Journal of Children's Orthopaedics

Previous classifications of tibial malformations are no longer sufficient and practical for clinics and treatment. They are not precisely defined, include incorrect pathological–anatomical definitions, are related to X-ray diagnosis only, miss complete formal types of malformation, or describe too complex concepts not useful for clinical applications (Jones et al., J Bone Joint Surg B 60:31–39, 1978; Kalamchi and Dawe, J Bone Joint Surg B 67:581–584, 1985; Henkel et al., Arch Orthop Trauma Surg 93:1–19, 1978). More precise preoperative diagnosis, including by sonography and MRI and experienced intraoperative analysis of anatomical structures ensure exact description of the pathological–anatomical situation which can be used because of new potential in therapy. Until now, no score was available for detection of additional limb malformations and, therefore, clinical and scientific comparison of the different tibial reduction deficiencies, especially in respect to the success of therapy, was not sufficiently realisable. A new classification and score is presented reflecting the improved therapy currently available.

In this classification and score the main pathological findings of the complete leg are included (coxa–femur–patella–tibia–fibula–pes), with specific importance of the tibia. Tibial malformations are divided into seven main groups and five of them into two subgroups. The cartilaginous anlage of the tibia which has not yet received much attention in the literature plays an important role in this classification. Only seven main types of tibial defect have to be recognized and, if necessary, additional defects of the whole leg, including the function of the affected parts, can be summarized in a-five-class-system.

With this classification and this score system which was evaluated on 95 affected limbs, with a sex ratio of 51%:49% (male:female), right:left affection, and unilateral:bilateral affection also, we found the sequence of the distribution of types as follows: 61% of cases with type-VII, 15% with type-III, 6% with type-I, 6% with type-V, 5% with type-II, 3% with type-IV, and 3% with type-VI. In comparison with the Jones et al. (J Bone Joint Surg B 60:31–39, 1978), Kalamchi and Dawe (J Bone Joint Surg B 67:581–584, 1985) and Henkel et al. (Arch Orthop Trauma Surg 93:1–19, 1978) classifications the tibial defects in the presented classification are detected more precisely, the pathological anatomical terms are correctly used, the whole leg and all main functions are included and, thus, reference to therapeutical possibilities is given.

The new classification and the score system allow simple, therapeutically relevant, and comprehensive classification and, additionally, scientific comparison of the different pattern of defects described by diverse authors. For daily clinical use the tibial classification only is preferred.

The ligamentum teres has primarily been considered as an obstruction to reduction in children with developmental dislocation of the hip (DDH). In the early surgical descriptions of both the medial (Ludloff) approach and the anterior (Salter) approach to the hip, it was generally accepted that the ligamentum teres was an obstruction to reduction and was excised (similar to the discarding of menisci for knee surgery in our orthopedic history). Because of the known propensity for early re-dislocation following open reduction, we developed surgical methods for maintaining the ligamentum teres when performing open reduction for hip dislocation in young children. This study presents the surgical methods developed for ligament maintenance and transfer, and analyzes the early clinical and radiographic results in a study group.

The techniques for open reduction by both the medial Ludloff approach and the anterior open reduction were developed and refined. Twenty-one children (23 hips) had ligamentum teres shortening and transfer performed as part of either a medial Ludloff or anterior open reduction for hip dislocation. Complete pre-operative and post-operative clinical and radiographic analysis was performed.

All patients had stable hips at follow-up. The transferred ligamentum teres appeared to provide additional stability to prevent repeat dislocation. We noted no apparent loss of hip motion or other adverse events. One patient had avascular necrosis (AVN).

In this series of 23 hips, in which ligamentum teres transfer/tenodesis was utilized, we found no residual subluxation or dislocation in either the medial Ludloff or the anterior open reduction groups. Based on these early positive results, we recommend the method for children treated with the Ludloff open reduction procedure. Although we have less experience with it, the technique presented for ligamentum maintenance and transfer in anterior open reduction may provide similar added stability. This is an early follow-up study, and long-term follow-up will be required to confirm the ultimate femoral head and acetabular development.

Traditionally, angular deformities are treated by means of osteotomy. In patients who are skeletally immature, this major intervention can be avoided by influencing or guiding the growth of the affected physis. Recently, a new device was presented as an alternative to the widely used Blount staple. Stevens developed a technique using a two-hole, non-locking plate with two screws to perform temporary hemiepiphysiodesis in children. We studied the effectiveness of this new device in correcting angular deformities in children even younger than 5 years of age.

We evaluated our first series of 11 patients (17 eight-Plates) who underwent treatment for angular deformities of various origins and were followed to completion of correction. The average age at hemiepiphysiodesis was 10 years and 2 months (age range 4 years and 11 months–13 years and 8 months). The device was inserted in the lateral distal femur (two cases), the medial distal femur (eight cases), the lateral proximal tibia (two cases), the medial proximal tibia (four cases), and the medial distal tibia (one case).

The eight-Plate was inserted for an average of 9.5 months (range 5–13 months). The joint orientation angles and the mechanical axis improved in all patients, with the exception of one 13-year and 8-month-old boy with a resected osteosarcoma and a compromised growth plate. In valgus cases (12 limbs, 13 eight-Plates), the mechanical axis deviation improved by an average of 30.7 mm (range 13–55 mm). In varus cases (four limbs, four eight-Plates), the mechanical axis deviation improved by an average of 38.8 mm (range 0–74 mm). No hardware failures, extrusion, growth arrest, or other complications were observed. None of our patients required an osteotomy or repeat eight-Plate insertion.

We consider the eight-Plate to be an ideal tool for treatment of angular deformities in growing children. It allows for precise insertion and is reliable. It is also less likely to extrude like the Blount staple.

The standard treatment of adolescent Blount disease includes proximal tibial osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. The purpose of the current study was to examine the results of treatment of patients with adolescent tibia vara treated by tibial osteotomy and Taylor spatial frame (TSF) without fibular osteotomy.

Correction of deformities was performed on eight patients (ten tibias) with adolescent Blount disease using TSF. The fibula was not osteotomized in any patient and was not fixed in the last five patients.

All patients had precise anatomical correction of deformities and no problems related to the fibula occurred during or after correction.

Based on our experience we believe that placement of the origin at the level of the proximal tibial fibular joint in conjunction with external fixation eliminates the need for fibular osteotomy and the potential morbidity of this procedure in patients with mild to moderate tibia vara.

The purpose of this study was to describe the skeletal manifestations of primary hyperoxaluria type 1 (PH1), the most common of the primary hyperoxalurias.

We clinically and radiographically reviewed 12 consecutive patients diagnosed with PH1, aged between 2 and 17 years. All patients had evidence of some type of renal involvement, 4 of whom were at end-stage renal disease (ESRD) and were under dialysis.

The main symptom was skeletal pain and was present only in the 4 severely involved patients and appeared during the second year of dialysis. The 2 most severely involved patients had evidence of pathological fractures. Radiological signs were present in patients with or without symptoms. These radiological signs were of two distinct types: those almost specific of oxalosis, such as dense and radiolucent metaphyseal bands and vertebral osteocondensations, which are found mainly in the severely involved individuals, and those less specific, such as signs of renal osteodystrophy, which are also found in less severely involved patients. Interestingly, our study revealed the presence of spondylolysis in 25% of cases. This latter finding is unique and has not previously been reported in the literature.

The skeletal manifestations of PH1 include specific and less specific radiological signs, with some patients being asymptomatic, and others presenting with bone pain and pathological fractures, as well as spondylolysis.

Cases of “non-idiopathic” scoliosis are deemed atypical. These require a comprehensive work-up in order to choose the best treatment (and to determine an extent of fusion if needed). Marfan syndrome (MFS) is a genetic disease often marked with the presence of scoliosis, which is poorly described in the literature. Knowing that the clinical diagnosis of MFS is not always obvious, we investigated how atypical the scoliosis associated with MFS was when compared with that of adolescent idiopathic scoliosis (AIS).

In our series, we included 30 patients diagnosed with MFS. Each patient was proposed to undergo a plain radiographic examination of the spine. Scoliotic patients were classified according to the Scoliosis Research Society (SRS) curve pattern classification. Curve patterns with a very low rate of occurrence in historic control were defined as “atypical”.

A total of 19 patients were defined as scoliotic. In 9 cases, the curve pattern was atypical. In the other 10, the curve pattern was typical, but a fine analysis revealed some atypical features in the position of the apex and end vertebrae.

Scoliosis associated with MFS was found to be atypical in all cases. This supports the idea that an atypical curve pattern should be considered as an argument in favour of a non-idiopathic aetiology and, therefore, an appropriate work-up should be performed before deciding treatment.

A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China.

The sample consisted of 202 consecutive children (mean age 7 years; range 3–12 years) with closed forearm fractures treated nonoperatively. Children with open, growth-plate fractures or fractures associated with dislocation of the nearby joint (i.e., monteggia fractures) were excluded. In 28 children who had torus fractures, radiographic examination was performed at the time of cast removal, 3 weeks after the start of treatment. In 63 children who had stable fractures that did not require reduction (undisplaced or minimally displaced, complete or greenstick), radiographic examination was performed 1 week after the start of treatment and again at cast removal 4–6 weeks later. In the remaining 111 children with complete, displaced, or greenstick fractures (all with angulation of more than 15°) who underwent closed reduction, an additional X-ray was taken 2 weeks after cast placement. All children (except those with torus fractures) were followed clinically, without further radiographic examination, for 3 months after cast removal.

Radiographs at cast removal showed good union in all stable fractures, indicating that additional X-rays on cast removal would have had no added value. In the children with unstable fractures, only 9 showed redisplacement with angulation of more than 15° on repeated X-rays during the first 2 weeks after cast placement. All 9 underwent successful re-reduction. On clinical evaluation 3 months after cast removal, all patients in the sample had full range of elbow and forearm motion. Repeated fracture did not occur in any of the patients.

On the basis of these results, radiographs are recommended 2 weeks after cast placement for greenstick or complete fractures. At the time of cast removal, if clinical examination does not show signs of nonunion or malalignment, no radiographic examination is necessary.

The purpose of this prospective study was to assess the impact of cast immobilization on the activities of daily living in children with fractured upper limbs.

Using the Activities Scale for Kids (ASK), 52 consecutive children (17 girls, 35 boys), aged 5–15 years (mean, 9 years), with upper limb fractures treated by means of above- or below-elbow casts were assessed. The files were reviewed for background and fracture-related data.

Mean score of the above-elbow group was 65.4 ± 15.5 points on the ASK capability domain (ASK-c) (with cast) and 98.7 ± 3 points on the ASK-performance domain (without cast). Corresponding scores for the below-cast group were 89.8 ± 13 and 99.5 ± 2. Factors that positively affected overall function were older age, male sex, shorter duration of pain, and less displacement. On multivariate analysis, only age proved to be a potential predictive factor. Cast position and hand dominance had no effect. The specific activities affected were personal hygiene, dressing, making a snack, and reaching high objects.

To ease their children's adjustment to forearm cast immobilization after fractures, parents should be educated in the areas of daily living that may be affected. This is particularly true for younger children with more displaced fractures that cause more pain.

In patients with cerebral palsy, the prevention of hip dislocation should be the “primum momens” of early surgery. The surgery consists of a myotomy of the adductor medium, mayor and gracilis, and, in non-ambulatory cases, a neurectomy of the second branch of the obturator nerve. The purpose of this study was to examine whether the adductor myotomy should be performed on the contralateral side at one sitting.

In a study performed by our team on 1,474 patients, 792 patients (53.7%) had a unilateral procedure and 682 a bilateral procedure.

The non-myotomized spastic adductors alter the movement of forces on the femoral head and, thus, 78.20% required a secondary contralateral procedure. The dislocation of the hip in patients whose operations were performed at two different sittings occurred in 20% of cases, and in those with a bilateral procedure at one sitting only in 1%. The increase in the cervicodiaphyseal angle occurred in 23.1% of patients with surgeries performed at two sittings and only in 10% of patients with bilateral procedures at one sitting.

Our results suggest that the bilateral surgical procedure at one sitting should be recommended to equalize the movements of force in spastic hips.

The goal of this study was to compare results of open arthrotomy versus arthroscopic drainage in treating septic arthritis of the hip in children.

This prospective controlled study was conducted on twenty patients (20 hips) with acute septic arthritis of the hip. Diagnosis was suspected if there was: a history of fever, non-weight-bearing on the affected limb, erythrocyte sedimentation rate (ESR) of at least 40 mm/h, and white blood cell count of more than 12,000 cells per cubic millimeter. Diagnosis was established by ultrasonographic examination of the affected hip followed by ultrasound-guided aspiration of the joint. Patients were allocated to have either open arthrotomy or arthroscopic drainage of the joint. There were ten patients (ten hips) in each treatment group. The mean age of the patients was 7.3 years in the arthrotomy group, and 8 years in the arthroscopy group. The mean temperatures for the arthrotomy and arthroscopy groups were 38.8 and 38.7°C, respectively. All the children were unable to bear weight on the affected limb.

Staphylococcus aureus was the most common causative microorganism in both groups. The mean duration of the children's hospital stay was 6.4 days in the arthrotomy group and 3.8 days in the arthroscopy group. The difference was highly significant. Infection could be eradicated in all patients of both groups. At the latest follow-up, seven children in the arthrotomy group (70%) had excellent results and three children (30%) had good results. In the arthroscopy group, nine children (90%) had excellent results and one child (10%) had good results. The difference was not statistically significant.

Arthroscopic drainage is an effective method in treating septic arthritis of the hip. It is a minimal invasive procedure which is associated with less hospital stay. Arthroscopic drainage of septic arthritis of the hip in children is a valid alternative procedure in early uncomplicated cases and for orthopedic surgeons skilled in pediatric arthroscopy.

We have evaluated the effect of internal and external osteosynthesis devices on the efficacy of vancomycin treatment in a rabbit model of methicillin-resistant Staphylococcus aureus (MRSA)-induced post-traumatic osteomyelitis.

Double tibial osteotomies in female New Zealand rabbits were performed, inoculated with a MRSA strain, then fixed with an intramedullary rod. A debridement was performed 4 days later for each rabbit, and a bacterial count in pus was determined (B1). In the first group (G1), the osteosynthesis material was removed and replaced by a new sterile nail. In the second group (G2), the intramedullary rod was removed and then replaced by an external fixator. Immediately after surgery, G1 and G2 rabbits were treated with vancomycin (60 mg/kg twice a day). The animals were sacrificed at the end of a 5-day period, and a bacterial count in pus was performed again (B2).

The difference of log₁₀ colony forming units per milliliter (CFU/ml) (B2−B1) was −1.2 ± 0.5 and −2.9 ± 1.1, respectively, for G1 and G2.

The efficacy of vancomycin treatment increased after removal of the internal osteosynthesis device.