[Fixation techniques for slipped capital femoral epiphysis : Principles, surgical techniques, and complications]. / Fixationstechniken bei der Epiphyseolysis capitis femoris : Prinzipien, operative Techniken und Komplikationen.

The purpose of this review is to present the pros and cons as well as the surgical techniques of conventional implants used for fixation of slipped capital femoral epiphysis (SCFE). Worth mentioning are K­wires, Hansson pins, transfixing screws, and gliding screws. We searched PubMed for "ECF" and "SCFE" in combination with "in situ fixation," "pin," "wire," "screw," and "nail." We considered Johansson nail, Knowles pin, and Nyström nail to be obsolete and of historical interest only. We noticed a trend from absolute stability towards some form of dynamic fixation over time, likely related to considerations of growth disturbance of the proximal femur and also the inherent potential for remodeling with time.

Development and prevalence of femoroacetabular impingement-associated morphology in a paediatric and adolescent population: a CT study of 225 patients.

We investigated the development of CT-based bony radiological parameters associated with femoroacetabular impingement (FAI) in a paediatric and adolescent population with no known orthopaedic hip complaints. We retrospectively reformatted and reoriented 225 abdominal CTs into standardised CT pelvic images with neutral pelvic tilt and inclination (244 female and 206 male hips) in patients ranging from two to 19 years of age (mean 10.4 years). The Tönnis angle, acetabular depth ratio, lateral centre-edge angle, acetabular version and α-angle were assessed. Acetabular measurements demonstrated increased acetabular coverage with age and/or progressive ossification of the acetabulum. The α-angle decreased with age and/or progressive cortical bone development and resultant narrowing of the femoral neck. Cam and pincer morphology occurred as early as ten and 12 years of age, respectively, and their prevalence in the adolescent patient population is similar to that reported in the adult literature. Future aetiological studies of FAI will need to focus on the early adolescent population.

Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review.

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff's clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.

Statistical shape modeling of proximal femoral shape deformities in Legg-Calvé-Perthes disease and slipped capital femoral epiphysis.

INTRODUCTION: The current understanding of morphological deformities of the hip such as femoroacetabular impingement (FAI), Legg-Calvé-Perthes disease (LCPD), and slipped capital femoral epiphysis (SCFE) is based on two-dimensional metrics, primarily involving the femoral head, that only partially describe the complex skeletal morphology. OBJECTIVE: This study aimed to improve the three-dimensional (3-D) understanding of shape variations during normal growth, and in LCPD and SCFE, through statistical shape modeling. DESIGN: Thirty-two patients with asymptomatic, LCPD, and SCFE hips, determined from physical and radiographic examinations, were scanned using 3-D computed tomography (CT) at a voxel size of (0.5-0.9 mm)(2) in-plane and 0.63 mm slice thickness. Statistical shape modeling was performed on segmented proximal femoral surfaces to determine modes of variation and shape variables quantifying 3-D shape. In addition, conventional variables were determined for all femora. RESULTS: Proximal femur shape was described by eight modes of variation and corresponding shape variables. Statistical shape variables were distinct with age and revealed coordinated, growth-associated differences in neck length-to-width ratio, femoral head medialization, and trochanter protrusion. After size and age-based shape adjustment, diseased proximal femora were characterized by shape variables distinct from those of asymptomatic hips. The shape variables defined morphology in health and disease, and were correlated with certain conventional variables of shape, including neck-shaft angle, head diameter, and neck diameter. CONCLUSION: 3-D quantitative analyses of proximal femoral bone shape during growth and in disease are useful for furthering the understanding of normal and abnormal shape deviations which affect cartilage biomechanics and risk of developing osteoarthritis.

T2* mapping of hip joint cartilage in various histological grades of degeneration.

OBJECTIVE: To evaluate T2* values in various histological severities of osteoarthritis (OA). METHOD: Magnetic resonance imaging (MRI) and T2* mapping including a three-dimensional (3D) double-echo steady-state (DESS) sequence for morphological cartilage assessment and a 3D multiecho data image combination (MEDIC) sequence for T2* mapping were conducted in 21 human femoral head specimens with varying severities of OA. Subsequently, histological assessment was undertaken in all specimens to correlate the observations of T2* mapping with histological analyses. According to the Mankin score, four grades of histological changes were determined: grade 0 (Mankin scores of 0-4), grade I (scores of 5-8), grade II (scores of 9-10), and grade III (scores of 11-14). For reliability assessment, cartilage T2* measurements were repeated after 4 weeks in 10 randomly selected femoral head specimens. RESULTS: T2* values decreased significantly with increasing cartilage degeneration (total P-values <0.001) ranging from 36.3 ± 4.3 ms in grade 0 regions to 22.8 ± 4.3 ms in regions with grade III changes. Pearson correlation analysis proved a fair correlation between T2* values and Mankin score (correlation coefficient = -0.362) that was statistically significant (P-value <0.001). Intra-class correlation (ICC) analysis demonstrated high intra-observer reproducibility for the T2* measurement (ICC: 0.949, P < 0.001). CONCLUSIONS: Given the advantages of the T2* mapping technique with no need for contrast medium, high image resolution and ability to perform 3D biochemically sensitive imaging, T2* mapping may be a strong addition to the currently evolving era of cartilage biochemical imaging.

Surgical hip dislocation in symptomatic cam femoroacetabular impingement: what matters in early good results?

In order to assess outcome and possible predictors of early good results, a prospective study on 22 patients who were treated with save surgical hip dislocation for symptomatic isolated cam-type femoroacetabular impingement (FAI) was performed. After a follow-up of 6 and 12 months, standard clinical and radiographic parameters were recorded. A statistically significant improvement of the clinical status according to the Harris hip score could be assessed at six months (p-value = 0.003) and 12 months (p-value = 0.001) post-surgery. By comparing standard clinical and radiographic preoperative parameters with various follow-up outcomes, we revealed no specific parameter with predictive value. These findings are important for centers that have just started to use this surgical technique and are still identifying their learning curve.

Surgical dislocation of the hip for the fixation of acetabular fractures.

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.

Fractures of the odontoid in children with an open basilar synchondrosis.

Fractures of the odontoid in children with an open basilar synchondrosis differ from those which occur in older children and adults. We have reviewed the morphology of these fractures and present a classification system for them. There were four distinct patterns of fracture (types IA to IC and type II) which were distinguished by the site of the fracture, the degree of displacement and the presence or absence of atlantoaxial dislocation. Children with a closed synchondrosis were classified using the system devised by Anderson and D'Alonzo. Those with an open synchondrosis had a comparatively lower incidence of traumatic brain injury, a higher rate of missed diagnosis and a shorter mean stay in hospital. Certain subtypes (type IA and type II) are likely to be missed on plain radiographs and therefore more advanced imaging is recommended. We suggest staged treatment with initial stabilisation in a Halo body jacket and early fusion for those with unstable injuries, severe displacement or neurological involvement.

Oblique pelvic osteotomy in the exstrophy/epispadias complex.

We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair. The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108). Of the 45 patients, 42 reported no pain or functional disability, although six had a waddling gait and two had marked external rotation of the hip. Complications included three cases of infection and loosening of the external fixator requiring early removal with no deleterious effect. Mid-line closure failed in one neonate managed in plaster. This patient underwent a successful revision procedure several months later using repeat osteotomies and external fixation. The percentage pubic approximation was measured on anteroposterior radiographs pre-operatively, post-operatively and at final follow-up. The mean approximation was 37% (12% to 76%). It varied markedly with age and was better when external fixation was used. The wide range reflects the inability of the anterior segment to develop naturally in spite of close approximation at operation. We conclude that bilateral oblique pelvic osteotomy with or without external fixation is useful in the management of difficult primary closure in bladder exstrophy, failed primary closure and secondary reconstruction.

Relapsed infantile Blount's disease treated by hemiplateau elevation using the Ilizarov frame.

We have treated seven children with relapsed infantile Blount's disease by elevation of the hemiplateau using the Ilizarov frame. Three boys and four girls with a mean age of 10.5 years were reviewed at a mean of 29 months after surgery. All had improved considerably and were pleased with the results. The improvements in radiological measurements were statistically significant (p < 0.001). Three-dimensional CT reconstruction was useful for planning surgery. There were no major complications. The advantages of this technique are that in addition to elevation of the hemiplateau, rotational deformities and limb-length discrepancies may be addressed.

Linear sebaceous naevus syndrome and resistant rickets.

The association between vitamin-D-resistant rickets and linear sebaceous naevus syndrome is extremely rare. Only eight cases have been described in the English literature and in none were the skeletal aspects addressed. We present three new cases and describe the musculoskeletal features. The details and outcome of surgery for correction of the deformities are discussed. The disturbances of metabolism of vitamin D and the effects of pharmacological treatment are also described.

Quadricepsplasty for knee stiffness after femoral lengthening in congenital short femur.

We review the results of a modified quadricepsplasty in five children who developed stiffness of the knee after femoral lengthening for congenital short femur using an Ilizarov external fixator which spanned the knee. All had a full range of movement of the knee before lengthening was undertaken. Unifocal lengthening was carried out in the distal metaphysiodiaphyseal region of the distal femur with a mean gain of 6.5 cm. The mean percentage lengthening was 24%. At the end of one year after removal of the Ilizarov frame and despite intensive physiotherapy all patients had stiffness. Physiotherapy was continued after the quadricepsplasty and, at the latest follow-up (mean 27 months), the mean active flexion was 102 degrees (80 to 130). The gain in movement ranged from 50 degrees to 100 degrees. One patient had a superficial wound infection which settled after a course of oral antibiotics. None developed an increased extension lag after surgery and all were very satisfied with the results. Quadricepsplasty is a useful procedure for stiffness of the knee after femoral lengthening which has not responded to physiotherapy.

A study of epidural pressures in infants.

BACKGROUND: The pressures exerted on fragile structures in the infant during epidural injections have never been studied previously. METHODS: We measured the pressure changes in the epidural space of 20 infants during injection of local anaesthetic solutions. The pressures developed during passage of the epidural needle through the ligaments of spine and in the epidural space during the injection of 1 ml at two rates of injection, over 1 and 2 min and the residual pressure 1 and 2 min after each injection were studied. RESULTS: The mean pressure while the needle was being advanced through the ligamentum flavum was 69.14 +/- 36.95 mmHg. The epidural pressure after needle had just penetrated the ligament without eliciting the loss of resistance was 1 +/- 9.759 mmHg. A distinct pulsatile waveform identical to the pulse waveform was observed as soon as the epidural space was entered. The pressure rise varied according to the rate of injection. The pressures were 27.79 mmHg when the rate of injection was 1 ml.min(-1), with a residual pressure after 1 min of 12 +/- 5.53 mmHg and 10.14 +/- 5.53 mmHg after 2 min of injection. When the rate of injection was 1 ml.2 min(-1), the pressures were 15.66 +/- 9.48 mmHg with a residual pressure after 1 min of 14.79 +/- 5.15 mmHg and 12.93 +/- 5.46 mmHg after 2 min of injection. CONCLUSIONS: The residual pressures seem to vary more with the volume injected than the rate of injection or the pressures developed during the injection. The relationship between the rate of injection and pressures is significant when compared with adults where the pressures have been measured after an injection rate of 1 ml.s(-1) and 1 ml.5 s(-1). This is a very fast rate compared with our rates of injection of 1 ml over 1 and 2 min. Based on the findings of this study, we recommend a rate of 1 ml.2 min(-1) in infants. In neonates, a slower rate of injection would be preferable.

Combined asymptomatic congenital anterior and posterior deficiency of the atlas.

Atlas anomalies in terms of clefts and aplasia are rare. They can sometimes simulate fractures and need further evaluation. Imaging in terms of CT and MR can help resolve diagnostic confusion and also outline associated neurological involvement. A rare anomaly of anterior and posterior atlas arch, previously unclassified, is presented.

The orthopedists' perspective: bone tumors, scoliosis, and trauma.

Although a detailed, comprehensive look at pediatric orthopedists' use of imaging is beyond the scope of this article, we offer an orthopedist's perspective of the role imaging plays in the care of children with tumors, scoliosis, and trauma. Given the growing, dynamic state of a child's skeleton, the long-term consequences of injury must always be considered.

Familial torticollis with polydactyly: manifestation in three generations.

Familial transmission of congenital muscular torticollis (CMT) has been reported in the literature, and postaxial polydactyly has been frequently reported in familial cases, but, to our knowledge, familial CMT with postaxial polydactyly has not been described. In this article, we report a rare case of CMT with postaxial polydactyly in 3 generations of a family and suggest an autosomal-dominant pattern of inheritance in these cases.

Complications of anaesthesia and surgery for laryngotracheo-oesophageal cleft.

Laryngotracheo-oesophageal cleft presents great difficulty in airway management. Tracheostomy and/or bilateral endobronchial intubation to secure the airway and a feeding gastrostomy are essential to sustain life until major definitive surgery can be planned. We describe the anaesthesia for these emergency life saving procedures in a 1.1-kg, 2-day-old neonate of 29 weeks gestation with apnoeic spells. Endoscopy to diagnose the extent of cleft, probable tracheostomy and gastrostomy were planned. Oesophagoscopy and bronchoscopy revealed a grade 3-4 cleft. Inadequate spontaneous ventilation during these procedures necessitated positive pressure ventilation. This resulted in a gaseous distension of an intact stomach which could be decompressed into the oesophagus. After the bronchoscopy, the use of a 3-mm tracheal tube without a Murphy's eye minimized the distension during gastrostomy. There was an accidental extubation after gastrostomy. Emergency reintubation with a 4-mm tracheal tube with a Murphy's eye resulted in gastric distension which led to tension pneumoperitoneum with a disappearance of PECO2. Misdiagnosis of this as loss of airway led to repeated intubations and extubation until the pneumoperitoneum was suspected and decompressed. After this setback, the baby's condition deteriorated over the next few hours ending fatally. The problems and suggestions to avoid these complications are discussed.