus.

AIMS: After the initial correction of congenital talipes equinovarus (CTEV) using the Ponseti method, a subsequent dynamic deformity is often managed by transfer of the tendon of tibialis anterior (TATT) to the lateral cuneiform. Many surgeons believe the lateral cuneiform should be ossified before surgery is undertaken. This study quantifies the ossification process of the lateral cuneiform in children with CTEV between one and three years of age. PATIENTS AND METHODS: The length, width and height of the lateral cuneiform were measured in 43 consecutive patients with unilateral CTEV who had been treated using the Ponseti method. Measurements were taken by two independent observers on standardised anteroposterior and lateral radiographs of both feet taken at one, two and three years of age. RESULTS: All dimensions of the lateral cuneiform on the affected side increased annually but remained smaller than the corresponding dimensions of the unaffected foot (p < 0.01). The lateral cuneiform resembled a 9 mm cube at two years and an 11 mm cube at three years. CONCLUSION: At one and two years, the ossification centre of the lateral cuneiform may not be large enough to accommodate a drill hole for tendon transfer. However, by three years, it has undergone sufficient ossification to do so. Cite this article: Bone Joint J 2017;99-B:1109-14.

How do different anterior tibial tendon transfer techniques influence forefoot and hindfoot motion?

BACKGROUND: Idiopathic clubfoot correction is commonly performed using the Ponseti method and is widely reported to provide reliable results. However, a relapsed deformity may occur and often is treated in children older than 2.5 years with repeat casting, followed by an anterior tibial tendon transfer. Several techniques have been described, including a whole tendon transfer using a two-incision technique or a three-incision technique, and a split transfer, but little is known regarding the biomechanical effects of these transfers on forefoot and hindfoot motion. QUESTIONS/PURPOSE: We used a cadaveric foot model to test the effects of three tibialis anterior tendon transfer techniques on forefoot positioning and production of hindfoot valgus. METHODS: Ten fresh-frozen cadaveric lower legs were used. We applied 150 N tension to the anterior tibial tendon, causing the ankle to dorsiflex. Three-dimensional motions of the first metatarsal, calcaneus, and talus relative to the tibia were measured in intact specimens, and then repeated after each of the three surgical techniques. RESULTS: Under maximum dorsiflexion, the intact specimens showed 6° (95% CI, 2.2°-9.4°) forefoot supination and less than 3° (95% CI, 0.4°-5.3°) hindfoot valgus motion. All three transfers provided increased forefoot pronation and hindfoot valgus motion compared with intact specimens: the three-incision whole transfer provided 38° (95% CI, 33°-43°; p < 0.01) forefoot pronation and 10° (95% CI, 8.5°-12°; p < 0.01) hindfoot valgus; the split transfer, 28° (95% CI, 24°-32°; p < 0.01) pronation, 9° (95% CI, 7.5°-11°; p < 0.01) valgus; and the two-incision transfer, 25° (95% CI, 20°-31°; p < 0.01) pronation, 6° (95% CI, 4.2°-7.8°; p < 0.01) valgus. CONCLUSION: All three techniques may be useful and deliver varying degrees of increased forefoot pronation, with the three-incision whole transfer providing the most forefoot pronation. Changes in hindfoot motion were small. CLINICAL RELEVANCE: Our study results show that the amount of forefoot pronation varied for different transfer methods. Supple dynamic forefoot supination may be treated with a whole transfer using a two-incision technique to avoid overcorrection, while a three-incision technique or a split transfer may be useful for more resistant feet. Confirmation of these findings awaits further clinical trials.

Pediatric calcaneal fractures.

Calcaneal fractures in pediatric patients are seen infrequently. We retrospectively reviewed 22 skeletally immature patients with 23 fractures of the calcaneus before their distal tibial physis had fused. Eighteen (78%) of these fractures were intraarticular and five (22%) were extraarticular. Nine patients were followed for an average of 4.4 years. Of these nine fractures, 8 were treated non-operatively and one was treated with open reduction and internal fixation. A modification of the American Orthopaedic Foot and Ankle Society scoring system, which focuses on residual complaints of pain, work or sports restrictions, ability to walk on different surfaces and gait abnormalities, was employed to assess their outcome. Seven of the nine patients were free of pain, had unrestricted foot function, and possessed no apparent gait abnormalities. Two patients had activity related and cold weather related pain. We believe that the excellent prognosis for both intraarticular and extraarticular fractures, seen in this study is multi-fold. First, the immature talus and calcaneus have a superior capacity to remodel. Second, pediatric calcaneal fractures are usually consequence of low energy trauma. Lastly, a favorable intraarticular fracture pattern, unique to the skeletally immature calcaneus may exist, rendering a good prognosis.

Open fractures of the forearm in children.

OBJECTIVE: To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children. DESIGN: Retrospective review of patients treated according to protocol. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: All children with an open fracture of the forearm during a four-year period (n = 76). Fourteen patients were excluded because of inadequate follow-up or incomplete medical records. INTERVENTION: All fractures were treated with irrigation and debridement, and parenteral antibiotics. Twenty-five patients were managed with cast immobilization only, and the remaining thirty-seven, with internal fixation either with transcutaneous pins, intramedullary pins, or plates and screws, followed by immobilization in a cast. MAIN OUTCOME MEASUREMENTS: Time to union, angular alignment at union, and incidence of complications. RESULTS: The average time to union was 8.9 weeks (median, eight weeks; range, 6 to 17 weeks). There were no nonunions, but three of the sixty-two fractures had delayed union. Eight of the sixty-two fractures healed with an angular deformity of more than 10 degrees, and two developed infections, one deep and one superficial. There were three preoperative and four postoperative nerve palsies, which all resolved spontaneously. CONCLUSIONS: Open fractures of the forearm in children, treated with prompt administration of parenteral antibiotics followed by debridement, were associated with a fairly low incidence of complications. Although we found that the use of some form of internal fixation tended to reduce both the need to remanipulate these fractures (p = 0.08), and to minimize the incidence of angular deformity greater than 10 degrees (p = 0.16), these findings did not reach statistical significance.

Skewfoot in patients with osteogenesis imperfecta.

We report skewfoot deformities in two patients who have osteogenesis imperfecta. A discussion will follow proposing etiologies of skewfoot, speculating that the ligamentous laxity often present in children who have osteogenesis imperfecta may predispose the development of skewfoot.

Posttraumatic tibia valga in children. A long-term follow-up note.

BACKGROUND: We reevaluated seven patients who initially had been managed nonoperatively because of a progressive valgus deformity that had occurred within approximately twelve months after satisfactory healing of a proximal tibial metaphyseal fracture sustained at an average age of four years (range, eleven months to six years and four months). All seven patients were described in a previous report from our institution, published in 1986. In that report, spontaneous improvement of the angulation was documented after an average duration of follow-up of thirty-nine months and nonoperative treatment of the deformity was recommended. METHODS: The patients were followed radiographically for an average of fifteen years and three months (range, ten years and four months to nineteen years and eleven months) after the injury. The radiographs were reviewed to determine the metaphyseal-diaphyseal angle, the mechanical tibiofemoral angle, the proximal and distal tibial remodeling angles, the limb-length discrepancy, and the deviation of the mechanical axis of the limb from the center of the knee joint. Knee function was assessed with use of the rating system of the Cincinnati Sportsmedicine and Orthopaedic Center, and ankle function was assessed with use of the rating system of the American Orthopaedic Foot and Ankle Society. RESULTS: Every patient had spontaneous improvement of the metaphyseal-diaphyseal and mechanical tibiofemoral angles. Most of the correction occurred at the proximal part of the tibia. The mechanical axis of the limb remained lateral to the center of the knee joint in every patient, with an average deviation of fifteen millimeters (range, three to twenty-four millimeters). The affected tibia was longer than the contralateral tibia in every patient, with an average limb-length discrepancy of nine millimeters (range, three to eighteen millimeters). The knee score on the affected side was excellent for five patients and fair for two; one of the patients who had a fair score had had a tibial osteotomy at the age of sixteen years because of pain in the lateral aspect of the knee that was thought to be due to malalignment. The ankle score on the affected side was excellent for three patients and good for four. CONCLUSIONS: Spontaneous improvement of the deformity occurred in all patients and resulted in a clinically well aligned, asymptomatic limb in most. We believe that patients who have posttraumatic tibia valga should be followed through skeletal maturity and that operative intervention should be reserved for patients who have symptoms secondary to malalignment.

Complications in the use of the Bailey-Dubow extensible nail.

The results of 40 extensible intramedullary nailing procedures in 15 children who had osteogenesis imperfecta were reviewed to identify risk factors leading to complications of this method of treatment. There were 40 complications, 17 major and 23 minor. The 17 major complications led to 15 additional procedures, 10 of which were to remove or replace the implant. The prevalence of major complications was highest in patients who were younger than 5 years when the nail was inserted. Nails placed in the tibia tended to produce a higher incidence of major complications than did those placed in the femur, but this difference was not statistically significant. By survivorship analysis, patients had a greater risk of requiring a revision procedure when a technical error occurred at the time the nail was inserted. Patients who had nails placed in the femur tended to have a lower risk of needing revision surgery than did those who had nails placed in the tibia, but this difference was not statistically significant. The results suggested that the extensible nail is most advantageous in the femur and in patients older than 5 years. Avoiding technical errors when inserting the nail may improve the longevity of the device.

Brace treatment of early infantile tibia vara.

We reviewed 24 children (42 extremities) who had a diagnosis of early infantile tibia vara treated by using a brace. The indication for bracing was either a varus deformity that was not improving by age 18-24 months, or a persistent varus deformity seen in a patient older than 24 months. We prescribed an above-the-knee brace with a free ankle, single medial upright with valgus-producing straps, and either no hinged joint or a locked hinge joint at the knee. The braces were worn during the day and were removed for bedtime. The patients were followed up for an average of 27.2 months (range, 12-72) from the initiation of brace treatment, and the outcome at latest follow-up was determined by using radiographic criteria. Before treatment, 29 extremities were Langenskiöld stage I, II were stage II, and two were stage III. Before treatment, the metaphyseal-diaphyseal angle averaged 16.4 degrees. Forty of the 42 extremities had metaphyseal-diaphyseal angles of > 11 degrees, and 20 were > 16 degrees. Based on our criteria, we rated 29 extremities good, nine fair, and four poor. We conclude that daytime, ambulatory brace treatment may favorably alter the natural history of tibia vara in patients who are younger than 3 years and who have Langenskiöld stage I or II deformity.

Comparison of different methods used to inhibit physeal growth in a rabbit model.

A rabbit model was used to compare the rate, efficacy, and histologic appearance of physeal growth inhibition effected by Phemister epiphysiodesis, epiphyseal stapling, and percutaneous epiphysiodesis. Each technique led to an effective physeal closure, although the Phemister and staple methods produced more rapid deceleration of growth. A slower rate of physeal closure was seen after percutaneous epiphysiodesis, because this technique produced a gap in the bone that initially filled with fibrous tissue before forming bridges of trabecular bone leading to closure of the growth plate. Elevation of the periosteum alone produced an initial growth stimulation followed by early physiologic physeal closure. The amount of physis to ablate when doing a percutaneous epiphysiodesis is controversial. These results suggest that a percutaneous technique with limited physeal ablation, as used in the current study, effects slower rate of growth inhibition than that by the Phemister and staple techniques. A percutaneous technique that ablates a larger portion of the physis may be desirable to obtain more rapid growth inhibition.

Demonstration of avulsion of the triceps tendon in an adolescent by magnetic resonance imaging.

Avulsion of the triceps tendon is an uncommon injury typically occurring in skeletally mature individuals. Although the diagnosis can be suggested by the physical findings and initial radiographs, it may be missed, especially when severe swelling of the soft tissues prevents an accurate physical examination and the radiographs do not show a small fragment of bone accompanying the avulsed tendon. This report describes an avulsion of the triceps tendon in an adolescent boy. Magnetic resonance imaging was useful in confirming the diagnosis.

Scaphocapitate syndrome in a child associated with a distal radius and ulna fracture.

A case is presented of scaphocapitate fracture syndrome associated with a Salter-Harris type II fracture of the distal radius and ulna occurring in an 11-year-old girl. The proximal fragment of the fractured capitate was rotated 180 degrees. The injury was treated by open reduction and internal fixation. One year after the injury, radiographs showed that fractures were united with no signs of avascular necrosis of the capitate. The patient had a full range of motion of the wrist, as well as full pronation and supination of the forearm. An awareness of this fracture entity is necessary to correctly diagnose this injury in a child.

Tibialis anterior transfer for calcaneal deformity: a postoperative gait analysis.

We retrospectively evaluated seven children who had low-lumbar-level spina bifida and who had undergone bilateral transfer of tibialis anterior to the calcaneus. The mean age at the time of operation was 8 years (range, 3-12), and the patients were monitored for an average of 40 months (range, 24-60). All children underwent a postoperative gait analysis to assess the function of the transfer and the need for continued postoperative bracing. Transfer of the tibialis anterior muscle to the calcaneus arrested progression of the calcaneal deformity; however, the transfer could not prevent excessive dorsi-flexion of the ankle during stance. The use of a pretibial ankle-foot orthosis improved velocity, increased stride length, decreased quadriceps activity at terminal stance, and led to decreased energy expenditure. We conclude that continued bracing is necessary to provide a more normal appearing and energy-efficient gait.

Acute hematogenous osteomyelitis. An unusual cause of compartment syndrome in a child.

Acute compartment syndrome of the leg developed in a 4-year-old child due to acute hematogenous osteomyelitis of the proximal fibula. Because of its unusual presentation, the diagnosis of osteomyelitis initially was missed. This report suggests that the diagnosis of acute hematogenous osteomyelitis of the proximal part of the fibula should be considered in young children who present with acute compartment syndrome of the leg and who have no history of recent surgery or trauma.

Acute hematogenous osteomyelitis of the epiphysis.

Acute primary infection of the epiphysis is uncommon. This article presents 2 cases. An acute osteomyelitis of the distal femoral epiphysis, which was not diagnosed until 2 weeks after the onset of symptoms, developed in a 4-year-old boy. The epiphyseal infection spread into the knee joint, necessitating surgical debridement. An acute osteomyelitis of the proximal tibial epiphysis developed in a 23-month-old girl. Although the diagnosis was not confirmed until 1 week after the onset of symptoms, she responded well to a course of intravenous antibiotics followed by oral antibiotics. The epiphysis is a potential site for acute hematogenous osteomyelitis. Prompt diagnosis and early treatment may prevent spread of the infection into the adjacent joint.

Bone mineral density in children with mild osteogenesis imperfecta.

We used dual-energy X-ray absorptiometry (DEXA) to compare the bone mineral density (BMD) of nine children aged from 2 years 7 months to 13 years 5 months who had mild osteogenesis imperfecta with an age- and sex-matched control group. The patients had only mild clinical symptoms but DEXA detected highly significant differences in BMD between them and the controls. The mean BMD in the children with osteogenesis imperfecta was 76.7% of normal in the lumbar spine (p < 0.001) and 71.2% of normal in the femoral neck (p < 0.001). DEXA is an objective, reproducible and sensitive method of measurement of BMD in children. It may help to establish the diagnosis, to assess prognosis and possibly to monitor the response to different types of treatment.

Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children.

Supracondylar fractures of the humerus in children are commonly treated with closed reduction and percutaneous pin fixation. Using an adult human cadaver model, we measured the resistance to internal rotation of the distal fragment of simulated supracondylar fractures, fixed with four different configurations of pins. The maximum stability was provided by two crossed pins placed from the medial and lateral condyles. In comparison, the torque required to produce 10 degrees of rotation averaged 37 per cent less with use of two lateral parallel pins and 80 per cent less with use of two lateral crossed pins (p < 0.05 for both). The average torque required to produce 10 degrees of rotation with use of three lateral pins was 25 per cent less than with use of two medial and lateral crossed pins, although the difference was not significant.

Displaced fractures of the apophysis of the olecranon in children who have osteogenesis imperfecta.

Seven fractures of the apophysis of the olecranon in five children who had mild osteogenesis imperfecta were treated with open reduction and internal fixation followed by immobilization in a cast. All of the fractures healed uneventfully. The patients were examined after an average duration of follow-up of thirty months (range, twelve to sixty months); at that time, no patient reported pain or limitation of function. In the four elbows that had been followed for three years or more, there had been no observable disturbance of growth.

Transient penetration of the hip joint during in situ cannulated-screw fixation of slipped capital femoral epiphysis.

Before the routine intraoperative use of fluoroscopy at our institution during procedures to stabilize a slipped capital femoral epiphysis, twenty-five patients (thirty hips) had in situ cannulated-screw stabilization of a slipped capital femoral epiphysis with use of biplane radiography. Thus, a permanent record of the procedure was available for review. Fourteen hips in fourteen patients had an intraoperative episode during which the joint was penetrated by the guide-pin assembly or cannulated screw, or both. This penetration was corrected at the time of the operation. Eleven patients were followed for a minimum of two years (mean, thirty-nine months; range, twenty-four to sixty-three months). All physes went on to closure. None of the patients had clinical or radiographic evidence of chondrolysis. Transient penetration of the hip joint did not lead to chondrolysis in this series. This suggests that a single episode of penetration by a pin or screw, with immediate removal from the joint, is not associated with the development of chondrolysis.