In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision.

A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings.

At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system.

We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful.

3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision.

Cite this article: Bone Joint J 2015; 97-B:899–904.

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis.

We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Cite this article: Bone Joint J 2013;95-B:694–98.

Aims: Pathologic studies in foetuses and stillborns with congenital clubfoot have shown atrophy of the musculature of the leg omolateral and incresased fibrous tissues within the muscles belly. Both the triceps surae and the tibialis posterior are mostly involved and their tendons thickened. Atrophy of the musculature of the leg has been described in various clinical studies on congenital clubfoot, but most of the authors believe that atrophy might be secondary to surgical treatment and prolonged immobilization in plaster cast and brace. In our study, we correlated the pathology of foetal leg muscle atrophy with leg muscle atrophy shown by patients with congenital clubfoot.

Methods: We investigated the MRI aspects of leg muscles in untreated babies and in children and adults who had been treated soon after birth for unilateral congenital clubfooft. The MRI aspects of the leg muscle in treated patients were compared to those of untreated babies, and to the histopathologic findings of the same muscles in foetuses with congenital clubfoot.

Results: The ratio between the muscles of the normal leg and the leg of the clubfoot side was almost the same as measured either on the histological sections of foetuses with congenital clubfoof or in patients before and after treatment, from birth to adulthood.

Conclusions: Our study shows that in congenital club-foot leg muscle atrophy is a primitive pathologic finding rather than secondary to treatment.

Five patients with isolated Madelung’s deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas average age at follow-up was 53 years. The deformity was bilateral in 4 patients and unilateral in 1.

At diagnosis deformity, pain and limitations of the range of motion were present in all the wrists except 2, which were painless but presented marked functional impairment. In all the patients the typical radial deviation of the hand, was observed, with dorsal prominence of the distal end of the ulna. The x-rays showed, in anteroposterior view, the V-shaped arrangement of the first carpal row, with the lunate at the apex of the V and the marked obliquity of the articular surface of the radius toward the ulnar side. In the lateral view, the articular surface of the radius was markedly angulated anteriorly, the ulna was subluxated posteriorly and carpal bones were translated anteriorly. In no patient did we observe growth disturbance of the other bones or deformities typical of osteochondrodysplasias. In some cases the deformity progressed rapidly, whereas in the others the progression was slow. Surgical correction was sought by both the family and the patients mainly for functional reasons, although cosmetic improvement was also expected.

The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At the operation all the patients had passed the adolescence growth spurt, although in 5 out of the 9 wrists growth plates were still open.

At follow- up, all the patients were satisfied with the results of the operations and the range of motion of the wrists was improved. Some residual radiographic abnormalities were present in 4 wrists, but all patients were mostly pleased with the absence of pain and improvement of wrist cosmesis. No radiographic osteoarthritis was present in any of the operated wrists, although 4 of the 5 patients were over 55 years of age.

Conclusions: An association of distal radial wedge-closing osteotomy and either distal ulnar hand resection or shortening distal ulnar osteotomy to correct Madelung’s deformity gave very good results in line with other reports. The limited number of our cases may be compensated by the very lengthy long-term follow-up of our series that showed how the results of these corrective operations do not deteriorate in time; moreover no radiographic osteoarthritis was present even almost 50 years after the operation.

Fibrous dysplasia is a genetic not hereditary disease of the skeleton, most frequently located at the femoral bone. The extension and the radiographic morphology of the femoral lesion are variable, and the prognosis is unpredictable. The purpose of this study is to propose a radiographic classification of the femoral lesion, related to the prognosis and the natural history of the disease.

The authors reviewed the radiographic examinations of 25 patients affected by fibrous dysplasia of bone with femoral involvement, who were followed-up at least two years after diagnosis. Eleven patients had bilateral localization of the disease, for a total of 36 affected femurs. A radiographic classification of the femoral lesion was proposed based on the localization, the extension and the type of the lesion.

The authors classify the femoral lesions as lytic, lytic with surrounding sclerosis, lytic and sclerotic, sclerotic and complex. They observed a prevalence of the lytic lesions and involvement of the proximal part of the femur. Many lesions (40%) expanded with age, and the sclerotic component also increased. The lytic lesions worsened with age, causing severe deformity of the femur. However the mostly sclerotic lesions turned out to be stable at follow-up. The worsening of the lesion was not related to the sex of the subjects; 77% of the worsened lesions were observed in patients younger than 20 years of age, while 66% of the stable lesions were found in patients older than 20 years.

In conclusion, this study demonstrated that the prognosis of the femoral lesion in fibrous dysplasia is related to the type of lesion, as per the radiographic classification here in described. Prognosis is also related to the age of the patient and the presence of a sclerotic component, which suggested a greater stability of the lesion.

OP-1 is a bone morphogenetic protein which induces bone formation. For this reason, this protein is used to treat congenital pseudoarthrosis and post-traumatic non-union as well as to improve healing of bone grafting in orthopaedic surgery. In the present study we report the results of treatment in 10 patients in whom OP-1 was used to improve bone healing. Four patients were operated because of post-traumatic non-union, one because of congenital pseudo-arthrosis and four because of spinal arthrodesis, whereas one had a tibial lenghthening with poor bone formation. At follow-up, ranging from 6 to 16 months after the operation, we observed satisfactory bone formation in all cases. Although the number of our cases is limited, our results confirm the effectiveness of OP-1 in the treatment of post-traumatic non-union and spinal arthrodesis.

We performed CT to investigate how treatment may modify the basic skeletal pathology of congenital club foot. Two homogenous groups of patients treated by one of the authors (EI) or under his supervision were studied. The first included 32 patients with 47 club feet reviewed at a mean age of 25 years and treated by manipulation, application of toe-to-groin plaster casts and an extensive posteromedial release. The second included 32 patients with 49 club feet reviewed at a mean age of 19 years and treated by the Ponseti manipulation technique, application of toe-to-groin plaster casts and a limited posterior release.

At follow-up the shape of the subtalar, talonavicular and calcaneocuboid joints was found to be altered in many feet in both groups. This did not appear to be influenced significantly by the type of treatment performed. Correction of the heel varus and the increased declination angle of the neck of the talus was better in the club feet of the second group, whereas reduction of the medial subluxation of the navicular was better in the first. There was a marked increase in the external ankle torsion angle in the first group and a moderate increase of this angle in the second group, in which medial subluxation of the cuboid on the anterior apophysis of the calcaneum was always corrected. Equinus was corrected in both groups but three-dimensional CT reconstruction of the whole foot showed that cavus, supination and adduction deformities were corrected much better in the second group.

We reviewed the radiographs of 49 patients with Perthes' disease at the stage of fragmentation and also after the end of skeletal growth to assess the value of the lateral pillar classification of Herring. The average age of the patients at diagnosis was 7 years 6 months and the mean follow-up was 24 years. Ten of the 11 Herring group-A hips showed good reconstruction of the femoral head. There were good results in group-B hips when the patients were less than nine years of age at diagnosis. All 11 group-C patients showed hip deformity at follow-up. The Herring classification provides a valid long-term prognosis in Perthes' disease, although age at diagnosis is also an important prognostic factor. The classification is relatively easy to apply, is reliable, and requires only an anteroposterior radiograph taken during the fragmentation stage of the disease.

We have attempted to identify the most important long-term prognostic factors in Perthes' disease by studying 61 patients affected unilaterally. The average age at diagnosis was 7 years 5 months and at follow-up it was 32 years, an average interval of 25 years. The age at diagnosis, age at follow-up, Catterall group, acetabular coverage, femoral head subluxation and the other head-at-risk signs were statistically correlated with Stulberg, Cooperman and Wallensten (1981) radiographic classes and the Iowa hip score. Statistically significant correlations were found between Stulberg class and Iowa hip score; age at diagnosis and Stulberg class; age at follow-up and Iowa hip score; and between lateral subluxation of the femoral head and Iowa hip score. Three age-groups of patients were found to carry different long-term prognoses. Those below five years of age at diagnosis showed a statistically significant correlation between Catterall group and Stulberg Classes I and II. Patients between five and nine years of age at diagnosis showed a significant correlation between Catterall group and Stulberg Classes I, II, III and IV while in patients diagnosed after nine years of age there was no statistical correlation between Catterall group and Stulberg class, all having a poor prognosis and ending up in Stulberg Classes III, IV and V.