Search

Introduction The use of the orthopaedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal femur fractures (DFFs) is still debated. In most centers, children with displaced DFF are treated using an OTT. In some other institutions, however, fracture reduction and stabilization by ESIN are performed on a radiolucent table without an OTT. The aim of this study was to evaluate the clinical and radiologic outcome of children with displaced DFF managed by ESIN with and without the use of an OTT. Methods Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining DFF managed by ESIN from 2011 to 2017 at 2 different institutions. In all, 69 consecutive children with displaced DFF were recorded, of whom 35 underwent operative treatment by ESIN with the use of an OTT with skeletal traction (Group A), and 34 by ESIN without OTT (Group B). The titanium elastic nails outcome measure scale score and Beaty radiologic criteria were used to evaluate the results. Results Average patient age at time of injury was 9 years (range, 5 to 13) and 10 years (range, 4 to 15) in Groups A and B, respectively. The mean follow-up was 54 months (range, 24 to 96). Overall, complications were observed in 6 patients (8.6%). Complication rate was higher among children managed without OTT (11.8%) than among children treated with OTT (2.5%); no complication related to pin insertion for skeletal traction was recorded. However, the number of patients with a poor outcome according to the titanium elastic nails outcome score was higher in Group A (20%) than in Group B (5.8%). Beaty radiologic criteria were comparable between the 2 groups. Mean length of surgery and mean cumulative time of radiation exposure during surgery were similar between the 2 groups. Conclusions Overall, both techniques work equally well although patients treated by ESIN with the use of an OTT and skeletal traction tended to have a lower rate of complications and radiologic outcome was worse than for patients treated without using an OTT; however, no statistically significant difference was found.Despite their limitations, the results of this study suggest that displaced DFF can be safely managed by ESIN with or without the use of intraoperative OTT and skeletal traction, according to the surgeon's preference. Further studies are now needed to consolidate these conclusions and clarify the role of the OTT. Level of evidence Level III.

Background Rod migration into the spinal canal after posterior instrumented fusion is a rare complication causing late-onset neurological symptoms. The purpose of the present study is to report a case of a 13-year-old boy with spastic cerebral palsy and related neuromuscular kyphoscoliosis who developed late-onset neurological deterioration secondary to progressive implant migration into the spinal canal over a 5-year period. Methods A decision was made to remove both rods to achieve decompression. Intraoperative findings were consistent with information gained from preoperative imaging. The rods were found to have an intracanal trajectory at T9-T10 for the right rod and T12-L2 for the left rod. Results The cause of implant migration, with progressive laminar erosion slow enough to generate a solid mass behind, was progressive kyphosis in a skeletally immature patient with neuromuscular compromise. Conclusions Fixation type, early surgery, and spasticity management contributed significantly to the presenting condition. Mechanical factors and timing of surgery played a decisive role in this particular presentation. Level of evidence Level IV--Case report and review of the literature.

BACKGROUND: The goals of cavus foot correction are to obtain a plantigrade foot with the heel in slight valgus position and to hopefully preserve joint motion in both the tarsal and metatarsal joints. The apex of many cavus deformities is near Chopart joint. We are reporting on a new technique involving navicular excision and cuboid osteotomy to correct severe stiff cavus feet. METHODS: A retrospective review of patients who underwent navicular excision and a cuboid dorsal closing wedge osteotomy to correct a rigid cavus foot deformity was performed. A total of 11 children and 16 feet were treated during the past 8 years at 2 centers. RESULTS: All feet had navicular excision and a cuboid dorsal closing wedge osteotomy to correct a rigid cavus foot deformity. The etiology of the deformity was as follows: multiply operated congenital clubfoot (5 feet), arthrogryposis (6 feet), and neurological deficits (5 feet). At a mean follow-up of 4.9 years, all had a plantigrade foot. CONCLUSIONS: This salvage procedure offers an alternative method to correct a severe stiff cavus deformity. The procedure is performed at the apex of the deformity and thus maximum correction can be obtained by this "wedge resection." The curved articular surfaces of the cuneiforms articulate with the head of the talus post navicular excision if no fusion is desired. Navicular excision has been used to correct children with vertical talus, but not previously reported as a method to handle severe cavus. It is a salvage procedure that should be considered to address severe rigid cavus. LEVEL OF EVIDENCE: Level IV.

Salter-Harris type III and IV medial malleolar fractures (MacFarland fracture) is a joint fracture of the ankle in children. The fracture line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of misalignment and osteoarthritis. The aim of this study was to evaluate the functional and radiological outcome of these fractures. We retrospectively analyzed the cases of 48 children with MacFarland fractures (31 boys and 17 girls), mean age at the time of trauma 11 years 6 months (range, 8-15 years). The fractures were classed into two groups according to the Salter and Harris classification for epiphyseal detachment: Salter III (30 cases) and Salter IV (18 cases). Surgical treatment was given in all cases (46 screw fixations, 2 pin fixations). Three outcome categories were used: good (no pain, no stiffness, no limp, no misalignment, no surgical complication, no healing problem), fair (pain and/or stiffness and/or limp and/or healing problem without misalignment, no surgical complication), and poor (misalignment or surgical complication). Mean follow-up was 3 years and 3 months (24-94 months). Twenty-eight children were skeletally mature at the longest follow-up. The three-month postoperative assessment showed 35 patients with good results and 13 children with fair results. Ankle stiffness was noted in 6 cases, ankle pain in 4 cases, wound healing complications in 4 cases, limp in 1 case, and snapping in 1 case. The long-term outcome was considered good for 45 patients, fair for 2 patients (1 wound adherence and 1 hypertrophic scar tissue), and poor for 1 patient (6-degree varus deformity). We did not note leg-length discrepancy or malunion at the longest follow-up. Our results show that growth arrest after MacFarland fracture is no fate. We used surgery more than is generally reported by other teams, opting for surgery as soon as the displacement was >or=1 mm. Surgical treatment was arthrotomy in all cases to achieve anatomical reduction under direct view, followed by osteosynthesis. We believe that it is difficult to evaluate if the reduction is perfect under the control of the intensifier screen alone. Arthrotomy did not lead to ankle stiffness, in any of our patients at longest follow-up.

The authors analyzed a series of 15 pelvic aneurysmal bone cysts (9 boys and 6 girls) in children and adolescents who were reviewed with an average follow-up of 50.3 months. Pain and limp were the main symptoms. Four patients had no treatment after the open biopsy. Eleven patients were treated with curettage. Preoperative selective arterial embolization was performed in three cases before curettage. Two recurrences were noted after curettage; recurrences were treated successfully with further curettage. As a result, the authors recommend curettage; more aggressive operative intervention does not appear to be indicated. No major intraoperative vascular complications occurred. Spontaneous healing in a few cases (even in active or aggressive lesions) argues for clinical and radiologic observation after biopsy when possible. In case of a propitious evolution, observation must be continued and surgery might be avoided, but if the lesion increases, treatment must be proposed.

In 83 children with slipped capital femoral epiphysis, puberty was staged at the time of diagnosis using bone age, closure of triradiate cartilage, Risser index, and the pubertal diagram of Dimeglio. In boys 95% and in girls 83% of slips occurred during the accelerating phase of puberty (stage 1 and 2), in which mainly the limbs grow. In boys (54%) and in girls (66%), most slips occurred in stage 1. The triradiate cartilage was still open at the time of diagnosis in 65% of boys and 64% of girls. Staging puberty is useful to differentiate the risk for slipped capital femoral epiphysis and to evaluate the risk for a contralateral slip. Closure of the triradiate cartilage is a simple measure to identify this risk. Once the triradiate cartilage is closed, there is a 4% chance of a contralateral slip.

We report a European study of idiopathic clubfoot that was compiled with the aid of a detailed questionnaire. The retrospective study was presented at the seventh meeting of the European Paediatric Orthopaedic Society (EPOS). Most EPOS members treat idiopathic clubfoot at birth with plaster cast, but a few use physiotherapy and splints. The results of this conservative treatment vary. Operation is usually indicated at an age ranging from 4 to 15 months. Some physicians perform extensive procedures, and others limit operation to the medial and posterior parts of the foot. We propose a classification system for idiopathic clubfoot in an attempt to standardize procedures.