Morscher's femoral neck lengthening osteotomy through surgical hip dislocation approach for preservation of Perthes and Perthes-like deformities.

Background: Typical sequelae of Perthes disease and Perthes-like deformities comprise a short femoral neck, aspherical femoral head, and greater trochanteric overgrowth. Morscher's osteotomy aims at restoring the normal extra-articular anatomy, but incapable of restoring a normal head-neck contour with residual impingement. Femoral neck lengthening osteotomy combined with osteochondroplasty through surgical hip dislocation approach was not previously described in the literature. We hypothesized that this technique is capable of near-normal restoration of the proximal femoral anatomy, increasing limb length, restoring abductor power, and simultaneous management of intra-articular chondro-labral disease. Methods: A prospective series of 21 consecutive patients with sequelae of Perthes disease and Perthes-like deformity (Stulberg II and III) were treated by Morscher's osteotomy through surgical hip dislocation approach. The mean age was 14.9 years (9-30 years) and the mean follow-up was 4.5 years (2-8 years). Results: The mean Harris hip score improved significantly from 66.5 to 89.5 points (p < 0.001), and the mean limb length discrepancy improved from 2.5 to 0.6 cm (p < 0.001). The mean alpha angle improved from 81.8° to 49.5°, the mean neck-shaft angle increased from 117.8° to 129.8°, and the articulo-trochanteric distance has improved from -6.7 to 20.8 mm. Six out of 21 patients required staged periacetabular osteotomy for residual acetabular dysplasia. No cases of chondrolysis or osteonecrosis were identified. Conclusion: Femoral neck lengthening osteotomy through surgical hip dislocation appraoch has proven to be safe and effective for preservation of symptomatic hips with Perthes and Perthes-like deformities and mild to moderate femoral head deformities (Stulberg II and III). A staged periacetabular osteotomy may be required in those patients with significant acetabular dysplasia. Level of evidence: Level IV.

Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount's disease: a new technique.

PURPOSE: Surgical treatment in advanced-stage infantile Blount's disease with medial plateau (MP) depression is challenging. Several osteotomies and fixation methods have been described with no established benchmark. We conducted this study to evaluate the efficacy and safety of a new single-stage technique for acute medial condyle elevation and metaphyseal osteotomies with internal fixation. METHODS: A prospective case series of 19 consecutive patients (21 knees) with severe infantile Blount's disease underwent a single-stage MP elevation and metaphyseal osteotomies, with internal fixation. The mean age was 10.3 years (8.2 to 13.6) and the mean follow-up was 5.1 years (3.2 to 8.3). The outcome measures included clinical and radiological parameters and patient-reported pediatric outcomes data collection instrument (PODCI) score. RESULTS: The mean PODCI score improved significantly from 50% to 88%. The mean internal tibial torsion improved from -27° to 11°. All cases maintained full knee extension, no limitation in flexion range of movement and no signs of instability or lateral thrust gait. All the radiographic parameters improved significantly; the mean tibiofemoral angle improved from -29° to 7°, the metaphyseal-diaphyseal angle improved from 33.4° to 4.7° and the angle of depressed MP improved from 38.3° to 2.4° (p < 0.001). At the latest follow-up, no cases of deformity recurrence were identified, the final limb-length discrepancy was < 1 cm in all patients. CONCLUSION: Single-stage MP elevation and metaphyseal osteotomies with internal fixation significantly improved the clinical and radiographic parameters and PODCI score in advanced infantile Blount's disease and precluded the use of external immobilization, with no evidence of deformity recurrence. LEVEL OF EVIDENCE: IV.

Combined Imhauser osteotomy and osteochondroplasty in slipped capital femoral epiphysis through surgical hip dislocation approach.

PURPOSE: Treatment of moderate to severe stable slipped capital femoral epiphysis (SCFE) remains a challenging problem. Open reduction by modified Dunn procedure carries a considerable risk of osteonecrosis (ON). Imhauser osteotomy is capable of realigning the deformity without the risk of ON, but the remaining metaphyseal bump is implicated with significant chondro-labral lesions and accelerated osteoarthritis. We conducted this study to evaluate the efficacy and safety of Imhauser osteotomy combined with osteochondroplasty (OCP) through the surgical hip dislocation (SHD) approach. METHODS: A prospective series of 23 patients with moderate-severe stable SCFE underwent Imhauser osteotomy and OCP through SHD. The mean age was 14.4 years (13 to 20) and the mean follow-up period was 45 months (24 to 66). The outcome measures included clinical and radiological parameters and Harris hip score (HHS) was used as a functional score. RESULTS: The mean HHS improved significantly from 65.39 to 93.3. The limb length discrepancy improved by a mean of 1.72 cm. The mean flexion and abduction arcs showed a significant improvement (mean increase of 37.5° and 18.5°, respectively). The mean internal rotation demonstrated the most significant improvement (mean increase of 38.5°). All the radiographic parameters improved significantly; including anterior and lateral slip angles (mean improvement 37.52° and 44.37°, respectively). The mean alpha angle decreased by 39.19°. The articulo-trochanteric distance significantly increased to a mean of 23.26 mm. No cases of ON or chondrolysis were identified. CONCLUSION: Combined Imhauser osteotomy and OCP through the surgical dislocation approach provide a comprehensive and safe management of moderate to severe stable SCFE. LEVEL OF EVIDENCE: IV.

Ankle Reconstruction in Fibular Hemimelia: New Approach.

BACKGROUND: Fibular hemimelia is a congenital disorder that is characterized by the absence of the fibula that could be either partial or complete. Successful management aims to restore normal weight bearing and normal limb length. The introduction of the Ilizarov method of limb lengthening has provided an attractive alternative to amputation. During lengthening, the tight posterolateral soft-tissue structures, the thick fibrous fibular band, and the shortened Achilles tendon become tighter and transfer a valgus force to the talus and calcaneus, further aggravating the deformity. QUESTIONS/PURPOSES: We have developed a strategy to address this in patients with Paley type III fibular hemimelia via ankle reconstruction that provides posterolateral stability and buttressing of the ankle and hind foot by reconstructing the lateral buttress. This is achieved through excision of the fibrous fibular anlage, centralization of the ankle, restoring talocalcaneal coronal alignment, and reconstruction of the lateral malleolus by transplanting the cartilaginous remnant of the lateral malleolus or by crafting a bone block autograft taken from the iliac crest or tibia. METHODS: A prospective non-randomized clinical trial included ten ankles in eight patients with fibular hemimelia Paley type III (two patients had bilateral deformity). The patients' ages ranged from 7 to 36 months. RESULTS: After a follow-up ranging from 48 to 96 months, a stable plantigrade foot was achieved in nine ankles; one ankle had residual equinus, five ankles had residual valgus heel, and eight ankles had complete range of motion of the ankle, whereas one patient lost 5° of dorsiflexion. One ankle had equinus deformity. CONCLUSIONS: To achieve satisfactory results, a stable plantigrade foot and ankle is necessary in patients with fibular hemimelia before attempting to equalize limb length discrepancy. It is important to reconstruct the ankle through an extra-articular soft tissue release, anlage resection, osteotomies, and restoring the abnormal talocalcaneal relationship before any attempt to equalize LLD.

Slipped capital femoral epiphysis: a review of management in the hip impingement era.

Slipped capital femoral epiphysis (SCFE) remains the most common adolescent hip disorder. Most cases present with stable slips, and in situ fixation is the most commonly adopted treatment worldwide. The introduction of the concept of femoroacetabular impingement and subsequent studies have revealed SCFE-related hip impingement to be a significant pre-arthritic condition, and the previously suggested remodeling of the proximal femur after in situ fixation has been called into question. Complex proximal femoral osteotomies and more recently intra-articular procedures via surgical hip dislocation have been employed. The literature is still lacking a strong evidence to undertake such aggressive procedures. Moreover, the application of a particular procedure regarding the nature of the slip, being stable or unstable, the degree of the slip, and the condition of the physis has not been extensively described in the literature. The purpose of this article is to outline the SCFE-related hip impingement, to review the best evidence for the current treatment options for both stable and unstable slips, and to develop an algorithm for decision making.

Antagonistic effects of Spirulina platensis against sub-acute deltamethrin toxicity in mice: Biochemical and histopathological studies.

Spirulina platensis (SP); a microalga with high antioxidant and anti-inflammatory activities, acts as a food supplement in human and as many animal species. Deltamethrin (DLM) is a synthetic pyrethroid with broad spectrum activities against acaricides and insects and widely used for veterinary and agricultural purposes. Exposure to DLM leads to hepatotoxic, nephrotoxic and neurotoxic side effects for human and many species, including birds and fish. The present study was undertaken to examine the potential hepatoprotective, nephroprotective, neuroprotective and antioxidant effects of SP against sub-acute DLM toxicity in male mice. DLM intoxicated animals revealed a significant increase in serum hepatic and renal injury biomarkers as well as TNF-α level and AChE activity. Moreover, liver, kidney and brain lipid peroxidation and oxidative stress markers were altered due to DLM toxicity. Spirulina normalized the altered serum levels of AST, ALT, APL, LDH, γ-GT, cholesterol, uric acid, urea, creatinine AChE and TNF-α. Furthermore, it reduced DLM-induced tissue lipid peroxidation, nitric oxide and oxidative stress in a dose-dependent manner. Collectively, that Spirulina supplementation could overcome DLM-induced hepatotoxicty, nephrotoxicity and neurotoxicity by abolishing oxidative tissue injuries.

Valgus osteotomy by external fixation for treatment for developmental coxa vara.

Valgus subtrochanteric osteotomy is the standard surgical treatment for coxa vara. Nevertheless, there is no consensus on the method of fixation and osteotomy technique. There are some reports on employing rigid internal fixation methods that preclude the need of postoperative immobilization. This is a technical description of a valgus osteotomy performed using external fixation with preoperative and postoperative data on a cohort of 9 patients. In this study, 9 hips in 9 patients with the diagnosis of developmental coxa vara underwent a subtrochanteric osteotomy with stabilization by an external fixator. The planned correction angle was obtained for all 9 patients with the osteotomies healing primarily. Radiographic analysis showed an improvement in Hilgenreiner's epiphyseal angle and the neck-shaft angle. There were no major complications associated with use of this method of stabilization. Minimal access surgery using external fixation for a valgus osteotomy of the proximal femur is safe and effective for the treatment for coxa vara and limb length discrepancy. It has potential advantages over commonly used open techniques and provides available alternative to currently applied methods used for fixation of proximal femoral osteotomies.

Pelvic support osteotomy by Ilizarov's concept: Is it a valuable option in managing neglected hip problems in adolescents and young adults?

For evaluating pelvic support osteotomy as a salvage procedure in managing neglected hip problems in adolescents and young adults, PSO was performed for 20 hips in 20 patients (5 men and 15 women). The mean age was 21.5 years. The etiology was neglected developmental dysplasia of the hip in 9 patients, post-septic hip sequelae in 9 patients, and paralytic dislocation due to poliomyelitis in 2 patients. All patients were treated by two osteotomies: a proximal femoral osteotomy to support the pelvis and correct the flexion and rotational deformities of the hip and a distal varization and lengthening osteotomy. Final clinical evaluation was done 6 months after frame removal. The mean external fixation time was 6.4. Lengthening and mechanical axis parallelism was achieved in all patients. At the final follow-up and according to a predesigned scoring system, there were 7(35%) excellent results, 6(30%) good results, 7(35%) fair results, and no poor results. Hip reconstruction by Ilizarov's concept can be technically demanding and involving lengthy period wearing the frame but found to be a valuable salvage procedure for numerous neglected hip problems particularly in young patients.

A safer technique for the double elevation osteotomy in severe infantile tibia vara.

Infantile tibia vara is a deformity of abrupt angulation into varus due to an affection of the postromedial aspect of the proximal tibial physis. The deformity often includes internal tibial torsion and limb length discrepancy. Gradual correction of the deformity is currently the treatment of choice for these challenging cases as it requires less invasive surgery, allows progressive and adjustable correction, permits bone lengthening if needed and achieves a more accurate correction compared to acute correction. Elevation of the depressed medial tibial condyle allows restoration of the joint architecture. Different techniques described to elevate the depressed medial tibial plateau are all technically demanding and carry potential risks of unsalvageable intra-operative complications. The aim of this study is to report the results of a safer technique for the double elevation osteotomy combined with gradual correction using the Ilizarov frame, allowing it to be more reproducible, less technically demanding and avoid those potential complications. This study included 12 limbs in 8 patients (mean age 9 years), all were classified as stage V or VI according to the Langenskiold classification. All osteotomies healed completely in all patients. The mean time in the frame was 23 weeks. The mean preoperative femoral shaft-tibial shaft angle was 36° of varus. This improved to 5° of varus. The mean preoperative femoral condyle-tibial shaft angle was 58°. This improved to 84°. The mean preoperative angle of depressed medial tibial plateau was 63°. This improved to 8°. All patients were maintaining full extension of the knee at the final follow-up, and all patients noticed a significant improvement in their gait pattern. We believe that this technique is safer and less invasive compared to traditional and even newly described techniques for elevating the depressed medial tibial plateau and correcting the deformity in severe infantile tibia vara, which will allow it to be more reproducible.

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique.

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.