Ultrasonic Evaluation of the Achilles Tendon in Patients Treated for Congenital Clubfoot: Comparison between Patients Treated with Plaster Alone, Achilles Tenotomy, and Z-Plasty Lengthening.

BACKGROUND: Clubfoot is a common congenital deformity. The Ponseti technique, involving early corrective manipulations followed by applying long leg casts and Achilles tenotomy, is widely accepted as the preferred treatment. Rapid tendon healing after surgery has been documented, but the aspect regarding long-term tendon structure and properties is not known. Three cases of Achilles tendon rupture in adolescents previously treated for clubfoot have been described in the literature. As rupture is a rare event in this age group, a possible correlation with previous surgery has been hypothesized. The primary aim of the study was to compare the ultrasound findings of the Achilles tendon in patients treated for clubfoot, between patients treated with casting alone and with patients who underwent surgery (percutaneous tenotomy or Z-plasty lengthening). METHODS: There were 22 asymptomatic patients (34 feet) with a median age of 12 years, previously treated for clubfoot, that were recruited for this study; the patients underwent an Achilles tendon ultrasound examination during a follow-up outpatient visit. RESULTS: A greater thickness and increased number of structural alterations with the presence of hypoechoic areas of the operated tendons compared with those treated with plaster alone were observed (p-value: 0.0498 and <0.001, respectively). These ultrasound findings were indicative of tendon suffering, as seen in tendinopathies. CONCLUSIONS: The presence of ultrasound alterations in asymptomatic patients operated on for clubfoot requires careful control of the extrinsic factors of tendinopathy in order to reduce the risk of subcutaneous rupture.

Achilles tendon surgery in clubfoot: Are long term sequelae predictable?

Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.

Congenital Dislocation of the Patella - Surgical Treatment Rationale and Literature Review.

INTRODUCTION: Congenital dislocation of the patella (CDP) is a rare condition and its treatment is not well defined. In CDP, patella is dislocated on the lateral aspect of the distal femur, laterally from the trochlear groove, it cannot be reduced manually and it is almost always associated with genu valgum, lateral torsion of the proximal tibia, and flexion contracture of the knee. This condition is present at birth, but the clinical findings can be subtle at birth due to the size and character of the structures being examined; early diagnosis is essential, but it may be delayed to late childhood or adulthood. If CDP is not promptly treated, the disability increases during growth, so surgical correction should be planned as soon as the diagnosis is confirmed. CASE REPORT: We report a case of bilateral CDP associated with bilateral proximal radioulnar joint stiffness; the patient at the age of diagnosis was 11 years old and underwent a bilateral delayed surgical procedure; the 4-year follow-up results are satisfactory. Surgical treatment rationale and literature are reviewed. CONCLUSION: Surgical correction for CDP is generally recommended, but there is no agreement in literature on the ideal treatment and in some cases, with mild impairment of the knee function, observation alone has been suggested. The decision about a surgical treatment can be difficult and depends on the degree of disability of the patient.

Pseudoarthrosis of second metatarsal fracture.

Metatarsal fractures make up the greatest portion of foot fractures in children. Most of them are treated with closed reduction and non-weightbearing cast immobilization.Usually, these fractures heal uneventfully and delay union and pseudoarthrosis are rare. We report a case of a 10-year-old child with non-union of the second metatarsal following a traumatic fracture, caused by an accident 10 months before, and treated successfully by osteosynthesis with plate and screws. Good clinical outcome was achieved at 2 years follow-up.

Transient femoral nerve palsy in spica cast treatment for developmental dysplasia of the hip.

A 4 months and half female child come to our attention for congenital dislocation of the left hip, previously treated in another hospital with abduction bracing, without satisfactory results. After progressive longitudinal bilateral traction, closed reduction under general anesthesia was performed and a spica cast was applied in the so-called human position. The patients remained in the spica cast for 6 weeks and then the plaster cast was renewed in narcosis for another 6 weeks. Once the second cast has been removed left femoral nerve palsy was detected. Orthopaedic treatment was interrupted and in 3 months the nerve completely recovered, while the hip was still stable. We followed the child regularly since then, she is now five years old, she is totally asymptomatic, X-rays shows a residual acetabular dysplasia, with no sign of avascular necrosis.

Revision of 120 tibial infected non-unions with bone and soft tissue loss treated with epidermato-fascial osteoplasty according to Umiarov.

Treatment of tibial infected non-unions with bone and soft tissue loss has to solve three problems: infection, lack of bone continuity and lack of skin coverage. The aims of treatment are infection healing, bone consolidation with preservation of limb length and soft tissue reconstruction. The most important stage in the planning is an accurate débridement. Soft tissue reconstruction can be achieved using plastic surgery, and bone reconstruction is accomplished with bone grafts or induced membrane technique, but these methods may present disadvantages and risks. Epidermato-fascial osteoplasty is a modified procedure of compression-distraction osteosynthesis that was first described by Umiarov in 1982. This procedure offers the advantages of exactly classifying the phases of simultaneous bone and soft tissue regeneration, and of eliminating large tissue losses without previous closure of soft tissues or use of grafts, because the transported fragment takes fascia and skin along during the transport and closes the edges of the soft tissue gap until the epidermic and fascial reconstruction is complete. A total of 120 patients underwent this kind of surgery between 1986 and 2010 and were followed up for 2-26 years. Average age was 34 years (range 21-57 years). Cultures were positive for Staphylococcus in all cases, and for Pseudomonas in 27 cases. Adequate antibiotic therapy was administered in collaboration with the Infectious Diseases Specialist. Tibial bone resection was from 6 to 18cm (average 9.5cm). The Ilizarov apparatus was used with the oblique wire technique for bone transport in all patients. No intraoperative complications were observed. One patient died 40 days after the operation because of pulmonary embolism. The duration of treatment for the remaining 119 patients was 7-18 months. In all cases, infection eradication, healing of regenerate bone, consolidation at the docking site (with the aid of an autoplastic bone graft in only 11 patients), and epidermic and fascial reconstruction were observed, and functional results were very good. These techniques are particularly demanding for the patient and for the surgical team, but our results demonstrate that they can provide excellent outcomes in the management of difficult cases of infected non-unions.

Evaluation of bone density in infancy and adolescence. Review of medical literature and personal experience.

The evolution of medical and surgical therapies allows the increased survival rate of a growing number of children affected by rare pathologies. In this light osteoporotic disease is also of orthopaedic interest as it is sometimes the outward manifestation of serious pathologies (i.e. osteogenesis imperfecta). Sometimes, even in infancy and adolescence, osteoporosis is associated with complications due to fractures; in other cases it seems to have no immediate consequence. Nevertheless it must be considered as a fracture risk factor in adulthood as it negatively affects the achievement of peak bone mass. The evaluation of variations in bone mass that take place during growth is thus of particular importance in order to guarantee a level of bone health suitable for the next phase. These remarks compose the premise of a study on bone resistance carried out on a study population of between 6 and 18 years of age in the city of Pavia. To determine the resistance of the bone an ultrasound device was employed (Omnisense™ , Sunlight Medical Ltd, Tel Aviv, Israel) in two skeletal sites, distal radius and midshaft of tibia. The analysis of our results and a review of the relevant literature indicate that the median values of normality, against which we compare the measurements of the patients under examination, depend not only on age, sex, skeletal sites, race, and even ethnic group. The introduction of this new parameter, to be kept in mind when interpreting the results, invites us to be very prudent in determining the diagnostic threshold values in paediatric age. As with anthropometric data (weight, height, cranial circumference) it is possible to suggest an interpretation of the patient's SOS values comparing them with the 'centile curves' typical to the region the child belongs to. Of course, further studies are required to understand what are the variables involved and to determine the extension of the geographical area to be examined to obtain suitable reference curves.