Is non-operative management of childhood neurologic cavovarus foot effective?

INTRODUCTION: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE: IV.

Sacral stress fracture after lumbar and lumbosacral fusion. How to manage it? A proposition based on three cases and literature review.

Sacral fracture after lumbosacral instrumentation could be a source of prolonged pain and a late autonomy recovery in old patients. Diagnosis remains difficult and usually delayed. No clear consensus for efficient treatment of this complication has been defined. Aim of this study was to determine how to manage them. Three patients who sustained sacral fracture after instrumented lumbosacral fusion performed for degenerative disease of the spine are discussed. History, physical examinations' findings and radiographic features are presented. Pertinent literature was analyzed. All patients complained of unspecific low back and buttock pain a few weeks after index surgery. Diagnosis was done on CT-scan. We always choose revision surgery with good functional results. Sacral stress fracture has to be reminded behind unspecific buttock or low back pain. CT-scan seems to be the best radiological test to do the diagnosis. Surgical treatment is recommended when lumbar lordosis and pelvic incidence mismatched.

Cervical spine surgery in ankylosing spondylitis: Review and current concept.

Ankylosing spondylitis of the cervical spine is associated with stiff kyphosis and increased risk of transversal unstable fracture. A spine surgeon may be involved mainly in the management of trauma cases, but in some situations, corrective surgery of a kyphotic cervical deformity is needed. Both types of cases carry specific aspects and rely on principles that differ from those associated with more common cervical surgery. This paper is a review of the literature regarding cervical surgery in cases of ankylosing spondylitis. It addresses practical technical questions.

Periacetabular cement extrusion in the course of total hip replacement: incidence and consequences. An analysis from 269 consecutive cemented total hips.

INTRODUCTION: Periacetabular cement extrusion during total hip arthroplasty is a frequent adverse event. This study sought to determine the contributing factors and any functional consequences of this type of extrusion, which has been insufficiently studied in the literature. HYPOTHESIS: We hypothesized that the occurrence of periacetabular cement extrusion could be the cause of an alteration in the functional result and/or intrapelvic complications. PATIENTS AND METHODS: We retrospectively analyzed a series of 269 total hip prostheses consecutively implanted through a posterolateral approach using a second-generation technique with high-viscosity cement over a period of 1 year (186 standard cemented cups [69%] and 83 retentive cemented cups [31%]). The series comprised 110 males and 159 females aged a mean 69.3±16.8 years (range, 35-96 years). The indication for arthroplasty was primary osteoarthritis in 135 cases (50.4%), necrosis of the femoral head in 56 cases (20.8%), fracture of the femoral neck in 71 cases (26.5%), and seven cases of inflammatory arthritis. We radiographically assessed the frequency of periacetabular cement extrusion and then sought to determine the contributing factors as well as any eventual functional consequences based on the Modified Harris Hip Score, the existence of hip pain, and signs of pelvic dysfunction. RESULTS: Periacetabular cement extrusion was found in 68 patients (25%) and was more frequent in women. No other contributing factor was identified, notably the indication for arthroplasty, the operator's experience level, or the type of cemented cup. Extrusion was not accompanied by a change in the Harris function score nor an increased frequency of urinary or pelvic disorders. DISCUSSION: Periacetabular cement extrusion is frequent but its consequences are rare (mechanical, vascular, neurological, urological, or visceral). Preventing their occurrence with well-adapted technique is warranted (avoidance of perforating anchoring holes, control of cement penetration). Given the rarity of the consequences, ablation of any extrusion diagnosed intraoperatively should be cautiously pondered upon to prevent any potential iatrogenic incident for a doubtful gain. In cases of local pain persistence, the usual causes of hip pain should be ruled out before attributing the source of functional discomfort to extrusion and envisioning its removal.