Forearm deformity is common in Hereditary Multiple Exostoses, for which multiple surgical treatments exist. Acute ulnar lengthening has been described in the literature, though in small numbers and not independent of adjunctive procedures. We hypothesise that acute ulnar lengthening as a primary procedure is safe and effective in correcting forearm deformity.

Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity, over an eight-year period. Radiographic parameters were assessed and compared preoperatively and postoperatively. Mean follow-up was 27 months. Complications and revisions were noted.

The mean pre-operative ulnar variance, 12.4mm (range 6.1 – 16.5), was significantly reduced post-operatively to a mean 4.6mm (p=<0.00001). A significant acute difference was achieved in carpal slip, (mean change of −2.2mm, p=0.02) but no significant change was seen with regard to radial bowing (p=0.98) or radial articular angle (p=0.74). There were three episodes of recurrence requiring revision. There were no major complications.

Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. Complications were infrequent. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening techniques. Acute ulnar lengthening for forearm deformity associated with HME, has been demonstrated to be a safe, reproducible and effective surgical procedure.

Closed reduction and percutaneous pinning has become the most common technique for the treatment of Type III displaced supracondylar humerus fractures in children. The purpose of this study was to evaluate whether the loss of reduction in lateral K wiring is non-inferior to crossed K wiring in this procedure.

A prospective randomised non-inferiority trial was conducted. Patients aged three to seven presenting to the Emergency Department with a diagnosis of Type III supracondylar humerus fracture were eligible for inclusion in the study. Consenting patients were block randomised into one of two groups based on wire configuration (lateral or crossed K wires). Surgical technique and post-operative management were standardised between the two groups. The primary outcome was loss of reduction, measured by the change in Baumann's angle immediately post –operation compared to that at the time of K wire removal at three weeks. Secondary outcome data collected included Flynn's elbow score, the humero-capitellar angle, and evidence of iatrogenic ulnar nerve injury. Data was analysed using a t-test for independent means.

A total of 52 patients were enrolled at baseline with 23 allocated to the lateral pinning group (44%) and 29 to the cross pinning group (56%). Six patients (5 crossed, 1 lateral) received a third wire and one patient (crossed) did not return for x-rays at pin removal and were therefore excluded from analysis. A total of 45 patients were subsequently analysed (22 lateral and 23 crossed). The mean change in Baumann's angle was 1.05 degrees, 95% CI [-0.29, 2.38] for the lateral group and 0.13 degrees, 95% CI [-1.30, 1.56] for the crossed group. There was no significant difference between the groups in change in Baumann's Angle at the time of pin removal (p = 0.18). Two patients in the crossed group developed post-operative iatrogenic ulnar nerve injuries, while none were reported in the lateral group.

Preliminary analysis shows that loss of reduction in Baumann's angle with lateral K wires is not inferior to crossed K wires in the management of Type III supracondylar humerus fractures in children. The results of this study suggest that orthopaedic surgeons who currently use crossed K wires could consider switching to lateral K wires in order to reduce the risk of iatrogenic ulnar nerve injuries without significantly compromising reduction.

To evaluate effectiveness and safety of acute ulnar lengthening osteotomy in Madelung's deformity associated with Hereditary Multiple Exostoses (HME)

Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity. Defined radiographic parameters were compared pre- and post-operatively using student's t-test; ulnar variance, carpal slip, radial bowing, radial articular angle. All complications were noted.

Mean follow-up was 27 months (range 1.5 – 72months). An increase in ulna length by a mean of 15.4mm (range 4.5 – 29.3mm) was achieved acutely, corresponding to an increase of 9.3% of total ulnar length. Negative ulnar variance was improved from a pre-operative mean of 12.4mm (range 6.1–16.5mm) to a post-operative mean of 4.6mm (range 0–11.25mm) (p=<0.00001). Carpal slip was significantly improved by a mean of 2.2mm (p=0.02). No significant change in radial bowing (p=0.98) or radial articular angle (p=0.74) was observed. Inter-rater reliability was excellent (r=0.96, Pearson Correlation).

Three patients required second procedures for recurrence of deformity at 18 months – 6 years following their primary operation. There were no incidences of compartment syndrome, neurovascular injury nor infection. One ulna fractured intra-operatively requiring a longer plate. One patient had a non union which united on revision surgery.

Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. The procedure is safe, with no compartment syndrome nor neurovascular injury and low complications rate. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening. Acute ulnar lengthening for forearm deformity associated with HME has been demonstrated to be a safe, reproducible and effective surgical procedure.

Introduction

Chronic pain is one of the adverse outcomes in surgery for degenerative lumbar pathology (DLP). Postoperative complications as DVT, and chronic pain in pathologies as thoracotomy or breast cancer have been associated with poor control of postoperative pain.

Introduction

An important number of factors affecting the outcome of surgical treatment have been identified, and these factors can affect the patient's selection for lumbar surgery.

Clubfoot is a complex three-dimensional deformity that is difficult to assess by clinical examination and conventional radiography. Pedobarography has been established as a useful technique for measuring pressure profiles of the foot, however its utility in the clubfoot population has not been established. The purpose of the present study is to describe the pedobarographic profiles of children with clubfeet and to establish the significant variables when compared with aged-matched controls.

Pedobarographic profiles were obtained using the Tekscan HR Mat Pressure Measurement System and data was analyzed using a custom built LabView program. Clubfoot patients aged 18 months to four years (n = 190) were tested and compared to aged matched controls (n = 82). Each foot was divided into five segments (heel, medial and lateral midfoot, medial and lateral forefoot) and each segment was analyzed for timing of initiation of force, timing of termination of force, force distribution, and impulse. The mean and standard deviation were calculated for each variable. Clubfoot pedobarographic means were compared to the aged matched controls and significant variables were identified using Student’s paired t-test (p < .05).

Nine of twenty-five variables were found to be significantly different in the clubfoot population. The heel showed a reduced force and impulse. The lateral mid-foot showed an increased force and impulse with an earlier initiation and later termination of forces. The medial forefoot showed a decrease force and impulse with a later initiation of force.

Pedobarography has been found to be a useful tool in the evaluation of foot pathology, but its utility in the clubfoot population has yet to be established. In this study, we describe the pedobarographic profiles of children with clubfeet and have noted significant differences when compared to age-matched controls.

Purpose of the study: Prenatal screening and search for risk factors has lead to early diagnosis of congenital hip dysplasia. The percent of excentration of the dysplastic hip can be quantified with ultrasonography. The purpose of this study was to evaluate the usefulness of ultrasound monitoring of confirmed hip dysplasia as a method for determining the appropriate time to discontinue treatment.

Material and methods: We collected a series of patients presenting unstable hips one month after birth. Ultrasonographic examinations were performed to quantify the instability. Initial treatment was forced abduction. If the infant’s weight was greater than 5.6 kg, a Pavlik harness was used. Physical examination and control ultrasound examinations were performed at 4, 8 and 12 weeks. Forced abduction and ultrasound surveillance were discontinued when the percent of acetabular cover was greater than 50%. Long-term surveillance consisted in physical examination and plain ap view of the pelvis at four months and at onset of walking.

Results: Ultrasound monitoring was instituted for 71 hips in 51 patients. Mean age at onset of the monitoring scheme was 37.7 days (range 38–74 days). Mean acetabular cover, as evaluated by ultrasound before treatment, was 35.5% (range 20–45%). After four weeks, mean cover for 42 hips was 54.7% (range 50–85%). For the other 29 hips, mean acetabular cover was 41.4% (range 36–47%) at four weeks. At eight weeks, 26 of these 29 hips had a mean cover of 60% (52–85%). Acetabular cover remained below 50% for three hips at twelve weeks. Mean HTE at four months was 20.7° (range 10–26°). At walking, all hips were centered and no irregularities were noted on the x-rays of the femoral nucleus.

Discussion: The majority of infants with unstable hips diagnosed at birth achieve spontaneous cure without treatment. For others, cure can be achieved with forced abduction but with a risk of osteochondritis. In our study, ultrasound monitoring enabled a reliable assessment of the proper moment to interrupt treatment.

Conclusion: Ultrasound examination of the hip joint is a satisfactory method for monitoring hip dysplasia in infants aged less than four months. It appears to be useful for determining the moment to interrupt treatment.

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated.

Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old).

Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients)

Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents.

Introduction and Aims: Hereditary Multiple Exostosis is an autosomal dominant condition in which multiple benign cartilage-capped tumors grow in relation to the growth plates of long and flat bones. The purpose of this study was to determine the relationship between the genotype and phenotype in HME.

Method: Ten families were identified with HME. Genotyping was completed by linkage analysis of all families and the EXT 1 or 2 gene was sequenced based on these results. Mutation identification and confirmation was performed. Phenotyping consisting of clinical and radiographic examinations generated 89 features for each subject.

Results: Eight of 10 mutations were identified, confirmed and segregation verified. Six of the mutations were unique and two previously had been reported in the literature. Three mutations were in EXT 1 and five in EXT 2. Two were missense, three nonsense, two splice site and one frameshift. EXT 1 patients were found to have more exostoses, with a higher percentage of flat and pelvic bone involvement. EXT 1 patients had more malalignment and were shorter. Males also had a more severe phenotype and modulated the severity of EXT 1 expression. No other genotypic factors were found to influence phenotype.

Conclusion: An established genotype phenotype correlation will aid in patient management in terms of surveillance, determining prognosis and management. It was found that a genotype phenotype correlation exists where EXT 1 is linked to a more severe phenotype.