Single- versus dual-rod anterior instrumentation of thoracolumbar curves in adolescent idiopathic scoliosis.

PURPOSE: Single or dual-rod instrumentation can be used for the anterior fixation of the spine in adolescent idiopathic scoliosis (AIS). We aim to compare the complications, radiographic and functional outcomes of patients with AIS who have undergone single and dual-rod instrumentation. METHODS: This is a multi-centre study involving the Royal Children's, Royal Melbourne and Epworth hospitals. Three primary surgeons were involved to ensure homogeneity of surgical technique and implants. Patients with AIS and thoracolumbar curves (Lenke 5 and 6) undergoing anterior instrumentation from 1st January 2000 to 30th June 2013 were included. Radiographic data were collected from X-rays. The functional outcome was measured through the Scoliosis Research Society questionnaire (SRS-30). RESULTS: The study included 58 patients (38 single-rod and 20 dual-rod patients). Thirty-nine patients were classified with Lenke 5 curves, while 19 patients had Lenke 6 curves. Structural interbody supports were used in 95 % of cases. In the preoperative to postoperative period, patients with single rods had an improvement of 75 and 51 % for primary and secondary curves, respectively, while patients with dual rods had an improvement of 70 and 38 % for primary and secondary curves, respectively. There were no cases of pseudoarthrosis or metalware failure in either group. Two patients (one single-rod and one dual-rod patient) required further unplanned posterior fusion. 91 % of patients were satisfied with the results of their back management. CONCLUSION: Pseudoarthrosis and metalware failure are rare complications of anterior instrumentation. Our study found no significant difference in functional or radiographic outcome between single and dual-rod instrumentation. LEVEL OF EVIDENCE: Level III.

Caput valgum associated with developmental dysplasia of the hip: management by transphyseal screw fixation.

PURPOSE: A late finding of some hips treated for developmental dysplasia of the hip (DDH) is a growth disturbance of the lateral proximal femoral physis, which results in caput valgum and possibly osteoarthritis. Current treatment options include complete epiphysiodesis of the proximal femoral physis or a corrective proximal femoral osteotomy. Alternatively, a transphyseal screw through the inferomedial proximal femoral physis that preserves superolateral growth might improve this deformity. METHODS: This study evaluates the effect of such a transphyseal screw on both femoral and acetabular development in patients with caput valgum following open treatment of DDH. These patients were followed clinically and radiographically until skeletal maturity. Preoperative and postoperative radiographs were assessed, measuring the proximal femoral physeal orientation (PFPO), the head-shaft angle (HSA), Sharp's angle and the center edge angle of Wiberg (CE angle). RESULTS: Thirteen hips of 11 consecutive patients were followed prospectively. The age at the time of transphyseal screw placement was between 5 and 14 years. The mean improvement of the PFPO and HSA was 14° (p < 0.01) and 11° (p < 0.001), respectively. The mean improvement of Sharp's angle and CE angle was 4.7° (p < 0.01) and 5.8° (p < 0.02), respectively. Five patients underwent screw revision. CONCLUSIONS: A transphyseal screw across the proximal femoral physis improved the proximal femur and acetabular geometry.

Pediatric pelvic fracture: a modification of a preexisting classification.

BACKGROUND: The classic pediatric pelvic fracture (PPF) classification was developed by Torode and Zeig in 1985 and is based exclusively on plain radiographs. The purpose of this study was to propose a modification to a previously accepted PPF classification scheme and discuss the significance of this modification with respect to treatment and management of PPF over an 8-year period at a large pediatric hospital. METHODS: PPFs were recorded on a prospectively identified hospital registry of all trauma admissions. Pelvic x-rays and computerized tomography scans were reviewed and classified according to a modified classification scheme. Correlation was made with age, sex, mechanism, associated injuries, intensive care unit stay, operations, and discharge outcome. Blood product usage was obtained from a hematology database. RESULTS: A total of 124 children were identified with PPF, comprising 1.6% of trauma admissions between July 2000 and June 2008. Radiology was available for 115 children (58 boys, and 57 girls, mean age 11.5 y). According to the modified classification, 71% (82/115) had type III-A or III-B injuries (type I=5 children, type II=17 children, type IV=11 children). There was a mortality of 5% (6/115 children) during the study. Eighty-one percent (93/115) of PPF resulted from being involved in a motor vehicle accident (occupant or pedestrian). Trend testing showed relationships between increasing fracture type and length of stay (P<0.001), as well as the need for blood transfusion (P=0.009) or pelvic operation (P<0.001). A total of 34 (30%, 34/115) children required blood products. Type III-B injuries were more likely to receive blood products than type III-A injuries (odds ratio 3.58; 95% confidence interval, 1.28-10.03). CONCLUSIONS: : The modified Torode PPV classification is predictive for significant morbidity and death in the setting of multitrauma. Stable type III-B fractures are indicative of increased blood product use, intensive care unit requirement, and overall hospital stay. This modified classification scheme will aid health care providers at all levels in managing PPF more efficiently during their initial resuscitation and treatment period. LEVELS OF EVIDENCE: Level III-retrospective case control study.

Low grade fibromyxoid sarcoma: problems in the diagnosis and management of a malignant tumour with bland histological appearance.

AIMS: To review the clinicopathological features and highlight the problems in the diagnosis and management of low grade fibromyxoid sarcomas (LGFMS). METHODS: Three cases of LGFMS were studied with histology and immunohistochemistry, and cytogenetics in one. The features and problems were compared with those in the literature. RESULTS: Two LGFMS had typical fibrotic and myxoid patterns showing abrupt transition from one to the other. Cellularity was low to moderate. Nuclei were medium sized and regular. In one of these the correct diagnosis was not made in the original needle biopsy resulting in inappropriate management. In the third tumour only myxoid areas were seen and the diagnosis was supported by cytogenetics showing a complex previously unreported translocation, t(7;18;16). One tumour recurred, one metastasised, and one has possible metastasis on imaging of the lungs. CONCLUSION: LGFMS is a tumour with low grade histological features but a high risk of local recurrence and a significant risk of metastasis which can be very late. There should be a high index of suspicion for this rare tumour and a low threshold for sending tissue for cytogenetics and/or molecular genetics. Special precautions should be exercised in the interpretation of small biopsies of a spindle cell lesion with bland cytological features in children. If the diagnosis is unclear there must be a detailed follow up plan with a person responsible for monitoring the plan.

Ligamentum teres tenodesis in medial approach open reduction for developmental dislocation of the hip.

BACKGROUND: When closed reduction of a developmental dislocation of the hip fails, some form of open reduction is required. In recent years, the many advantages of the medial approach open reduction have been emphasized. However, there have been suggestions that the rate of growth disturbance in the proximal femur and the requirement for secondary surgical procedures may be higher with this route than with others. The purpose of this study was to investigate the efficacy and safety of a modified medial approach open reduction, in which the stability of the reduction is enhanced by resection of the redundant ligamentum teres and suturing of the stump of the tendon to the anteromedial capsule. METHODS: The hospital records and radiographs of 92 infants and children with 109 dislocated hips were reviewed retrospectively. Key demographic and pretreatment data were collected by the first author and compared with the outcome at the most recent follow-up. In addition, 69 children returned for a clinical evaluation by the first author. The outcome at the most recent follow-up was graded according to Severin, and associations were sought between pretreatment grade of dislocation according to Tonnis, the presence of ossific nucleus, changes in the acetabular index, the requirements for secondary surgery, associations with previous treatment, and the position of abduction in the postoperative cast. RESULTS: At a mean follow-up of 9 years, 89% of hips were classified as Severin grade 1 or 2. Avascular necrosis (AVN) was classified according to the system of Kalamchi and MacEwen. The incidence of AVN was 41%, but two thirds of these were grade 1 (temporary irregular ossification), and the Severin grading in these hips was not compromised. The presence of ossification in the capital epiphysis and a range of abduction of less than 60 degrees in the hip spica were noted to be protective against the development of AVN. Three hips redislocated and required additional treatment. Thirty-eight hips required a total of 44 additional surgical procedures. CONCLUSIONS: We have demonstrated that it is possible to use a medial approach for open reduction of the congenitally dislocated hip in combination with tenodesis of the ligamentum teres to the anteromedial joint capsule. The incidence of growth disturbance in the proximal femur is high and cumulative with long-term follow-up. However, in this large series, the rate of hip stability, growth disturbance, and need for secondary surgery are comparable to other series. We conclude that the many advantages of open reduction by the medial approach outweigh the disadvantages.

Function and upright time following limb salvage, amputation, and rotationplasty for pediatric sarcoma of bone.

We wished to determine the relative physical and psychosocial merits of limb-sparing reconstruction, above-knee amputation, and rotationplasty in survivors of childhood and adolescent lower extremity bone sarcoma. In comparing minimum 5-year disease-free survivors, we found that outcome was somewhat dependent on the measuring tool administered. A superior score of statistical significance on the system of evaluation of the Musculoskeletal Tumour Society and a trend toward higher Toronto Extremity Salvage Scores were found among patients with a limb-sparing reconstruction compared with those with an above-knee amputation. Short-Form 36 results and the amount of time spent in the upright position (uptime), as assessed with a remote activity monitor, were similar between these groups. Uptime was highest in patients who had undergone rotationplasty, although statistical assessment of this group was not feasible. Psychosocial outcome was similar between all groups. This information may be useful in discussing reconstruction with patients and their families.

Orthopaedic sequelae of meningococcal septicemia.

The records of 143 patients admitted with a diagnosis of meningococcal septicemia were reviewed to identify vascular, cutaneous, and osseous sequelae. During the acute phase of the disease there were 21 deaths and 17 patients lost tissue. Thirty-six digits were allowed to autoamputate and six surgical amputations were performed. Each of the latter developed physeal growth arrests proximal to the level of amputation. Four patients underwent fasciotomies for compartment syndrome. Two of these patients had absent distal pulses and at surgery were found to have nonviable limb segments; the authors conclude that fasciotomy is rarely indicated. Sixteen patients were identified with a total of 41 growth arrests. Twenty-three of these occurred under areas of cutaneous scarring and were diagnosed 2 to 9 years after the index admission. The authors believe that patients requiring débridement and/or skin grafting of areas of skin necrosis should be reviewed regularly during the growth period to identify physeal damage at a stage when less complex surgery may be indicated.

Medial approach for corrective osteotomy of cubitus varus: a cosmetic incision.

Osteotomies described previously to correct cubitus varus had been associated with unsatisfactory results such as a prominent lateral scar and condyle and injury to the triceps. The authors evaluated the results of a medial approach for the corrective osteotomy of 14 consecutive children (mean age 8.4 years) with cubitus varus. The incision was made medially and the ulnar nerve was identified and protected. An image intensifier was used to identify the wedge. Lateral closing wedge osteotomy was performed and secured with cross K-wires, and the distal fragment was translated medially to reduce the lateral prominence. Both hyperextension and internal rotation deformity could be corrected with the osteotomy. The mean carrying angle and hyperextension of the elbow of 19.3 degrees varus and 22.2 degrees were corrected to 2.4 degrees valgus and 8.8 degrees respectively. Radiographically, the Baumann's angle and the flexion angle were improved from 90.1 degrees to 77.3 degrees and 24.2 degrees to 37.2 degrees respectively. No patient had a prominent lateral condyle, and the operative scars were well concealed along the medial aspect of the elbow. There was one case of transient ulnar nerve paresis with residual varus.

Changing glenoid version after open reduction of shoulders in children with obstetric brachial plexus palsy.

Twenty-three patients who had obstetric brachial plexus palsy and shoulder subluxation or dislocation that required open reduction and tendon lengthening were entered into a prospective study to evaluate glenoid version after surgery. All the patients had a preoperative computerized axial tomograph and postoperative computed tomography scan of both shoulders at approximately yearly intervals to assess the degree of congruity of the glenohumeral joint and glenoid version. Surgery was performed between 1988 and 1997. There were 11 girls and 12 boys. The mean age was 2 years 5 months (range 8 months-6 years 7 months). The left shoulder was affected in 12 patients and the right shoulder was affected in 11 patients. At mean follow-up of 3 years 7 months, the mean glenoid retroversion for the dislocated shoulder progressively decreased. The difference in glenoid version between the dislocated and the normal side decreased. The angle of glenoid retroversion in the affected shoulders decreased by a mean of 31% after open reduction, and the retroversion continued to improve at 9% per year.