Background

Dislocation is a common complication after proximal and total femur prosthesis reconstruction for primary bone sarcoma patients. Expandable prosthesis in children puts an additional challenge due to the lengthening process. Hip stability is impaired due to multiple factors: Resection of the hip stabilizers as part of the sarcoma resection: forces acts on the hip during the lengthening; and mismatch of native growing acetabulum to the metal femoral head. Surgical solutions described in literature are various with reported low rates of success.

Purpose: Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external fixator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external fixator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation first and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a final phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method.

Methods: During a five-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, five had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with fibular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program.

Results: All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superficial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the first metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases.

Conclusions: We believe that the Ponseti sequence of correction can be applied to older children with residual club-foot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed.

Significance: The Ponseti-inspired method of residual club-foot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures.

Introduction: The standard treatment of adolescent Blount’s disease includes proximal tibial valgus osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. We performed correction of deformities in eight patients (10 tibiae) with adolescent Blount’s disease using the Taylor Spatial Frame (TSF). In all patients, the origin (virtual hinge) was placed at the level of the proximal tibial fibular joint. The purpose of this study was to review treatment outcome of proximal tibial osteotomy without osteotomy of the fibula in patients with adolescent Blount disease.

Methods: Eight patients (10 tibiae) were treated by proximal tibial osteotomies and gradual correction by TSF without fibular osteotomy over a period of three years. All patients were males with a mean age of 14.6 years (range, 14–17 years). All patients had severe proximal tibial varus, four had significant proximal tibial procurvatum, and six had internal tibial torsion. The fibula was not fixed in five patients, and fixed distally in three.

Results: Frames were removed at an average of 12.8 weeks (range, 12–15 weeks). The mean preoperative proximal tibial varus was 16.2^o (range, 12–19^o), corrected to normal values in all patients. The mean preoperative MPTA was 71.4^o (range, 67–77^o) and corrected to a mean MPTA 87.1^o (range, 85–89^o). In four patients (5 tibiae) with proximal tibial procurvatum, the PPTA was corrected to normal range.

Mean correction of internal tibial torsion was 10^o (range, 5–15^o), performed in six patients (8 tibias). Pre-operative MAD was 55.8 mm medial to center of the knee (range, 44–77 mm), corrected to a mean MAD of 4.9 mm medial to center of the knee (range, 2–11 mm).

Complications included superficial pin tract infections in seven patients.

No complications related to the fibula were observed during/after correction.

Conclusion: Based on our initial experience, we believe that most patients with adolescent Blount disease could have successful and predictable correction of tibial deformities without a need for osteotomy and fixation of the fibula.

Introduction: The standard treatment of displaced supracondylar fractures of the distal humerus in children is closed reduction and pin fixation, but the optimal pin configuration is controversial. Crossed-pin fixation of the humerus is mechanically more stable than any other kind of pin configuration, but this fixation may cause iatrogenic ulnar nerve injury. Many authors recommended fixation from the lateral side in order to eliminate this complication. Since 1999, we have been using a 3-pinfixation technique with insertion of the first two pins with the elbow in full flexion, followed by insertion of the third wire through the medial side with the elbow in full extension. We call this the “flexion-extension cross-pinning technique”.

Method: This is a retrospective review of 64 displaced supracondylar fractures fixed by flexion-extension cross pinning.

Results: Eleven children had Gartland type 2 fractures and 53 children had Gartland type 3 fractures. There was no iatrogenic ulnar neve palsy. Loss of reduction in two children was related to technical errors. One patient had superficial pin tract infection.

Conclusion: We feel that this technique and pins configuration is safe and easy to learn. It has become the standard method of fixation of displaced supracondylar fractures in our institution.