We present a new technique for corrective osteotomies in the lower limbs.

The method combines the advantages of both external and internal fixation as well as minimizing soft tissue disruption and scarring.

Material and Methods: Between January 2004 and August 2006, eleven osteotomies were performed on six patients. Mean age was 9.5 yrs. (6.4–15.9) Underlying pathology included cerebral palsy (3 pts), microcephaly (1), giant axonal neuropathy (1) and post traumatic growth disturbance (1). Osteotomies were performed in seven femurs (bilateral in 3 pts and unilateral in 1) and 4 tibias (2 pts bilaterally). Correction was in the transverse plane in four pts (4 femurs & 4 tibias), in the sagittal plane in one pt (2 femurs) and in multiple planes in one pt (1 femur).

Surgical Technique:

Insertion of Schanz screws perpendicular to the deformed segments

Results: All limbs were corrected to within 3 degrees of planned correction.

Patients were allowed full ambulation. Casts were applied only if soft tissue releases were performed concomitantly. Ambulation as tolerated was initiated post operatively. There were no surgical complications. All osteotomies showed good callus formation within 6 weeks.

The plate was removed uneventfully from one patient.

Discussion: Multiple methods have been described for corrective osteotomies in long bones. They vary in the osteotomy level, degree of exposure, osteotomy technique and fixation method. The technique presented has the advantage of minimal violation of the periosteum and the surrounding musculature, inducing early bony union and good rehabilitation. The temporary external fixation enables accurate correction and intraoperative assessment.

Disadvantages include increased surgical time and radiation exposure – however these decrease with the learning curve and hardware improvements.

Aim: To evaluate the long term effect of Distal transfer of the greater trochanter in Perthes’ disease.

Patients and methods: Twelve patients (thirteen hip joints, 10 males and 2 females) who suffered from Perthes’ Disease were treated by distal transfer of the greater trochanter (DTT). The operation was performed because of progressive shortening of the articulo-trochanteric distance accompanied by signs of insufficiency of the hip abductors. Total or near total femoral head involvement was found in all the patients except for one of them. Follow up period was 28 years (21–35). Mean age at diagnosis of Perthes’ was 7 years (4–11). Patient were studied in 1992 and reviewed again 13 years later, using the Harris hip score, short form 36 (SF36), physical examination and A-P X-rays.

Results: Not one of the patients underwent a total hip arthroplasty. Mean Harris hip score is 80 (range 54–100, 4 patients under 70 score). Mean SF36 score was 71 (range 30–94) and was correlated to the Harris score. Three of the patients were working in a physically demanding profession. The rest were office workers. Two of them chose non strenuous type of work due to the hip condition. Limb length discrepancy was 1.7 cm short on the operated side (range 0–3) and correlated with Trendelenburg sign (4 patients with positive sign). Femoral head sphericity according to Stulberg classification was good in 5 patients (grades 1–2), fair in 3 patients (grade 3) and poor in 4 patients (grade 4–5). Head sphericity was not correlated to age at diagnosis, Harris score, SF36 score or level of hip pain.

Conclusions: Long term outcome are surprisingly good in those patients, considering the degree of head involvement, advanced age at diagnosis and severity of disease which necessitated high degree of varus osteotomy and hence trochanter transfer.

Purpose: To evaluate the predictive value of a prenatal ultrasound diagnosis of clubfoot, the ability to differentiate isolated clubfoot from complex clubfoot, and establish valid recommendations for follow-up and additional investigations.

Materials and Methods: Clubfoot (CF) was diagnosed by prenatal ultrasound (US) in 85 feet in 48 fetuses at a mean gestational age of 21.6 weeks (14–35.6).

All mothers were examined prenatally in a multidisciplinary clinic for fetal abnormalities. Postnatal outcome was obtained by chart review (24) or telephone interview (24) and feet were classified as Normal (N), Positional Deformity (PD), Isolated Clubfoot (ICF) and Complex Clubfoot (CCF).

Results: At initial diagnosis, 65 feet in 38 fetuses were classified as ICF and 20 feet in 10 fetuses as CCF. Diagnosis was changed during follow-up US in 12 fetuses (25%) and final US diagnosis was N in one, ICF in 29 and CCF in 18 fetuses.

Post natal clubfoot was found in 73 feet in 40 children giving a positive predictive value (PPV) of 85%. Accuracy of specific diagnosis was significantly lower – 65% initially and 75% at final US. No post natal CCF had been undiagnosed and inaccuracies were all overdiagnoses.

24 kariotypes were performed. Three were abnormal but had additional US findings and had been classified as CCF. No abnormal kariotypes were found in fetuses diagnosed as ICF.

Conclusions:

The prenatal diagnosis of clubfoot carries a positive predictive value of 87% with lower values of ICF (76%) and CCF (69%).

Purpose: To determine the need for routine serial radiographs in the management of forearm fractures in children.

Material and Methods: A binational study was conducted in 202 consecutive children with closed forearm fractures. In the 91 patients with stable fractures that did not require reduction, clinical and radiographic examination was performed one week after the start of treatment and again on cast removal 4–6 weeks later. In the remaining 111 patients who underwent closed reduction, an additional X-ray was taken two weeks after cast placement. Outcome was defined as the occurrence of redisplacement.

Results: Redisplacement occurred during the first 2 weeks of cast management in 9 of the children who required reduction and in none of the children who did not.

Conclusion: Radiographs should be performed one week after cast placement for greenstick or complete fractures that do not require reduction, and repeated at 2 weeks from start of treatment for fractures that require reduction. They need not be performed on cast removal, if clinical examination does not show signs of nonunion or malalignment. The adoption of these recommendations will lead to more cost-effective management and will spare children unnecessary radiographic exposure.

Purpose: To investigate sciatic nerve conduction during hamstring lengthening.

Conclusion: Sciatic nerve traction is caused during hamstring lengthening.

Summary of method, results, and discussion: Ten children with spastic cerebral palsy underwent distal hamstring lengthening, average popliteal angel before surgery was 80 degrees.

Methods: The tendon of the semitendinosus was elongated by sliding lengthening. The gracilis tendon was cut and the tendons of the biceps and semimembranosus were elongated by dividing the aponeurosis. Thereafter to elongate the hamstring the hip and knee were flexed to 90 degrees and the knee slowly extended with continuous evoked EMG monitoring. Bipolar nerve stimulation placed near the sciatic nerve consisted of the delivering of rectangular impulses of amplitude 0.8-1.2 ma for 100 US duration. The EMG recordings were performed from the tibialis anterior muscle.

Results: In all patients motor potential amplitude gradually decreased during extension of knee (hamstring lengthening). The average decrease of the amplitude at popliteal angle of 60 degrees was 37 percent (16-75) and at 30 degrees 83 percent (36-98). The elongation was stopped at 30° of popliteal angle. On extending the hip and knee motor potential amplitude returned to normal. Discussion: Elongation of hamstring muscle is associated with traction on the f sciatic nerve as appears by decrease in sciatic nerve motor potential amplitude. To avoid nerve injury no excessive hamstring lengthening should be done and no nerve traction should be allowed at postoperative immobilization.

Purpose: Congenital insensitivity to Pain (CIP) is a rare peripheral neuropathy which may affect various sensory pathways and often affects the autonomic nervous system. Musculoskeletal manifestations include infections, fractures, growth disturbances, avascular necrosis, Charcot arthropathy, joint dislocations and heterotopic ossification. The purpose of the study was to review the orthopaedic problems in patients with Congenital Insensitivity to Pain and make treatment recommendations.

Methods: Thirteen patients from eight families were examined and all charts and radiographs were reviewed. A quantitative sweat test was performed in five patients and an intradermal histamine test in ten.

DNA was prepared in all patients and examined for specific mutations.

Results: Three clinical presentations were found:

Type A – Five patients presented with multiple infections requiring many surgical procedures ranging from local debridement to below knee amputation.

Type B – Three patients presented with fractures and growth disturbances of the lower limbs as well as avascular necrosis of the talus or femoral condyle. Two patients underwent corrective osteotomies due to deformities. Type C – Five patients presented with Charcot arthropathies, joint dislocations, fractures and infections. Four of them were mentally retarded.

Patients underwent multiple surgical procedure to control infections.

Attempts surgical stabilization of joints were unsuccessful.

Mutations were found in four patients.

Conclusions

Patient education, shoe ware and periods of non weight bearing are important in prevention and early treatment of decubitus ulcers.