Aims

Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates.

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.

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.

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.

Club foot was diagnosed by ultrasonography in 91 feet (52 fetuses) at a mean gestational age of 22.1 weeks (14 to 35.6). Outcome was obtained by chart review in 26 women or telephone interview in 26. Feet were classified as normal, positional deformity, isolated club foot or complex club foot.

At initial diagnosis, 69 feet (40 fetuses) were classified as isolated club foot and 22 feet (12 fetuses) as complex club foot. The diagnosis was changed after follow-up ultrasound scan in 13 fetuses (25%), and the final ultrasound diagnosis was normal in one fetus, isolated club foot in 31 fetuses, and complex club foot in 20 fetuses.

At birth, club foot was found in 79 feet in 43 infants for a positive predictive value of 83%. Accuracy of the specific diagnosis of isolated club foot or complex club foot was lower; 63% at the initial ultrasound scan and 73% at the final scan. The difference in diagnostic accuracy between isolated and complex club foot was not statistically significant. In no case was postnatal complex club foot undiagnosed on fetal ultrasound and all inaccuracies were overdiagnoses. Karyotyping was performed in 25 cases. Abnormalities were noted in three fetuses, all with complex club foot and with additional findings on ultrasound.

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.

Traction injury to the sciatic nerve can occur during hamstring lengthening. The aim of this study was to monitor the influence of hamstring lengthening on conduction in the sciatic nerve using evoked electromyography (EMG).

Ten children with spastic cerebral palsy underwent bilateral distal hamstring lengthening. Before lengthening, the evoked potential was recorded with the patient prone. During lengthening, it was recorded with the knee flexed to 90°, 60° and 30°, and at the end of lengthening with the hip and knee extended.

In all patients, the amplitude of the evoked EMG gradually decreased with increasing lengthening. The mean decrease with the knee flexed to 60° was 34% (10 to 77), and to 30°, 86% (52 to 98) compared with the pre-lengthening amplitude. On hip extension at the end of the lengthening procedure, the EMG returned to the pre-lengthening level.

Monitoring of the evoked EMG potential of the sciatic nerve during and after hamstring lengthening, may be helpful in preventing traction injury.

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.

We reviewed 13 patients with congenital insensitivity to pain. A quantitative sweat test was carried out in five and an intradermal histamine test in ten. DNA examination showed specific mutations in four patients. There were three clinical presentations: type A, in which multiple infections occurred (five patients); type B, with fractures, growth disturbances and avascular necrosis (three patients); and type C, with Charcot arthropathies and joint dislocations, as well as fractures and infections (five patients, four with mental retardation).

Patient education, shoeware and periods of non-weight-bearing are important in the prevention and early treatment of decubitus ulcers. The differentiation between fractures and infections should be based on aspiration and cultures to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities can be managed by corrective osteotomies, and shortening by shoe raises or epiphysiodesis. Joint dislocations are best treated conservatively.

Ultrasonography of the hip was performed sequentially by two different examiners in 75 infants. The ultrasound strips were reviewed twice by three paediatric orthopaedic surgeons and classified by the Graf method. The intraobserver and interobserver agreement between the interpretations was analysed using simple and weighted kappa coefficients calculated for agreement on the Graf classification and for grouping as normal (types 1A to 2A), and abnormal requiring treatment (types 2B to 4).

When examining the same ultrasound strip, intraobserver agreement for the Graf classification was substantial (mean kappa 0.61), but interobserver agreement was only moderate (kappa 0.50).

For the grouping into normal and abnormal, the mean kappa value for intraobserver agreement was 0.67 and for interobserver agreement 0.57. Because of the significant differences in agreement between normal and abnormal hips, we analysed a subgroup of those with at least one abnormal interpretation. Intraobserver agreement within this subgroup showed moderate reliability (kappa 0.41), but interobserver agreement was only fair (kappa 0.28).

Interpretations of two different strips performed sequentially showed significantly lower agreement with an intraobserver kappa value of 0.29 and an interobserver value of 0.28. In the subgroup with at least one abnormal reading, the intraobserver kappa was 0.09 and the interobserver 0.1.

Our findings suggest that both the technique of performing ultrasonography and the interpretation of the image may influence the result.

We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group.

The early postoperative course was similar, but the EF group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections.

At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5°, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied.

We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.