Bending osteotomy through the distal tibial physis for stable reduction of the ankle joint in fibular hemimelia. Update at skeletal maturity.

Fibular hemimelia is a complex longitudinal malformation of the lower extremity with partial or complete deficiency of the fibula resulting in dorso-fibular dislocation of the hindfoot. Typically associated are talocalcaneal coalition, absence of rays of the foot, diaphyseal tibial deformity of valgus-procurvatum type and longitudinal growth deficiency. We have addressed the deformity of the distal tibial epiphysis surgically by a metaphyseal osteotomy to bend through the physis inspired by the Pemberton's acetabular osteotomy in 7 to 21-month-old children. Short-term results of a maximum of 42 months of follow-up have been published. Meanwhile, the first 4 patients thus treated have reached skeletal maturity, and the long-term results are presented. Three patients with unilateral and one patient with bilateral fibular hemimelia were operated on as described before at ages 7, 9, 15, and 18 months. Subsequently, several other procedures have been performed on all patients mainly consisting of lengthening of the tibia combined with axial corrections as well as additional foot alignment if needed. The osteotomy leads to stable axial retainment of the hindfoot in all patients without premature closure of the physis. Most of them need adaptation of footwear. None of the patients at present would favor to have been treated by amputation. The technique has shown good clinical results with preserved growth of the physis of the distal tibia and full axial weight bearing at long-term. In selected cases, this technique should be considered as a valuable alternative to other reconstructions.

The Assessment of Steroid Injections as a Potential Risk Factor for Osteochondral Lesions in Children with Juvenile Idiopathic Arthritis.

OBJECTIVE: Intra-articular corticosteroid injections (IACIs) are frequently used to suppress local inflammation, that is, in children with juvenile idiopathic arthritis (JIA). While systemic high-dosage corticosteroids are known to trigger osteonecrosis and result in osteochondral (OC) lesions, the effect of IACIs on joint cartilage and subchondral bone remains unclear. This study was conceived to analyze the coincidence of IACI and the subsequent manifestation of osteochondral lesions in a large cohort of pediatric JIA patients. DESIGN: Retrospective data assessment and comparative analysis of skeletally immature JIA patients treated with IACIs between 1993 and 2017. RESULTS: A total of 280 JIA patients were included in the analysis, the majority were girls (64%). Osteochondral lesions were present in 16 patients (5.7%) at a mean age of 10.7 years (range 4-14 years) and appeared on average after 63-month duration of disease. The majority was present at atypical locations such as the lateral femoral condyle. Multivariable analysis using cox regression showed that steroid injections were a risk factor to develop an OC lesion (hazard ratio [95%CI] for number of steroid injections per year, 8.20 [3.18, 21.16]). CONCLUSIONS: Pediatric patients with JIA show a relatively high incidence of osteochondritic lesions, which present at an early age and in rather atypical locations and repetitive steroid injection need to be considered an associated risk factor.

Guided growth with tension band plate or definitive epiphysiodesis for treatment of limb length discrepancy?

BACKGROUND: It is not exactly known whether guided growth or definitive epiphysiodesis techniques are superior in treating limb length discrepancy (LLD). The purpose of the present study was therefore to find out if definitive epiphysiodesis is associated with more powerful LLD correction than tension band plate epiphysiodesis. METHODS: Pediatric patients with LLD treated either with tension band plating as a guided growth technique (temporary epiphysiodesis) or a percutaneous drilling technique (definitive epiphysiodesis) around the knee and a minimum follow-up of 12 months were included in this retrospective study. Radiographic measurements were performed by two independent reviewers. The reduction in side difference between preoperative radiographs and last follow-up was calculated and compared between surgical techniques. RESULTS: Thirty-eight patients (mean age 13.6 years) were included, 17 treated with temporary and 21 with definitive epiphysiodesis. Average follow-up was at 578 days. The reduction of the LLD in 12 months was 5.7 mm in patients treated with temporary epiphysiodesis and 8.4 mm with definitive epiphysiodesis, respectively (p = 0.22). In both groups, LLD could be statistically significantly reduced after 12 and 24 months. Definitive epiphysiodesis had a lower revision rate (4.8% vs. 17.6%). Intra- and interobserver reliability of the measurements was excellent. CONCLUSIONS: As in earlier studies supposed, temporary epiphysiodesis with tension band plating seems to correct LLD less powerful compared to definitive percutaneous epiphysiodesis. However, in the present study, the differences of LLD correction were not statistically significant. We do not recommend the use of tension band plates for LLD correction due to inferior correction with higher complication and revision rate.

Impact of Sleep Deprivation on Surgical Laparoscopic Performance in Novices: A Computer-based Crossover Study.

OBJECTIVE: The 24-hour work shifts are newly permitted to first-year surgical residents in the United States. Whether surgery novices' motor activity is affected by sleep deprivation is controversial. MATERIALS AND METHODS: This study assesses sleep deprivation effects in computer-simulated laparoscopy in 20 surgical novices following 24 hours of sleep deprivation and after resting using a virtual-reality trainer. Participants were randomly assigned to perform simulator tests either well rested or sleep deprived first. RESULTS: Of 3 different tasks performed, no significant differences in total time to complete the procedure and average speed of instruments were found. Instrument path length was longer following sleep deprivation (P=0.0435) in 1 of 3 tasks. Error rates (ie, noncauterized bleedings, perforations, etc.), as well as precision, and accuracy rates showed no difference. None of the assessed participants' characteristics affected simulator performance. CONCLUSIONS: Twenty-four hours of sleep deprivation does not affect laparoscopic performance of surgical novices as assessed by computer-simulation.

Fractures of the Bilateral C2 Neurocentral and Lateral Dental Synchondroses with Kyphotic C1-C2 Subluxation in a 3-Year-Old Girl: A Description of a Rare Fracture Pattern and Its Treatment: A Case Report.

CASE: Spinal fractures are rare in young children. Because spinal anatomy and biomechanics differ in children and adults, knowledge of the deviations of the juvenile spine is necessary for adequate treatment. We present the case of a young girl with an unusual C2 fracture that included rupture of both of the neurocentral and lateral dental synchondroses, with an opening of the synchondroses and a caudal dislocation of both vertebral arches following a head-on motor vehicle collision. The whole body and apex of the dens was displaced anteriorly and cranially with a kyphotic angulation of 34°. We describe the treatment and clinical and radiographic outcome after 1 year. CONCLUSION: Using passive hyperextension and distraction of the head, a closed open-mouth digital reduction was performed under continuous fluoroscopy. At the 1-year follow-up, the patient had full range of motion of the head without pain or neurologic dysfunction.

Femoral torsion assessment with MRI in children: Should we use the bony or cartilaginous contours?

OBJECTIVE: To assess whether the use of cartilaginous contours at the femoral condyles instead of bony contours significantly changes femoral torsion measurements in children. MATERIALS AND METHODS: Femoral torsion was measured in 32 girls (mean age 10.1 years±2.3 standard deviation) and 42 boys (10.9 years±2.5) on axial magnetic resonance (MR) images by two independent readers (R1,R2). The femoral condyle angle was measured using each the cartilaginous and bony contours of the distal femur. Cartilage thickness at femoral condyles was assessed. Intraclass-correlation-coefficient (ICC) and Pearson's correlation were used for statistical analysis. RESULTS: Mean difference between cartilaginous and bony femoral torsion in girls was -1.1°±1.75 (range, -5.4° to 3.1°) for R1 and -1.64°±1.67 (-6.3° to 2.1°) for R2, in boys -1.5°±1.87 (-8.4° to 1.1°) for R1 and -2.28°±1.48 (-4.3° to 9.7°) for R2. Weak-to-moderate correlations between difference of cartilaginous-versus-bony measurements and cartilage thickness (r=-0.15 to -0.55, P<0.001-0.46) or age (r=-0.33 to 0.46, P<0.001-0.006) were found for both genders. Intermethod-ICC for cartilaginous versus bony femoral torsion measurements was 0.99/0.99 for R1/R2 in girls, and 0.99/0.98 in boys. CONCLUSION: There is only a small difference when measuring femoral torsion through cartilaginous versus bony contours, and no major difference in this between boys and girls.

Femoral and tibial torsion measurements in children and adolescents: comparison of MRI and 3D models based on low-dose biplanar radiographs.

OBJECTIVE: The aim of our study was to evaluate the reliability and interchangeability of femoral (FT) and tibial torsion (TT) measurements in children using magnetic resonance (MR) imaging compared to measurements on 3D models based on biplanar radiographs (BPR). MATERIALS AND METHODS: FT and TT were measured in 60 children (mean age 10.1 years; range 6.2-16.2 years; 28 female) using axial MR images by two readers. MR measurements were compared to measurements based on BPR-3D models by two separate independent readers. Interreader and intermethod agreements were calculated using descriptive statistics, the intraclass correlation coefficient (ICC), and Bland-Altman analysis. RESULTS: FT/TT was -8.4°-54.1°/0°-45.9° on MR images and -13°-63°/4°-52° for measurements on BPR-3D models. The median of difference between the two methods was -0.18° (range -13.6°-19.1°) for FT and -0.20° (range -18.4°-9.5°) for TT, respectively. Interreader agreement (ICC) of FT/TT measurements was 0.98/0.96 on MR images and 0.98/0.94 on BPR 3D models. Intermethod agreement (ICC) for MR measurements was 0.95 [95% confidence interval (CI), 0.93-0.96] for FT and of 0.86 (CI, 0.24-0.95) for TT. Mean interreader differences at MR were 3.1° (0.0°-8.0°) for FT and 3.2° (0.1°-9.5°) for TT. On Bland-Altman plots all measurements were within the 95% limit of agreement (-10.8°; 11.5° for FT; -14.6°; 4.2°) for TT-except for five measurements of FT and six measurements of TT. CONCLUSION: FT measurements on MR images are comparable to measurements using BPR-3D models. TT measurements differ between the two modalities, but the discrepancy is comparable to measurement variations between CT and BPR.

Paediatric lower limb deformity correction with the Eight Plate: adverse events and correction outcomes of 126 patients from an international multicentre study.

No large multicentre studies have yet been published on tension-band-like implants such as the Eight Plate to treat limb-length discrepancies and varus valgus deformities in children. Therefore, we carried out a retrospective international multicentre study including 126 patients to assess outcomes and to reliably quantify the incidence of implant-related and growth-plate related adverse events (AEs). Correction was achieved in 66% of varus valgus deformities and in 59% of limb-length discrepancies and maintained in 85%. Twenty (18%) patients experienced 43 AEs, which were primarily screw-related. The AE rate of the Eight Plate is low; however, many of them could be avoided through tighter monitoring.

Arthroscopic osteochondroplasty in patients with mild slipped capital femoral epiphysis after in situ fixation.

PURPOSE: Mild slipped capital femoral epiphyses (SCFE) nevertheless show significant femoral head-neck deformities which may put cartilage and acetabular labrum at risk. Whether this deformity can be restored to normal has not yet been described in the literature. METHODS: In a prospective follow-up study, 14 patients with mild SCFE underwent in situ fixation with a single 6.5-mm cancellous, partially threaded screw. In 14 patients arthroscopic osteochondroplasty was performed, and in 13 patients pre- and postoperative measurements of the α-angle were made using antero-superior radial magnetic resonance imaging. RESULTS: After arthroscopic osteochondroplasty, the mean α-angle decreased from 57° (range 50°-74°) to 37° (range 32°-47°; p < 0.001). Six patients showed beginning degenerative intra-articular changes (four antero-superior cartilage and three antero-superior labrum lesions) at the time of hip arthroscopy. No intra-operative complications occurred. In one patient, arthroscopic debridement was necessary due to arthrofibrosis and persistent pain. CONCLUSION: Arthroscopic osteochondroplasty can successfully correct the antero-superior α-angle in patients with mild SCFE to normal values. Clinical randomized controlled studies with long-term follow-up are required to find evidence of improved functional and radiographic mid- and long-term outcome compared to in situ fixation alone.

The compliance with and knowledge about radiation protection in operating room personnel: a cross-sectional study with a questionnaire.

INTRODUCTION: Radiation protection is becoming more important with an ongoing increase in radiation exposure due to the use of X-rays in minimally invasive procedures in orthopaedic and trauma surgeries. However, sufficient education in medical physics and radiation protection can often be improved. MATERIALS AND METHODS: A questionnaire consisting of four questions about personal data and ten questions about radiation protection was distributed to lead consultants, consultants, residents, medical students, and medical technical assistants at two institutions, a level 1 trauma center and a children's hospital. RESULTS: This study consisted of 83 participants. The compliance with radiation protection, i.e., usage of a dosimetry, an apron, and a thyroid shield on a regular basis was only seen in 54 %. Participants from the trauma center wore a dosimeter and thyroid shield significantly more often. The regular use of a thyroid shield differed significantly between job positions. It was observed in 80 % of students, but only 15 % of technical assistants. Only 65 % of all knowledge questions were answered correctly. There was a discrepancy between incorrectly answered knowledge questions (35 %) and those marked as uncertain (20 %). Different job positions did not have an impact on the answers to the questions in most instances. CONCLUSIONS: The compliance with and the knowledge about radiation protection seems to be unnecessarily low in trauma physicians and technical assistants. The discrepancy in falsely answered questions and those marked as uncertain may suggest that participants may overestimate their knowledge about radiation protection, which is potentially harmful due to the increased radiation exposure. Therefore, we advocate a quick and valuable training of trauma surgeons and medical staff addressing the important preventive measures, some of which are illustrated in the present study. These consist of wearing dosimetry and protection devices, reduction in X-ray duration, preferably antero-posterior C-arm positioning with the image intensifier close to the patient and the surgeon, maximal distance, collimation, and increased voltage. Furthermore, the use of visual feedback on complex and potentially hazardous radiation facts may be useful for training purposes. STUDY DESIGN: Cross-sectional study with a questionnaire.

LCP 140° Pediatric Hip Plate for fixation of proximal femoral valgisation osteotomy.

PURPOSE: Femoral osteotomy is one of the most widely performed reconstructive operations in pediatric orthopedic surgery. Many implants for fixation have been used, but so far there is no literature about the application and outcome of the LCP 140° Pediatric Hip Plate for proximal femoral valgisation in children. METHODS: Data of patients with a valgisation of the proximal femur using the LCP 140° Pediatric Hip Plate between February 2011 and July 2012 were retrospectively collected and analyzed. RESULTS: We included 10 patients (11 hips) with a mean follow-up of 15.3 ± 6.3 months (range 5.6-23 months). The mean age was 9.6 ± 1.2 years (range 7.3-11.8 years) with a mean hospital stay of 5.2 ± 1.7 days (range 3-9 days). Callus formation was observed in all cases at 6 weeks postoperative control and consolidation was shown after a mean time of 14.1 ± 2.3 weeks (range 12.1-19.1 weeks). There was no delayed union or any case of non-union in our series. The stability of the operative reduction including the corrected neck-shaft angle (mean 19° ± 7.9°; range 10.5°-38.5°) was maintained during the follow-up period. No cases of recurrence (varisation) or complications requiring further treatment or revision were observed. CONCLUSIONS: In our series, the 140° LCP Pediatric Hip Plate was shown to be safe and applicable in the clinical setting with good results. We therefore consider this device to be valuable for the correction of pathologic varus conditions of the proximal femur in children.

Femoral and tibial torsion measurement in children and adolescents: comparison of 3D models based on low-dose biplanar radiography and low-dose CT.

OBJECTIVE: The purpose of this study was to evaluate the interchangeability and reliability of femoral and tibial torsion measurements in children using 3D models based on biplanar radiography compared with CT measurements. MATERIALS AND METHODS: Femoral and tibial torsion were measured in 50 patients (mean age, 10.9 years; range, 4.7-14.8 years) using 3D models based on low-dose biplanar radiography by two independent readers. Measurements on transverse CT images by two independent readers served as the reference standard. Intermethod and interreader agreement was calculated using descriptive statistics, intraclass correlation coefficient (ICC), and Bland-Altman analysis. RESULTS: Femoral and tibial torsion were -6°-65° and 6°-51° for 3D models based on biplanar radiography and -13°-59° and 4°-52° for CT measurements. The average difference (±SD) between the two methods was 4.9°±3.8° and 5.5°±4.1°, respectively. The intermethod ICC for biplanar radiography was 0.90 (95% CI, 0.87-0.92) for femoral torsion and 0.75 (0.68-0.80) for tibial torsion. The interreader ICC was 0.93-0.97. Mean measurement differences between the two biplanar radiography readers were 3.4° (0.0°-11.0°) for femoral torsion and 3.9° (0.0°-15.0°) for tibial torsion. Mean interreader differences at CT were 3.3° (0.0°-9.0°) for femoral and 3.0° (0.0°-10.0°) for tibial torsion. There was no trend for larger intermethod differences with decreasing age of the children. CONCLUSION: Femoral and tibial torsion measurements in children using 3D models based on biplanar radiography are comparable to CT measurement results. Despite skeletal immaturity, torsion measurements in children on biplanar radiography seem to be as reliable as those on CT images.

Persisting growth after prophylactic single-screw epiphysiodesis in upper femoral epiphysis.

BACKGROUND: Prophylactic fixation of the contralateral hip in cases of slipped upper femoral epiphysis is controversial. Therefore, using a single-cannulated screw has been widely accepted. However, differing reports exist on the occurrence of persisting growth after prophylactic epiphysiodesis. The aim of this retrospective study was to evaluate the presence of persisting growth of the upper femoral epiphysis after prophylactic fixation. METHODS: From 2006 until 2009, 11 children underwent prophylactic pinning using a single-cannulated 6.5-mm cancellous screw. Time to fusion, persisting growth, and overgrowing of the screw were measured on plain radiographs taken postoperatively and at least after the growth plate was fused. RESULTS: All patients except 1 (91%) showed a persisting growth of the epiphysis, and in 2 cases a hardware replacement was necessary. The mean increase of the femoral neck length was 8.2% (SEM 1.46%). Mean follow-up was 37 months (range, 12 to 49 mo). All patients had a Risser sign grade 0 at the time of surgery, and equal or less than grade 3, when the growth plate was fused. CONCLUSIONS: Despite previous reports that a prophylactic fixation using a single-cannulated cancellous screw is unproblematic and safe, we showed that in our series growth persistence was the rule and in some cases the physeal overgrowth necessitates a hardware replacement. Careful follow-up until fusion of the growth plate should be recommended.

Normal values of Wiberg's lateral center-edge angle and Lequesne's acetabular index--a coxometric update.

BACKGROUND: The historical pathological cut-off values for Wiberg's lateral center-edge (LCE) angle and Lequesne's acetabular index (AI) are below 20° and above 12° for the LCE and AI, respectively. The aim of this study was to reassess these two angles more than 50 years after their introduction using a standardized conventional radiological measurement method, considering changing social habits and their associated physiological changes. METHODS: A total of 1,226 anteroposterior radiographs of the pelvis (2,452 hips) were obtained according to a strict standardized radiographic technique allowing reliable measurements of the LCE angle and the AI. RESULTS: Distributions of the LCE and AI were pronouncedly Gaussian, with mean values of 33.6° for the LCE and 4.4° for the AI. The 2.5th and 97.5th empirical percentiles were 18.1 and 48.0° for the LCE and -6.9 and 14.9° for the AI. These intervals contained 95 % of the data in our large sample. Small but statistically significant differences between the sexes and right and left hips have been demonstrated. Correlation between age and coxometric indices was low. CONCLUSION: The above findings do not conflict with the historical benchmarks. Statistical differences between sexes and between right and left hips were not clinically relevant. No conclusion can be drawn about coxometric indices and clinical manifestations of hip dysplasia.

Spontaneous reduction of spondylolisthesis during growth: a case report.

Isthmic spondylolisthesis is a common cause of low back pain in children. It is associated with a defect in the pars interarticularis of the vertebra. The treatment depends on the clinical course and degree of spondylolisthesis. Low-grade isthmic spondylolisthesis usually shows a benign course without significant progression and therefore, conservative treatment is advised. Although isthmic pars defect can heal, initial existing degree of slippage persists. A complete reversion of deformity was never described yet. We present the case of a 7½-year-old girl with symptomatic grade 2 isthmic spondylolisthesis according to the Meyerding classification. Without any specific therapy, there was a radiologically documented near total reversion of slippage and total relief of clinical symptoms during 8 years of follow-up. Computed tomography scan after this period showed persisting pars interarticularis defect without signs of healing. This case report indicates that during growth, spontaneous reversion of vertebral slip in isthmic spondylolisthesis can occur, even without healing of the pars defect.

The endlock tumor prosthesis with short-length fixation: a clinical study.

Anchorage of segmental replacement prostheses in diaphyseal bone remains a challenge in lower limb reconstructions. We developed and studied a new prosthesis design that features an intramedullary anchorage system for which finite element analysis predicted favorable bone remodeling. We retrospectively analyzed the cases of all patients who underwent implantation of the new stem. Their data were prospectively collected. Twenty-four patients (25 prosthetic reconstructions using diaphyseal fixation of the prosthesis) had 18 primary implantations and 7 revision cases. At a mean follow- up of 61 months, TESS (Toronto Extremity Salvage Score) and MSTS (Musculoskeletal Tumor Society Rating Scale score) were 80% and 65% that of a normal extremity, respectively. SF-36 (36-Item Short-Form Health Survey) Mental and Physical scores were 54 and 44 points, respectively. Minimum follow-up was 31 months (mean, 61 months; range, 31-107 months). Radiographic evaluation (1991 International Symposium of Limb Salvage [ISOLS] Radiological Implant Evaluation System) revealed 65% excellent and 35% good bone remodeling around the implant as a whole, 65% excellent and 35% good results for the anchorage proper, and 70% excellent and 30% good findings for lucencies at the bone-metal interface. Two patients (1 traumatic event) developed a loose stem. The results support the expectations as shown by finite element analysis - that the risk for loosening is reduced and that favorable bone remodeling occurs around the stem over time.

Femoral fractures in adolescents: a comparison of four methods of fixation.

BACKGROUND: The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. METHODS: We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. RESULTS: The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for débridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required débridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. CONCLUSIONS: External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

Open mouth digital reduction of an odontoid synchondrosis fracture: a case report.

The "odontoid synchondrosis fracture" represents a rare but typical injury of the upper cervical spine in children less than 7 years. Conservative treatment with closed reduction and external fixation shows fusion rates across the synchondrosis in about 90% cases. When closed reduction cannot be achieved, open reduction and internal fixation is usually performed. We present the case of a girl aged 3 years and 5 months, whose closed reduction by passive manipulation of the head failed, but the same could successfully be achieved through transoral manipulation of the dens. After treatment with a Minerva plaster cast, the fracture was healed without complication. We suggest transoral manipulation in cases of otherwise irreducible "odontoid synchondrosis fracture." This technical hint may avoid unnecessary surgery in children with this type of injury.

Fixation of subtrochanteric extending/derotational femoral osteotomies with the Locking Compression Plate in ambulatory neuro-orthopaedic patients.

PURPOSE: Patients with neuro-orthopaedic disorders often develop hip flexion contractures or rotational hip deformities. Increasing deformities impair the already diminished walking abilities and proximal femoral osteotomies are often performed to maintain/improve walking abilities. Fixation of the osteotomies with condylar plates has been successfully used but does often not allow immediate postoperative full weight bearing. To avoid a substantial postoperative rehabilitation deficit and additional bone loss due to inactivity, a postoperative treatment with full weight bearing is, therefore, wishful. Newer fixed-angled implants with stronger anchoring in osteopenic bone might fit these demands. The objective of this study was to evaluate bone healing and the complication rate after proximal extending and/or derotational femoral osteotomy fixed with 3.5/4.5 Locking Compression Plate (LCP; Synthes(®)) and postoperative full weight bearing in ambulatory neuro-orthopaedic patients. METHODS: Fifteen ambulatory neuro-orthopaedic patients (12 cerebral palsy [CP], 1 trisomy 21, 2 hemiparesis) with a mean age of 13.7 years (range 7-22) with hip flexion contractures and/or rotational deformities underwent subtrochanteric (n = 26) osteotomy between July 2004 and October 2007. All patients were allowed to bear their full weight postoperatively. We investigated the fusion rate, implant failure, and general complication rate until union had occurred. RESULTS: Fourteen patients (mean weight 42.0 kg [range 21.8-59]) uneventfully achieved solid fusion. One patient (19 years of age, 73 kg) needed revision surgery due to implant failure with consecutive varus deformity and achieved solid fusion after the second intervention. Besides one superficial wound infection, no other complications occurred. CONCLUSIONS: Subtrochanteric extending and/or derotational osteotomies fixed with an LCP are a reliable procedure in neuro-orthopaedic patients. Most patients can be treated with early postoperative full weight bearing. However, in heavier patients, possible implant failure must be considered.

Treatment of reduced femoral antetorsion by subtrochanteric rotational osteotomy.

The purpose of this study was to assess bone healing and complication rate following subtrochanteric rotational osteotomy fixed with a 4.5/5.0 Locking Compression Plate (LCP, Synthes) for reduced femoral antetorsion with early full weight bearing. The effects of the osteotomy on the range of internal rotation of the hip and complaints due to reduced antetorsion were also recorded. Between July 2004 and October 2007, 25 children (39 hips) with a mean age of 13 years (range, 9-18 years) were treated for reduced internal rotation of the hip by a subtrochanteric rotational osteotomy. Four patients (six hips) were excluded from this study due to concomitant surgeries prohibiting full weight bearing. Of the 21 patients who were allowed full weight bearing, nine had a unilateral and twelve a single-stage bilateral correction. We investigated time to union, implant failure, and complication rate as well as improvement in the range of internal rotation. All osteotomies healed without secondary displacement or angulation. Internal rotation improved from a mean of 8.6 degrees (-5 degrees to 20 degrees) preoperatively to 37.3 degrees (25 degrees to 60 degrees) postoperatively. We noted no complication related with the femoral osteotomy. Subtrochanteric rotational osteotomy appeared as a reliable procedure to improve internal rotation of the hip. Fixation with 4.5/5.0 LCP allows simultaneous bilateral correction and immediate full weightbearing with crutches, with a minimal risk of implant failure.