Aims

To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot.

Introduction: School screening for scoliosis aims to reduce the need for surgery by detecting curve changes in children at an early stage when bracing may be effective in halting the progression of the deformity. Although the effectiveness of the current screening techniques has not been established yet, AAOS and SRS continue to support school screening.. The major criticism focuses on the cost-ineffectiveness of the process, as too many students are unjustifiably referred to specialists. Moreover, examiner’s skills and experience are important factors in screening outcome. An ongoing, large-scale study of school screening is conducted in public schools at the northern part of Israel comparing the screening performance of a Scoliometer and a new, hand-held computerized device (SpineScan). SpineScan was designed to automatically measure the “angle of trunk inclination” (ATI), and is less dependent on examiner’s level of medical training. Furthermore, this tool enables also fast assessment of the kyphosis angle.

Methods: In a first phase of the study, 1000 children aged 10 to 14 years were screened. Each child underwent “blinded” examinations by two examiners with different skills (a pediatric orthopaedic surgeon and a physiotherapist), each of whom using a different tool (a Scoliometer and SpineScan, respectively). Screening was performed in examination positions specific for true scoliosis (standing and sitting forward bending) and ATI measurements were compared. Children with an ATI =or > 7º measured with either tool at both positions were referred to undergo a standard full spine X-ray in standing position, on which an experienced pediatric orthopaedic surgeon measured the Cobb angles. Curves = or > 10º were considered true positive findings for scoliosis. Statistical analysis included specificity, sensitivity and predictive value estimates of both methods.

Results: Referral rate for Scoliometer was 2.5% and for SpineScan 1.9%. SpineScan reached 80% sensitivity vs. 70% of the Scoliometer. Moreover, SpineScan achieved higher PPV values than the Scoliometer (80% vs. 54% respectively).

Discussion: These results imply that efficient and cost effective screening can be performed by minimally skilled examiner using SpineScan.

Introduction: Accurate and quantitative measurements of the spine are essential for deformity diagnosis and assessment of curve progression. There is much concern related to the multiple exposures to ionizing radiation associated with the Cobb method of radiographic measurement, currently the standard procedure for diagnosis and follow-up of the progression of scoliosis. In addition, the Cobb method relies on two-dimensional analysis of a three-dimensional deformity. The Ortelius800TM aims to provide a radiation-free method for scoliosis assessment in three planes (coronal, sagittal, apical) with simultaneous automatic calculation of the Cobb angle in both coronal and sagittal views. This new device is based on direct measurement of the position of the tips of the spinous processes in space. A low intensity electromagnetic field records the spatial position of a sensor attached to the examiner’s finger while palpating the patient’s spinous processes. This study investigates the correlation of spinal deformity measurements with Ortelius800TM radiation-free system as compared to standard radiographic measured Cobb angles in order to assess Ortelius800TM clinical value while enabling a significant reduction of x-ray exposure.

Methods: 124 patients diagnosed with Adolescent Idiopathic Scoliosis (AIS) from four different medical centers were measured with the Ortelius800TM system using the same standard protocol. The entire process required an average of 2 minutes. The Ortelius800TM measurements were correlated with the standard Cobb angle as measured on routine standing coronal and sagittal radiographs. The Pearson correlation coefficient was calculated for matched pair measurements. The mean difference and the absolute mean difference between measurements with the two methods was estimated.

Results: Standing full-spine coronal radiographs were obtained for each patient. Radiograph analysis for these 124 patients revealed 249 deformity measurements. The deformity measurements were comprised of 142 thoracic curves with a mean of 18.3° and 107 lumbar curves with a mean of 17.4°. Lateral radiographs were obtained from 38 patients with a mean of 36.1°. Correlation between Cobb angles measured manually on standard erect posteroanterior radiographs and those calculated by this new technique showed an absolute difference between the measurements to be significantly less than +\−5° for coronal measurements and significantly less than +\−6° for sagittal measurements indicating good correlation between the two methods.

Pearson’s correlation coefficient between deformity angles obtained by the two methods was highly significant (0.86) with a P value < 0.0001. The measurements from four independent sites were not significantly different.

Discussion: The results reveal good correlation between the two measuring methods in both coronal and sagittal views. We propose the Ortelius800TM as a clinical tool for the routine follow-up measurements of AIS patients, thus enabling a significant reduction of radiation exposure.

Background: Congenital dislocation of the patella can cause significant functional disability and is often associated with limb deformity in childhood. Two types or clinical manifestations of this condition have been previously described, namely the fixed lateral dislocation and the habitual or obligatory dislocation of the patella. Few surgical procedures have been suggested for the treatment of the complex condition.

Objective: We reviewed our surgical approach in ten knees (seven children) with both types of patellar dislocation, and evaluated the clinical and functional outcomes.

Methods: All our patients underwent an extensive sub-periosteal mobilization of the extensor mechanism from the lateral side of the thigh combined anteriorly with plication of the medial patellar retinaculum. This procedure was supplemented by medialization of half of patellar tendon in the skeletally immature patients, and by tibial tuberosity transfer that was performed in one skeletally mature patient.

Results: In six children, patellar dislocation was a part of a diagnosed syndrome, namely Down (3 patients), Larsen (1 patient), Rubinstein-Taybi (1 patient) and fibular hemimelia (1 patient). Six knees had fixed type and four (all Down syndrome) had obligatory type of patellar dislocation. Average age at surgery was 9.5 years (range 3.5–14) and the mean follow-up period was 19 months (range 7–33). There was no recurrence during the follow-up period. Two children with Down syndrome, who had flexion contraction and were non-ambulatory, began to walk three months and five months after the surgery. A significant resolution of the valgus deformities was obtained in the operated knees. Two complications were recorded, an undisplaced supracondylar fracture following removal of plastic cast and transitory peroneal nerve palsy.

Conclusions: Abnormal anatomical muscular and bony changes, soft tissue structural changes and limb alignment contribute to patellar dislocation and to subsequent clinical deterioration and deformity progression. Our surgical intervention aimed to realign the extensor mechanism and was effective in treating both types of congenital dislocation of the patella. Based on our experience, the long-standing habitual dislocation is accompanied by changes in the extensor mechanism of the knee that are similar to those occurring in the fixed patellar dislocation and therefore should be addressed surgically in a similar manner.

Background: The treatment of extensive soft tissue injury with bony involvement due to orthopaedic trauma or other pathologic conditions has undergone great improvement in the last decade.

The main fields that assisted with that progress are: the ability to transfer autogenous vascularized soft and/or bony tissues to the injured areas and the possibility to apply external fixation either statistically for acute stabilization of a limb or using dynamic frames to correct late occurring contractures or deformities.

Objectives: To present our experience in treating young patients with severe, post traumatic or tumor resection soft tissue and bony injuries including bone loss and late joint contractures. That was treated by a combination of free vascularized flaps and static or dynamic circular external fixation with special emphasis on preplanning and technical issues critical for the success of such complex procedures.

Methods: Seven patients were included in the study; six post traumatic patients who received free vascularized myocutaneous latissimum dorsi or fasciocutaneous anterolateral thigh flaps to the calf and foot. All six patients had an Ilizarov frame for initial stabilization; two of them needed late dynamic correction of equines with the frame. The seventh patient had surgery for removal of osteosarcoma and received a vascularized osteocutaneous fibula flap with fixation by Ilizarov frame, this patient also needed late dynamic frame application for equines correction.

Results: The mean age at surgery was 11.6 years (range 7–14 years); mean follow up was 1.8 years (range 2 months – 3.4 years).

All microvascular flaps but one survived where the patient with the failed latissimus dorsi flap had the second muscle transferred at the next day. One patient needed 2 vascular revisions. All bone flap showed solid union at 3 months post operatively. Four patients achieved plantigrade foot initially. The three patients with dynamic correction achieved plantigrade foot at frame removal.

Complications: Equinus contracture of the ankle in three patients, injury to the vascular anastomosis in one patient. Pin tract infection in all patients that responded well to antibiotics.

Conclusions: The circular external fixator is a reliable method for initial fixation of injured limb. It is advised to apply the fixator before the transfer of the free flap. Position of the fixation pins should be discussed before hand with the plastic surgeons to allow free access to the microvascular anastomosis site. Free flaps allow the coverage of large soft tissue defects while the external fixators maintain anatomical position of the limb. Late occurring contractures after the incorporation of the flap can be safely corrected gradually with the circular frame. It is of paramount importance to include the foot in the frame and maintain neutral position of the ankle joint to prevent equines contractures.

Background: Ankle-foot orthoses (AFO) are frequently recommended to children with CP to improve their functional ambulatory ability, namely to increase walking velocity and stride length, and decrease cadence. Several studies examined the effectiveness of different types of AFOs based on gait analysis. AFOs however, are usually prescribed upon clinical examination alone. Based on our first year experience at the Dana Gait Lab not all AFOs improved function significantly.

Objective: To investigate the effect of prescribed AFOs on gait performance of children with cerebral palsy.

Methods: Twenty-two children with cerebral palsy (aage 5–17 y; gender: 11 males, 11 females, of them: 8 hemiplegic, 11 diplegic, 3 quadriplegic) were referred for full 3D instrumented gait analysis for different purposes. Using the Vicon 612 system they were studied walking both barefoot and with their prescribed AFOs. The two modes were compared in terms of spatio-temporal parameters and ankle-knee kinematics. Statistical analysis included paired t-test, and Pearson correlation coefficient; level of significance was set to .05.

Results: Using the prescribed AFOs, stride length was significantly increased (on average, 9.95±0.11 cm, p=0.000) while no significant changes were found in walking velocity and cadence (p= .111, p= .420, respectively). Split-by diaganosis revealed significant reduction in cadence (12.7 step/min, p=0.034) in the hemiplegic children. There was no significant improvement in the symmetry index of the stride length and step time due to the use of AFOs. Ankle and knee kinematics at initial contact and at loading response revealed non-significant changes. In the hemiplegic group knee flexion increased significantly (p=0.002) while ankle dorsiflexion at initial contact was almost significant (p=0.3).

The consistency of the results within subject and between modes was highly correlated (r=0.858–0.928) and statistically very significant (p< 0.000).

Discussion: In the current study, the only benefits of AFOs were increasing stride length and some improvement in ankle and knee kinematics. Our findings show that the use of an AFO, by itself, does not change dramatically other walking parameters. The high correlation between barefoot and AFO modes suggests that the child’s basic capability is the main factor that affects the gait pattern. Inappropriate AFO may partly be the reason for the non-significant results in this study.

We conclude that AFO’s should be given only after optimization of the child’s physical capabilities. Prescription should be made after careful evaluation using gait analysis whenever possible.

We believe that soft tissue release and articulated hip distraction distinguishes itself in the short term as a good salvage procedure for late onset severe Perthes disease of the hip.

Our series is made of 10 patients with late onset Perthes disease. All 10 patients were above 9 years of age at diagnosis (average = 11 years). There were 7 boys and 3 girls in the series. All patients had significant limp and pain with positive Trendelenburg sign. All patients used crutches or wheelchairs and had symptoms for a period of 0.5 to 3 years before the operation; all hips had limited ROM. Two patients had previous soft tissue release. There were 2 children with Down syndrome and 1 child had Gleophysic Dysplasia. On preoperative radiographs, 8 patients had a saddle shape subluxating femoral head with hinge abduction and 2 subluxations only. Nine hips were graded Catterall IV and Herring C and 1 hip Catterall III Herring B. There were at least 3 and mostly 4 Catterall prognostic risk signs for these hips. All patients had a broken Shenton line, increased medial joint distance and low Epiphyseal index before surgery.

After adductor and ileopsoas release an orthofix hinged apparatus for distraction is applied to the hip. The distraction continues until overcorrecting of Shenton line achieved. The external fixator is left in place for 4–5 months while in the apparatus flexion and extension of the hip is possible and encouraged. The follow-up ranged from 0.5 to 3 years. At last follow-up all patients were walking freely with improved hip ROM. All patients resumed daily ambulatory status and 2 were involved in regular sports. Latest radiographs showed that the saddle shape disappeared in 7 of 8 hips, in all patients hip subluxation decreased as measured by medial joint distance and Shenton line was corrected to between 0.6 mm. The Epiphysis index and joint congruency improved in most cases.

The level of satisfaction from the operation was very high for all patients and their parents.

Drawing of final conclusion will be possible only after assessing the long-term results.

Despite the impressive advancements in prenatal planning and assessment, obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth.

Although the majority of infants with plexopathy recover with minor or no residual functional deficits, a number of children do not regain sufficient limb function and develop significant functional limitations, bony deformities and joint contractures.

Recent developments in the technique of microsurgical reconstruction of peripheral nerve injuries proved to be effective in selected cases of children with obstetrical brachial plexus injury.

Many of these children and those who were defined as having minor injury will remain with considerable functional limitation and deserve late orthopaedic reconstruction.

Based on that, we developed a multidisciplinary Brachial Plexus clinic gathering a microsurgeon, a pediatric orthopaedic surgeon, an electrophysiologist clinician, physiotherapists and occupational therapist in order to assess and evaluate these children.

A total of 105 children were seen and followed up in our clinic during the last 2 years.

Most of these children were referred to our clinic from other centers and from physiotherapists treating these children on an out-patient basis.

We report the orthopaedic reconstruction operations performed in 9 cases of residual functional disabilities in children born with obstetric palsy.

4 patients had latissimmus dorsi and teres major transfer.

2 patients had derotation osteotomy of the humerus.

1 patient had Steindler flexorplasty of the elbow.

2 patients had open reduction and capsulorrhapy for a dislocated shoulder.

Video assessment of these children was performed before and after the operation. Function was also analyzed before and after operation by a physiotherapist and an occupational therapist.

Significant functional improvement was achieved, to the satisfaction of patients and parents.