EPOS/IFPOS Combined Meeting EPOS - 26th Annual Meeting

Oral Presentations

Session 2: Tumors of the musculoskeletal system

1

MRI guided biopsy and treatment of osseous lesions

in children

Author: Thomas Wirth (Germany)

Co-Authors: Micha Langendorfer (Germany), Peter Winkler(Germany)

Purpose: MRI has evolved to a dominant diagnostic tool for evalu-ating pain and detecting skeletal lesions in children. Often MRIidentifies non-specific signal enhancements which need to be clarifiedhistologically forprecisediagnosis.WehavedevelopedapreciseMRIguided biopsy method to precisely find and diagnose such lesions.

Methods: UnderMRI control the area for biopsy is identified and atitanium wire is placed in the center of the lesion using the naviga-tion potential of the system. The correct position of the wire isverified. For biopsy purposes the sample is then taken with the wireas a guide byuse of abiopsy needle.A representative bone cylinder issent for histology. For treatment, e. g. drilling of a bony lesion, atitanium drill system suitable for MRI is used.

Results: Up to date 12 MRI guided biopsies and 6 MRI guidedtherapeutic interventions have been performed in 16 patients. Therewere five girls and eleven boys. The diagnoses were osteoidosteoma(n = 6), osteomyelitis (3) Ewing sarcoma (2), metastatic disease,eosinophilc granuloma and synovial sarcoma in one case each. Infour patients recurrence of a tumour was to be ruled out. Thesamples were taken from the femoral neck in five patients, iliac wing(4) sacrum (3), lumbar spine (2), tibia (2), humerus (1) and talus (1).There was no complication. In two cases the biopsy had to be re-peated due to recurrence of the disease. In particular in cases withdrilling of bony lesions such as osteoidosteomas a significantlearning curve is experienced.

Conclusions: The harvest of bone biopsies under MRI control is anentirely newmethodwhich is particularly suitable in children since itdoes avoid any radiation. Themethod is extremely precise as it is theonly way of exactly hit bony lesions which are mainly identified onMRI images. The method is also very efficient in the treatment ofbony lesions like osteoidosteoma by minimal invasive approaches.

Significance: This work represents an entirely new approach totake biopsies from the bone that can only identified by MRI.Further the method avoids any radiation and is therefore perfectlyapplicable in children.

2

Whole body MR imaging in malignant bone tumor

in children : preliminary results.

Author: Olivier Lousteau (France)

Co-Authors: Jerome Sales de Gauzy (France), Christiane Baunin(France), Guillaume Moscovitch (France), Francois De Maupeou(France), Herve Rubie (France), Eric Ouhayoun (France), JeanRailhac (France)

Purpose: The purpose of this study is to evaluate the accuracy ofWhole body MR imaging, WBMRI, for the detection of bonemetastases in children with malignant bone tumor, MBT.

Methods: This is a prospective study that was leaded betweenOctober 2004 andSeptember 2006. The patient population included10 children who ranged in age from 7 to 17 years. Primary bonetumor comprised 5 osteosarcoma and 5 Ewing’s sarcoma. All thesechildren had 3 whole body imaging modalities: WBMRI, skeletalscintigraphy and 18-FDG positron emission tomography (PET).WBMRI consisted of coronal STIR sequences acquired in 3 or 4overlapping stations. The results of these exams where comparedwith surgical and histologic results.

Results: In 2 cases,WBMRI showed bonemetastases thatwhere notseen by other modalities and induced therapeutic changes. In onecase, WBMRI and PET showed bone metastases that where notseen by scintigraphy. This induced therapeutic changes. In one caseWBMRI showed benign lesion but this induced no therapeuticchanges. In one case WBMRI showed signal anomalies related tobone hyperostosis. In four cases both WBMRI and PET showedenlarged inguinal lymph node. Biopsy found no malignant cells. Inone case all modalities not showed bones metastases.

Conclusions: These preliminary results suggest that WBMRI couldbe more sensitive than skeletal scintigraphy and PET for screeningchildren with MBT. Further evaluation is necessary to precisesensibility and specificity of WBMRI before to use it in routine.

Significance: WBMRI would be useful in the future for screeningof MBT.

J Child Orthop (2007) 1:S13–S132

DOI 10.1007/s11832-007-0015-7

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ABSTRACTS

EPOS/IFPOS Combined Meeting

EPOS - 26th Annual Meeting

Sorrento, 11–14 April 2007

3

Scintigraphic evaluation of osteoblast activity after

implantation of bas-0 bioactive glass-ceramics into long bone

defects

Author: Pavel Sponer (Czech Republic)

Co-Authors: Karel Urban (Czech Republic), Karel Karpas (CzechRepublic), Elen Urbanova (Czech Republic)

Purpose: The purpose of the study was to evaluate a radionuclideuptake at the site of defects in long bones filled with the non-resorbable bioactive glass-ceramic material BAS-0 by three-phasebone scintigraphy at a long follow-up.

Methods: 14 men and 6 women operated on between 1990 and 2000for benign bone tumors or tumor-like lesions localized in the femur,tibia or humerus were comprised in the study. Their average age atthe time of surgery was 14 years (range 8 to 24 years). The me-taphysis was affected in 8 and the diaphysis in 12 patients. Clinical,radiological and scintigraphic examinations were carried out at 2 to12 years (7 years on average) after surgery. Osteointegration ofglass-ceramics was investigated on radiographs. Radionuclide up-take was considered normal when the index value was equal to 1.0,mildly increased at an index value up to 1.2,moderately increased at1.2–1.5 and markedly increased at an index value higher than 1.5.

Results: The clinical evaluation showed that 6 patients had nosubjective complaints and 2 reported transient pain in the group ofpatients with implants in metaphyses. In the patients with non-resorbable glass-ceramics in diaphyses, pain was recorded in 9 andno complaints were in 3 patients. No restriction in weightbearingof the limb treated was reported by any of the patients. Onradiography 18 patients were free from any disease residue orrecurrence. Two patients had a residual defect. The bioactive glass-ceramic material BAS-0 was completely incorporated in allpatients. On three-phase bone scans radionuclide distribution onthe flow and soft tissue phases was symmetrical in the both limbs ofall patients. For the metaphyseal location of implants, the delayedimages demonstrated physiological radionuclide distribution in 1patient, mildly increased distribution in 4, moderately increaseduptake in 2 patients, and markedly increased uptake in 1 patient.For the diaphyseal location of implants, the delayed scans demo-strated mildly increased radionuclide distribution in 2, moderatelyincreased in 2 and markedly increased uptake in 8 patients.

Conclusions: This paper presents problems associated withimplantation of the non-resorbable bioactive glass-ceramicmaterial BAS-0 in the treatment of diaphyseal defects of longbones. The results show that, for filling of the defects describedherein, non resorbable glass-ceramic materials are not suitable.

Significance: The tissue during incorporation of a non-resorbablesynthetic material is influenced by stress-shielding. This changeslocal mechanical signals, which has a negative effect on the adjacentbone tissue. Stress accumulating at the interface of a rigid implantand bone tissuemay result in pain, and is detected by scintigraphy asan increased nucleotide uptake, particularly in diaphyseal implants.

4

Preservation of the Native Knee in Patients with Malignant

Bone Tumors in the Metaphyseal Area of the Distal Femur

and Proximal Tibia, Using Massive Allografts.

Author: J. Ivan Krajbich (United States)

Co-Authors: Kelly Alexander (United States)

Purpose: Demonstrate the feasibility of preservation of thepatient’s native knee in malignant bone tumors about the knee as

long as the epiphysis of the distal femur or proximal tibiarespectively is free of tumor and can be preserved.

Methods: Fourteen patients who met the criteria of havingmalignant sarcoma in either distal femoral or proximal tibia me-taphysis with no invasion into the epiphysis and underwent kneesaving procedure using massive metaphyseal allograft were re-viewed. There were four distal femur lesions and ten proximaltibial lesions with eight females and six males. All patients had atleast a two-year follow-up. Final outcome and complications werereviewed in all patients.

Results: Patients were alive and well at the time of the review.There were three infections necessitating allograft removal andlocal recurrence. There were allograft fractures which healed withfixation revision and bone graft. All patients with retained allo-graft regained at least 90� of the knee range of motion. There wereno significant long term complications, although several patientsuse a knee brace for sports activity.

Conclusions: Our study demonstrates good long-term results ofmetaphyseal allograft replacement and knee preservation inpediatric age group treated for malignant bone tumors. Carefulselection of patients to avoid local tumor recurrence is mandatory.Complication rates are about the same as for any other limbsalvage group other than the fact that long-term results are con-siderably better than the literature reported data for endopros-thetic replacement patients.

Significance: Attractive alternative to endoprosthetic replace-ment in the pediatric age group in a carefully selected groupof patients.

5

Complications of Osteochondral Tibial Allografts in Pediatric

Osteosarcoma Reconstruction: Review of 12 cases

Author: Mihir Thacker (United States)

Co-Authors: H. Thomas Temple (United States), J. DavidPitcher, Jr. (United States), Sean Scully (United States)

Purpose: Reconstruction after resection of tumors of the prox-imal tibia is challenging due to its unique anatomic features.Various reconstructive options are available, with the bias beingtowards a more biologic reconstruction in younger patients. Theaim of this study was to review our experience with the use oftibial osteochondral allografts in pediatric patients with osteo-sarcoma.

Methods: This was a retrospective review of 12 pediatric patients(<18 years) with Stage IIB tibial osteosarcomas treated withresection and reconstruction with osteochondral allografts. Thedemographic features, techniques of reconstruction, use of flapsand their effect on functional and oncologic outcomes werestudied.

Results: There were five boys and eight girls with a median age of13.5 years (10–17). All patients received chemotherapy and nonehad radiation. Gastrocnemius flaps were used in 10/12 patients aspart of the index procedure. The mean follow-up was 54.5 months(14–198). There were 20 complications in 12 patients. These in-cluded allograft fractures (6) at an average of 37.5 months, deepinfection (5), non-unions (2), nerve injury (2), arthrosis (1). Theevent-free survival was 23 months (2–65). Three patients neededrevision to allo-prosthetic composites, two to metallic endopros-theses and one underwent an amputation. There were two localrecurrences and three patients died of metastatic disease. Thepredicted five year survival was 41%.

Conclusions: Deep infections and allograft fractures were the mostcommon causes of return to the operating room. Osteochondral

S14 Oral presentations: Abstracts 1–123/J Child Orthop

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allograft reconstruction for tibial osteosarcoma is associated witha high complication rate.

Significance: Osteochondral allografts used for reconstruction inpediatric patients with osteosarcoma have a high complicationrate and better alternatives should be sought.

6

Case series on ‘lipoblastoma’, a rare tumour in children

Author: Harvey Lappakkaran George (United Kingdom)

Co-Authors: Yogesh Joshi (United Kingdom), Leroy James(United Kingdom), Neraj Garg (United Kingdom), Colin Bruce(United Kingdom)

Purpose: To discuss on Clinical presentations, Investigations,Histopathology, Differential diagnosis and Treatment optionsbased on a series of six Lipoblastomas that we encountered in ourpaediatric orthopaedic practice.

Methods: This series consists of six children with lipoblastomawho attended Alder Hey Hospital between 2000 and 2006. Meanage 17 months. Mean follow up was 26 months. The youngestwas a six month old infant with a swelling on his right instep.The second patient was a three year old girl who presented witha limp and swelling in her foot, the third patient was an18 month old boy with a swelling on the dorsum of his leftforearm, fourth patient had a swelling of his left thigh and twopatients had swellings in their back. They were investigatedappropriately with MRI, CT or USG and surgical excisionplanned accordingly.

Results: Male to female ratio was 5:1. Age groups; 2 patientswere of less than 12 months of age, another two of them wasbetween 12 to 24 months and the last two were under36 months at the time of diagnosis. Anatomically three patientshad swellings in the lower limb, 2 had swellings over dorsum oftheir trunk one patient had a forearm swelling. Investigationsinclude MRI for one patient and CT for another USG wasdone for the remaining four. There was no post op complica-tion for any of them. None of them have shown any recurrenceduring the follow-up.

Conclusions: All patients were originally thought to have simplelipomas or soft tissue swellings. This is primarily becauselipoblastoma is a rare tumour and is rarely encountered inorthopaedic training. It is important that we orthopaedic sur-geons be aware that lipoblastoma is in fact the most likelydiagnosis of a fatty lump in a child of less than two years ofage. Lipoblastomas needs through imaging and if possiblecytogenetic evaluation for accurate diagnosis before surgerybecause complete surgical resection is mandatory to prevent alikely local recurrence.

Significance: Lipoblastomas are uncommon, benign tumour ofembryonal mesenchymal cells. It is a rare tumour but occursmostly during infancy and early childhood. It most often presentson the extremities, back, head and neck.

Histology: cellular neoplasm composed of lipoblasts in differentstages of maturation and fine vascular network, with well definedsepta. Cytogenetic evaluation often shows chromosomal anoma-lies of tumour cells like abnormalities of the long arm of chro-mosome 8, leading the rearrangement of the PLAG1 gene. Biopsyof the lesion is recommended, as clinical and radiological diag-noses can be misleading. These tumours tend to spread locally andmay recur in case of incomplete resection; metastatic potential hasnot been reported. Differential diagnosis includes myxoid lipo-sarcoma, well-diffrentiated liposarcoma, spindle cell lipoma, typ-ical lipoma and soft tissue sarcoma.

7

Step Activity Assessment in Limb Salvage Children

Author: Melissa Sheiko (United States)

Co-Authors: Kristie Bjornson (United States), Kit Song (UnitedStates), Ernest ‘‘Chappie’’ Conrad (United States)

Purpose: The goal of a limb salvage procedure is to retain afunctional extremity. However, the measurement of that functionis challenging. We compared the physical and emotional healthand orthopedic functional evaluation to the activity levels ofchildren after limb salvage.

Methods: The children of this study were age and gender matchedto typically developing youth (TDY) controls. To qualify for thelimb salvage group, children had to be between 10 and 20 years ofage, diagnosed with a malignant bone tumor of the lower limb andat least one year post-op from their initial limb salvage. The 21recruited patients (12 females and 9 males) had an average age of15 years. Patients’ activity was measured with a Stepwatchactivity monitor for 1 week, which counted the number of stepsthe patient took every minute. In addition, patients and controlsubjects completed the Youth Quality of Life questionnaire, ChildHealth Questionnaire, the Activities Scale for Kids questionnaire,and the Musculoskeletal functional questionnaire.

Results: The initial analysis of 13 limb salvage children and 13typically developing youth showed limb salvage children walkedan average of 5730 [3881–7580] steps per day, as compared to 7601[6235–8968] steps per day for the normals. Limb salvage childrenspent 45.33% [37.61–53.06] of their time being active, whereasTDY spent 50.83% [45.02–56.64] of their time being active.Subdividing the active time into levels of high, medium, andlow activity rate reveals limb salvage children spent 64.42%[56.63–72.20] of their time at a low activity level, while the nor-mals spent 54.33% [49.16–59.51] of their time at low. Limb sal-vage children walked at a medium level for 28.33% [22.67–33.99]of their time, and normals were 33.92% [30.42–37.41]. Finally,limb salvage children moved at a high activity rate for 7.25%[3.84–10.66] of their time in contrast to 11.92% [8.50–15.34] fornormals. Also of interest, the BMI of the limb salvage groupmeasured 20.53 [16.66–24.39] versus 16.93 [14.80–19.07] for nor-mals. In the Activities Scale for Kids- performance version, limbsalvage children reported an activity level of 88.3 [83.9–93.7], andnormal children reported a level of 93.6 [88.6–99.5].

Conclusions: Initial analysis showed some statistical significance,but the calculations were swayed by one limb salvage subject whoexhibited a much higher activity level than any other child in thestudy (12,056 steps per day).

Significance: We hope to increase the statistical significance of ourresults with a longer study cohort. Further analysis comparing agedifferences, site of the tumor, allograft vs. implant, and activitylevels versus reported physical and emotional health will be per-formed, which will include 21 limb salvage children compared to21 matched normals.

8

Perceived Quality of Life in Children with Primary Bone

Sarcoma

Author: Jenny Margareta Frances (United States)

Co-Authors: Carol Morris (United States), Zarko Nikolic (UnitedStates), Edward Athanasian (United States), Patrick Boland(United States), Alexandre Arkader (United States), John Healey(United States)

Oral presentations: Abstracts 1–123/J Child Orthop S15

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Purpose: To evaluate perceived quality of life in children withpediatric sarcoma to identify predictors of quality of life andevaluate our treatment strategies.

Methods: Quality of life data, using the Pediatric Outcomes DataCollection Instrument (PODCI), was collected annually after in-dex procedure in 43 children age 6–16, with primary Ewings sar-coma, osteosarcoma or chondrosarcoma. A retrospective chartreview was done to collect clinical data. Statistical analysis wasdone to evaluate change of quality of life (QOL) over time and toidentify potential predictors of quality of life.

Results: Children with primary bone sarcoma reported low scoresin the Sports domain, good scores in the Pain, Happiness andGlobal function domains, and high scores in Upper Extremity andTransfer, in an average followup of 3 years. Scores were lowestthe first 12 months after surgery, with significant improvementseen at 24 months after surgery. Tumor size larger than 8 cm wasa negative predictor for Sports and Physical Function. Girls re-ported lower scores in Sports, Pain and Global Function thanboys. Although there was no difference in scores between patientswho underwent limb sparing surgery of the lower extremity(n = 31) or not (n = 7), a larger study group would be needed toverify the accuracy of this observation.

Conclusions: The PODCI gives discriminatory detailed texturedevaluationof theoutcomeof children treated for skeletalmalignancy.

Significance: The PODCI is a good tool in evaluating QOL inchildren with bone sarcoma. Further development of QOL mea-sures is needed to make the PODCI helpful enough to guidetreatment.

9

Non Rhabdomyosarcoma Soft Tissue Sarcomas

in children –Management and outcome

Author: Franck Chotel (France)

Co-Authors: R Grimer (United Kingdom), Lee Jeys (UnitedKingdom), A Abudu (United Kingdom), R Tillman (UnitedKingdom), S Carter (United Kingdom)

Purpose: To establish whether our current regime for managementchildren with non rhabdo, STS is successful and to establishprognostic factors for survival and local control.

Methods: We reviewed the patient, tumour, treatment and out-come data for 85 children with non rhabdo STS under the age of21 at diagnosis who had definitive treatment at our centre from aprospectively compiled tumour database. All patients had >2 yrsfollow up. Management was based on a combination of surgery,chemotherapy and radiotherapy. Chemotherapy was used in largetumours and in patients with metastases whilst radiotherapy wasused postoperatively in cases with uncertain excision margins.

Results: We identified 85 children (56 boys) with non rhabdo STSover a time period of 22 yrs. The most common diagnosis wassynovial sarcoma (n = 30) followed by peripheral nerve sheathtumour (n = 8) and leiomyosarcoma (n = 6). Whilst the meanage was 14,5 yrs, the most common age was 19. 37% of the tu-mours were high grade and 33% intermediate and 30% low grade.The mean diagnosis delay was 21 months for intermediate andlow grade and 10 months for high grade. Seven patients havemetastasis at diagnosis. The median size was 7 cms. 60 were deepand 28 superficial. Chemotherapy was used in initial managementin 23 patients, and radiotherapy in 15. Overall survival was 75%at 5 yrs and 65% at 10 yrs. Local recurrence arose in 19%. Theonly factor related to LR was an inadequate pathological margin,whilst factors affecting overall survival were increasing sizeand high grade. Neither age at diagnosis or depth of the tumour

was significant. Because chemotherapy was often used forpatients thought to have a poor prognosis, it proved impossible toshow that chemotherapy benefited survival, but in this series allbut 2 of the patients who received chemotherapy subsequentlydied.

Conclusions: Children with non rhabdo STS have the best chanceof cure if the tumour is diagnosed early and treated by surgeryobtaining clear margins.

Significance: Chemotherapy and radiotherapy should be used inselected cases as part of an international trial.

10

Simple bone cyst of the proximal humerus - Factors predictive of

recurrence and healing

Author: Kar Hao Teoh (United Kingdom)

Co-Authors: Adam Watts (United Kingdom), Robin Reid(United Kingdom), Daniel Porter (United Kingdom)

Purpose: The proximal humerus is the most common site for thesimple bone cysts. Cyst recurrence in the proximal humerus occursmore frequently than other sites in the body. The purpose of thisstudy was to examine the characteristics of pathological fracturescaused by simple bone cysts in the proximal humerus and evaluatefactors predictive of fracture and of healing following surgicalcurettage.

Methods: From a cohort of patients held on a national databasethe factors predictive of recurrence following surgical curettage inpatients with a simple bone cyst of the proximal humerus wereexamined. Thirty two cases were identified. The mean age was11.4 years and 90% were male.

Results: Most patients presented with a pathological fracture(97%) following a history of trauma (78%). Ten patients (31%)had recurrence of the lesion or re-fracture following curettage.The time to recurrence/resolution of the cyst was 12.4 months inour series (range: 2–49 months). None of the patients in whomthe fracture occurred after skeletal maturity had a recurrence(p = 0.014). Simple bone cyst in the right proximal humerus weremore likely to recur than the left (p = 0.01). Obliteration of thecyst occurred more frequently in those with impacted fractures(p = 0.04) and appeared multilocular (p = 0.004) on pre-oper-ative radiographs. A higher cyst index at presentation also in-creased the likelihood of recurrence (p = 0.039).

Conclusions: Factors predictive of recurrence following curettagewere young age, right limb laterality, large size of cyst, multiloc-ular cysts and fractures without impaction on initial radiographs.Patients with these features should be followed up until oblitera-tion of the lesion or skeletal maturity.

Significance: Based on the largest reported series of biopsy provenSBC in the proximal humerus, factors have been identified thatshould alert clinicians to the risk of recurrence or refracture whentreating patients.

11

Outcome at 45 years of open reduction and innominate

osteotomy for late presenting developmental hip dislocation.

Author: Simon Robert Thomas (United Kingdom)

Co-Authors: John Wedge (Canada), Robert Salter (Canada)

Purpose: A consecutive series of 76 patients (101 hips) under-went primary open reduction, capsulorrhaphy and innominate


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osteotomy for late presenting developmental hip dislocation.They were aged 1.5 to 5 years at the time of surgery between1958 and 1965. This study was designed to review their out-come into middle age.

Methods: We located and reviewed 60 patients (80 hips) using apublic records search. This represents a 79% rate of follow-up at40–48 years postoperatively. 19 patients (24 hips) had undergonetotal hip replacement and 3 had died of unrelated causes. Theremaining 38 patients (53 surviving hips) were assessed by theWOMAC� and Oxford hip outcome questionnaires, physicalexamination and standing pelvic radiograph. The radiographswere analysed for minimum joint space width and the Kellgrenand Lawrence score. Accepted indices of hip dysplasia weremeasured.

Results: Kaplan-Meier survival analysis is presented using the endpoint of total hip replacement. Survival rates at 30, 40 and 45 yearspost-reduction are 99% (95%CI+/–2.4), 86% (+/– 6.9) and 54%(+/–16.4) respectively. Average Oxford andWOMAC� scores forsurviving hips were 16.8 (range 0–82) and 16.7 (range 0–71)respectively. Of 51 surviving hip radiographs, 38 had a minimumjoint space width in excess of 2.0 mm, 13 had definite osteoarthritis(OA) on this criterion. 29 wereKellgren and Lawrence grade 0/1(noor doubtful signs of OA), 7 grade 2 (mild OA), 15 grade 3 or 4(moderate or severe OA). The average centre-edge and acetabularangles were 40� (range 0–61�) and 32� (20–43�) respectively. Therewas no significant association between outcome and the modifiablerisk factors of body mass or age at surgery. Bilaterally treated hipswere at significantly greater risk of failure.

Conclusions: This method of treatment achieves a 54% rate of hipsurvival at 45 years. Two thirds of surviving hips have an excellentprognosis at this stage.

Significance: This study is unique in following so large a group ofpatients with this condition into middle age. This is very impor-tant data to inform clinicians as to expected outcomes followingsurgery of this kind.

12

Does Salter Innominate Osteotomy with transiliac lengthening

effect triradiate cartilage or cause posterior coverage

insufficiency?

Author: Hasan Hilmi Muratli (Turkey)

Co-Authors: Tugrul Gunal (Turkey), Halil Yalcin Yuksel (Turkey),Ertugrul Aksahin (Turkey), Levent Celebi (Turkey), Serap Gulcek(Turkey), Ali Bicimoglu (Turkey)

Purpose: In the treatment of DDH, we performed Salter innom-inate osteotomy with a modification of transiliac lengthening de-scribed by Klisic et al. By this method we believed that we canobtain better anterior and lateral coverage. However this methodmay have several disadvantages including increased posteriorcoverage deficiency and triradiate cartilage injury due to increasedperiosteal stripping in order to obtain much more tilt. That is whyin this study we aimed to investigate if this modified SalterOsteotomy and increasing amount of tilt cause posterior coverageproblem and triradiate cartilage defects.

Methods: 45 patients with unilateral DDH treated by open reduc-tion and femoral shorthening and modified Salter innominateosteotomy were included in this study.

Mean age was 38.44 ± 19.79 (mean ± S.D) months at the oper-ation. Mean follow up was 49.84 ± 27.73 months. We measuredamount of the tilt of iliac bone (difference of acetabuler index valuesbetween the preoperative and postoperative X-rays obtained assoon as after the operation). And we divided the hips in two groupsaccording to tilt amount with the cut off value as 20 degrees. There

was 29 hips in group 1 (deviation amount is under 20 degrees) and 16hips in group 2 (deviation amount is 20 degrees or higher).

At the latest follow-up pelvic –X ray examination and axial planecomputed tomographic analysis were performed in all patients.We measured medial wall thickness, tear drop width and hemipelvis heights in order to evaluate triradiate cartilage intactnessindirectly. And posterior center edge angle which reflects posteriorcoverage of the hip in the CT scans was also measured. Thencomparison between the groups were performed by covariantanalysis (age was accepted as a dependent variable) and Mann-Whitney u-Wilcoxon Rank sum W tests.

Results: There was no difference between groups regarding allmeasured parameters (p > 0.05).

Conclusions: As long as definite intraoperative stability tests areperformed and intraoperative stability is obtained, modified Salterosteotomy with trans iliac lengthening can be performed safelyand better coverage can be obtained in frontal and axial planewithout damage of triradiate cartilage.

Significance: As long as definite intraoperative stability tests areperformed and intraoperative stability is obtained, modified Salterosteotomy with trans iliac lengthening can be performed safely andbetter coverage can be obtained in frontal and axial plane withoutdamage of triradiate cartilage.

13

Changes of acetabular orientation and hip muscle lengths

by Salter innominate osteotomy

Author: Thomas Pressel (Germany)

Co-Authors: Stefan Max (Germany), Henning Windhagen(Germany), Christof Hurschler (Germany)

Purpose: Despite early sonographic screening for dysplasia of thehip, some children are still diagnosed late or conservative treat-ment fails. Early operative correction of severe dysplasia is indi-cated to prevent degenerative osteoarthritis. Salter innominatepelvic osteotomy is an established procedure for improving thecoverage of the femoral head in children. While the operativetechnique is well defined, the effects of variations like height of theosteotomy or the insertion angle of the bone wedge on the ace-tabular position are not known exactly. In this study the effect ofosteotomy height and wedge insertion angle on lengths of threehip muscles and acetabular correction was investigated with acomputer model.

Methods: The bony structures of left hemipelvis and proximalfemur of an eight year old girl with severe dysplasia of both hipswere segmented from computed tomography (CT) image data andimported into the multibody analysis software MSC.ADAMS.Patient-specific joint centers and segment masses were importedfrom an anthropometric database. Origin and insertion points ofmuscles were determined based on the anatomical literature. Astandard virtual bone wedge was inserted between two contactplanes from different angles which were combined with osteotomyheights from baseline to 20 mm cranially. Acetabulum edgepositions, muscle insertion points and hip center location werecalculated for each step before and after the operation.

Results: An insertion angle of the bone wedge of 40� relative to thefrontal plane led to a maximal inferior displacement of the lateraland ventral acetabular edge at baseline osteotomy height. Whilegenerally glutaeal muscles were lengthened in comparison to thepreoperative situation, extreme anterior insertion angles over 65�even shortened these muscles. An osteotomy higher than 15 mmabove baseline shortened glutaeal muscles in comparison to thepreoperative situation; piriformis was shortened when smallinsertion angles relative to the frontal plane were investigated.


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Conclusions: Pelvic geometry and particularly acetabular orienta-tion is variable so that the results of this study which were based onindividual imaging data might be different in other patients. Thesymphysis and sacroiliac joint were represented by simplified idealjoints; the postoperative pelvic geometry might also be influencedby soft tissue forces which were not accounted for in this model.Not only geometrical changes influence the surgical outcome, butalso biomechanical consequences of the procedure have to beconsidered and have to be investigated in future studies.

Significance: Multibody computer simulation is a valuable tool forgeometrical and biomechanical analysis and optimization ofSalter innominate osteotomy. The method can only suggestimprovements of the surgical technique.

14

Is still the labrum an obstacle to reduction of congenital

dislocation of the hip?

Author: Maurizio Pietro De Pellegrin (Italy)

Co-Authors: Desiree Moharamzadeh (Italy)

Purpose: The fibrocartilaginous labrum acetabulare enlarges theacetabular socket and contributes to the stability of the femoralhead. In DDH the labrum is everted and pushed upwards by thefemoral head. In the dislocated hip the labrum is often invertedinto the acetabular cavity and obstructs anatomic reduction. Inthe past, excision of the labrum was performed to allow thereduction of the femoral head. The aim of the study was toevaluate the position of the labrum in early detected decenteredhips and its role in the early treatment of DDH.

Methods: During the eleven-year period from 1992–2002, 21 709neonates (43 418 hips) were examined both by ultrasound and byOrtolani’s test to establish the diagnosis of DDH.

Results: According to Graf’s classification the following hips werepresent: 298 type D hips, 252 type IIIa hips, 4 type IIIb and 20 typeIV. Therefore 431 of the patients (356 F 75 M), showed 574 so-nographically unstable hips affected by DDH (1.32%). Due to itsechogenic structure, the fibrocartilaginous labrum is clearly visibleby ultrasound. In type D, type IIIa, and type IIIb it was alwayslocated cranially to the femoral head; in type IV it was locatedmedially to the femoral head. The average age of the children at thetime of the diagnosis was 42 plus/minus 33 days. Ortolani’s test waspositive in 61 hips (10.63%) and negative in the remainder of thehips (89.37%). 21.5% of the cases were diagnosed within the secondweek of life, 52.9% between the third and the eighth week, and25.5% after the eighth week. The labrum was not inverted in any ofthese cases, nor was an open reduction necessary in order to removeit as an obstacle to the closed reduction.

Conclusions: In conclusion, earlyUS-diagnosis (by the 8thweekof age)was possible in 74.5%of the cases; in no case was the labrum inverted;the labrum did not represent an obstacle to closed reduction.

Significance: When an early diagnosis of DDH is made the labrumis not inverted and a closed reduction is always possible.

15

Axial STIR and axial proton density MRI images, a fast and

accurate method of confirming femoral head reduction

in Developmental Hip Dysplasia.

Author: Eimear Conroy (Ireland)

Co-Authors: James Harty (Ireland), Marcus Timlin (Ireland),Frank McManus (Ireland)

Purpose: Non-concentric reduction of the femoral head within theacetabulum is detrimental to its delicate cartilaginous structure

and may result in a growth disturbance. Successful relocation ofthe dislocated femoral head depends on subtle clinical findingsand radiography. The combination of a dislocated femoral headand a severely dysplastic acetabulum can result in a clinical examthat is unhelpful in confirming reduction under anaesthesia. Incases where uncertainty existed regarding head reduction in aspica cast we performed axial STIR and axial proton density MRIscans. We retrospectively reviewed the efficiency and accuracy ofMRI in confirming femoral head location after closed reductionand spica application in eight children.

Methods: 153 cases of developmental dysplasia were treated withexaminationunder anaesthesia, and spicaapplication inourunitovera three-year period. Eight caseswhereMRI scanwas performedwereidentified. These children were galeazzi positive and had limitedabduction necessitating a percutaneous adductor tenotomy. Beforeapplication of the spica cast we used radiographic screening to assessthe stability of the reduction.Absence of the ossificnucleuswithin thefemoral head made confirmation of location with the image intensi-fier unreliable. To confirm concentric femoral head location afterclosed reduction and spica application we performed anMRI scan inthe immediate post operative period.

Results: All scans were performed within 30 minutes of applica-tion of the spica, the average time for each scan was 5 minutes. Alleight children who had MRI post application of spica had con-centric reduction of the femoral head. MRI allowed three-dimensional appreciation of the acetabulum and femoral head.Use of the axial STIR images allows accurate assessment of thecartilaginous ossific nucleus. All patients were discharged thesame afternoon, and followed up at outpatients. No patient in ourgroup required contrast arthrography.

Conclusions: While not indicated in all cases of femoral headdislocation MRI is useful to confirm concentric reduction of thefemoral head in a dysplastic acetabulum when examination underanaesthesia and radiographic screening have been uncertain. Inour series 1 in 20 cases needed MRI.

Significance: This is a reliable, non-invasive method confirmingdefinite reduction of the femoral head prior to discharge in all ourpatients.

16

Long-term results after closed reduction of late-detected hip

dislocation

Author: Terje Terjesen (Norway)

Co-Authors:

Purpose: This retrospective study was undertaken because there islimited knowledge about the long-term results in late-detected hipdislocation. The aims were to evaluate the outcome after skeletalmaturity and to find predictive factors for good and poor results.

Methods: The material included 60 patients (78 hips, 53 girls)treated during the period 1958–62. The primary treatment wasskin traction for 36 (16–76) days. Closed reduction was performedin all the hips except 4 that needed open reduction. The mean ageat reduction was 20 (4–65) months. Hip spica plaster was worn for9 (6–20) months. Within 3 years from the start of treatment, de-rotation femoral osteotomy was performed because of increasedfemoral anteversion in 35 patients. Later, 28 patients underwentadditional surgery on the femur or acetabulum to improve fem-oral head coverage. Radiographs at the time of diagnosis andduring follow-up to skeletal maturity were assessed. The averageage of the patients at the most recent follow-up was 26 (15–42)years.

Results: The femoral head coverage normalized during the pri-mary treatment and decreased thereafter somewhat during the


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remaining growth period. The dysplasia of the acetabulum im-proved markedly during the first year after reduction and con-tinued to improve, but to a much lesser degree, until 8–10 years ofage. A satisfactory radiographic outcome at skeletal maturity(Severin grades I and II) was obtained in 63% of the hips.Avascular necrosis of the femoral head occurred in 14% of thehips. Risk factors for unsatisfactory outcome at skeletal maturitywere high initial dislocation, steep acetabulum 1 year afterreduction, reduced femoral head coverage at age 8–10 years, andavascular necrosis. Osteoarthrosis had occurred in 7 of the 26 hips(27%) with follow-up longer than 30 years.

Conclusions: The present treatment regime with long traction time,closed reduction, and relatively long time in hip spica plaster, gavegood radiographic results at skeletal maturity in nearly two thirdsof the patients. Early derotation osteotomy of the femur did notimprove the outcome.

Significance: The treatment concepts have changed considerablysince these patients were treated more than 40 years ago. Never-theless, the specific risk factors and the long-term results would bevaluable for comparison with outcome studies after more moderntreatment regimes.

17

The Weinstein antero-medial approach for the treatment

of DDH. Results after a minimal follow-up of 5 years.

Author: Edilson Forlin (Brazil)

Co-Authors: Dulce Grimm (Brazil), Luiz Munhoz Cunha (Brazil),Luis Munhoz Rocha (Brazil), Michelle Zanferari (Brazil)

Purpose: Open reduction of DDH in younger children is indicatedfor no reducible or unstable hip for conservative treatment. Theantero-medial (Weinstein) or medial approach is no widely usedbecause the believe of major risk for avascular necrosis. The goalis to review the results and complication of the anteromedial ap-proach as described by Weinstein in patients with DDH.

Methods: We reviewed 36 patients with 47 hips treated. Thirty-onewere girls and five boys. The mean age was 8, 4 months (range, 2to 21 months). The hips treated were left in 16, right in 9 andbilateral in 11. Twenty-four hips in 19 patients had previoustreatment: Pavlik harness in 13, closed reduction in four patientsand a combination of Pavlik harness and closed reduction in two.The results were evaluated clinically by McKay criteria andradiographic ally classified by Severin proposal. The mean follow-up was 8 years (5 to 11 years). The technique of open reductionwas that described by Weinstein. The length of casting rangedfrom 10 to 16 weeks. A abduction brace was used in all patientsfor a mean length of 8 months.

Results: The mean age at last visit was 9, 2 years (range from 5, 2to 13 years). Clinically 41 hips were considered satisfactory and 2unsatisfactory (because a Trendelenburg sign). For Severin clas-sification there were 28 hips class IA, 2 IB, 10 as IIA, one as IIB,and two as III. There were no immediate complications. Two hipshad significantly avascular necrosis. Seventeen hips needed asecondary acetabular procedure for persistent or progressivedysplasia, in others two the surgery was indicated. Overall resultspresented 83% as satisfactory and 17 % as unsatisfactory. Sec-ondary acetabular correction indication was 44%.

Conclusions: The Weinstein antero-medial approach showed to beeffective, safe and a with a low incidence of avascular necrosis forreduction of DDH in younger children. The indication for ace-tabular correction is high.

Significance: A safe and reliable treatment for unstable DDH inyoung children.

18

Complications, Radiological Outcome and Patient Satisfaction

After Periacetabular Pelvic Osteotomy

Author: Rainer Biedermann (Austria)

Co-Authors: Leo Donnan (Australia), Andreas Gabriel (Austria),Roland Wachter (Austria), Martin Krismer (Austria), HannesBehensky (Austria)

Purpose: Periacetabular osteotomy (PAO) is a well establishedmethod to treat hip dysplasia in the adult. There are, however, anumber of complications associated with this procedure that caninfluence the long term result. It is essential that patients are fullyinformed as to the effectiveness of PAO, the likelihood of complica-tions and their influence on the subjective outcome prior to givingconsent for surgery. Generic outcomemeasures offer the opportunityto determine treatment efficacy and the influence on the outcome bycomplications.

Methods: 60 PAOs on 50 patients were investigated retrospectivelyafter a mean follow up of 7.4 years. The patients’ self reportedassessment of health and function was evaluated by the SF-36 andthe WOMAC questionnaires at last follow-up. 40 healthy personsserved as a control group.

Results: The centre-edge angle improved from a mean of 8.7� to31.5�. The weight bearing surface improved from a mean lateralopening of 8.7� to 4.2�. The degree of osteoarthritis improved in onecase, remained unchanged in 20 and deteriorated in 17. There was atendency of higherCE-angles towards ahigher rate of deterioration,indicating that overcorrection may increase osteoarthritic degen-eration. 13 of the 60 interventions had no complications. Minorcomplications occurred in 25 (41%) interventions and in 22 (37%)at least one major complication occurred. SF-36 summary measurewas 76.4 for PAO patients and 90.3 for the control group. MeanWOMAC score was 25.1. The severity of ectopic bone formation,incidence of postoperative peroneal nerve dysfunction and delayedwound closure did not influence the subjective result. Patients withmajor complications had a similar subjective outcome as patientswith minor or no complications, but persistent dysesthesia due tolateral femoral cutaneous nerve dysfunction led to a worse sub-jective function as assessed with the WOMAC score.

Conclusions: There was a tendency of higher CE-angles towards ahigher rate of deterioration, suggesting that overcorrection is a rea-son for increased osteoarthritic degeneration. Patients with majorcomplicationshavea comparable subjectiveoutcomeaftermore thanseven years as do patients with minor or no complications. Never-theless, the outcome as measured with SF-36 and WOMAC are re-duced when comparedwith a healthy control group, but comparablewith patients after THR according to literature. Lateral femoralcutaneous nerve dysfunction with persistent dysesthesias appears toreduce the patients’ subjective function in themid termand a surgeonshouldbeaware that this ostensiblyminor complication is important.

Significance: The PAO is demanding procedure with a high initialrate of complications and a steep learning curve. Unless 20 to 50operations are performed in one centre, all operations should becarried out by a single surgeon.

19

Application of arthroscopic surgery for Developmental displasia

of the hip

Author: Hajime Sugiyama (Japan)

Co-Authors: Yoshiki Hamada (Japan), Tadahiro Horiuchi(Japan), Kenyuu Kimori (Japan), Takatoshi Ide (Japan)


123

Purpose: We report the usefulness of an arthroscopic surgery forreduction of developmental displasia of the hip (DDH).

Methods: The patients were five female and two male children,average age was 2 years old (range 1 to 4 year old) . The ar-throgram of the hip joint revealed filling defects, which were dueto hypertrophy of the acetabular pulvinar and the inverted lab-rum. The operation was done under arthroscopic observationusing three portals as in adult cases. After hypertrophic acetabularpulvinar was resected using electric cauterization scalpel, invertedlabrum was reversed by placing incisions at 2 to 3 sites in aradiating form using a clow formed probe.

Results: After operation, the femoral headswere reduced into noramalacetablum position, with significant improvement in CE angle. Thefilling defect observed preoperatively due to inverted labrum andhypertrophy of the acetabular pulvinar disappeared on the postoper-ative arthrographic findings. All caces have a exellent reduction aftersurgery, and good CE angles were continued except one elder case.

Conclusions: Open reduction of DDH is a considerable invasivetechnique, and excessive growth of the femoral head after oper-ation poses a problem. In 7 cases of DDH reported in this paper,reduction was successfully conducted with less insult by resectionof the tissue impairing reduction and reduction under arthro-scopic observation. In general, in cases where reduction is difficultwith conservative therapy, causes that open reduction are con-sidered to lie within the joint. Therefore arthroscopic surgery isthe useful method for the treatment of DDH.

Significance: Arthroscopic suregery is less invasive and the risk offemoral head defomity is less. Arthroscopic surgery is consideredto be one of the methods useful for the treatment of DDH.

20

Symptomatic developmental dysplasia

of the hip (DDH) -arthroscopic findings

Author: Yasuharu Nakashima (Japan)

Co-Authors: Masanori Fujii (Japan), Yasuo Noguchi (Japan),Seiya Jingushi (Japan), Takuaki Yamamoto (Japan), TaroMawatari (Japan), Eiji Suenaga (Japan), Toshio Fujii (Japan),Yukihide Iwamoto (Japan)

Purpose: The purpose of this study was to clarify the intra-artic-ular pathology of the symptomatic DDH in patients who were lessthan 20 years old.

Methods: We conducted the hip arthroscopy during the operationof corrective osteotomy in 21 hips in 20 patients. All the patientswere female and the average age at operation was 16.0 years old.Seventeen hips were in prearthritic stage (acetabular dysplasiawithout apparent radiological change) and 4 hips were in earlystage (sclerosis, joint space narrowing). Fifteen hips in 15 patientshad the history of the treatment for DDH. The degeneration ofthe cartilage was classified into 4 grades, Grade 0: no degenera-tion, 1: cartilage softening, fine irregularity, 2: fibrillation, erosion,3: subchondral bone exposure. The presence and location of thelabrum tears were also recorded.

Results: Fourteen hips (82%) in prearthritic stage had cartilagedegeneration of grade 1 or more. Cartilage lesions were more fre-quent in acetabulum than in femoral head (70.6% versus 17.6%).Sixty-five percent of the acetabular lesions were located at the an-tero-superior area. The labrum tears were observed in 76.5% of hipsin prearthritic stage and located at the antero-superior (64.7%),superior (47%) and posterior area. Isolated cartilage degenerationwas seen in only 23.5% and the isolated labrum lesions were seen in17.6%. Many of hips had the both findings. The degree of cartilagedegeneration and labrum lesions in early stage was more severe, butthe pattern of the lesions was basically the same.

Conclusions: The incidence of the intra-articular lesions such ascartilage degeneration and labrum tears of DDH was high even inthe prearthritic stage. These lesions originated in the antero-superior area of the acetabulum and were generally progressive.

Significance: This study focused on the intra-articular lesions ofthe symptomatic DDH in the patients who were leass than20 years old. The incidence of the intra-articular lesions such ascartilage degeneration and labrum tears of DDH was high even inthe prearthritic stage. These lesions originated in the antero-superior area of the acetabulum and were generally progressive.

Session 4: Infection

21

Pediatric bone and joint infections due to Panton Valentine

leukocidin-positive Staphylococcus aureus. Setting the surgical

treatment.

Author: Bruno Dohin (France)

Co-Authors: Jerome Etienne (France), Daniel Floret (France),Remi Kohler (France)

Purpose: Panton-Valentine Leukocidine (PVL) secreted byStaphylococcus aureus is a necrotizing toxin. Deep-seated infec-tions associated with PVL-positive S. aureus strains are frequentlycharacterized by their severity and those of osteomyelitis andarthritis is not well define.

Methods: The demographics, selected clinical features, biologicaland microbiological data, and imaging findings were collected for14 cases of PVL-positive S. aureus osteomyelitis and arthritis thatoccurred in children between 2001 and 2005. Factors affectingoutcome (antibiotic treatment, surgical procedures) were studied.

Results: Severity of PVL-positive S. aureus bone and joint infections(BJI) was confirmed by clinical features of severe sepsis, 6 of the 14patients presented a septic shock. At admission, median value ofleukocyte count was 9.7 G/L (2.8–17.6) and CRP median rate was185 mg/L (58.7–415). Eleven patients presented local extension ofinfection observed by magnetic resonance imaging and 7 patientspresented severe deep-seated infectious complications observed bycomputed tomography (CTS). The median time of hospitalizationwas 45 days (10–90). The median duration of intra venous antibiotictreatment was 48 days (10–112). A mean of 3 surgical procedureswere needed in 10 patients (1–5). Mean patient follow-up was25 months and only 2 cases recovered without complication. Noactive chronic osteomyelitis was noted at final follow-up.

Conclusions: PVL-positive S. aureus BJI must be treated withappropriate antibiotics. In case of failure, local complicationshave to be detected by MRI and treated by surgical drainageswithout unnecessary antibiotic treatment modification. Surgicaltreatment appears to be an important part of the treatment ofPVL-positive S. aureus BJI.

Significance: PVL-positive S. aureus BJI as other deep-seatedinfections associated with PVL-positive S. aureus strains are fre-quently characterized by their severity. The present studyemphasizes that either surgical drainage than antibiotherapy,appear to be as important parts in the treatment in such BJI.

22

CRMO – Do we need a new diagnostic algorithm?

Author: Micha Langendoerfer (Germany)

Co-Authors: Toni Hospach (Germany), Guenther Dannecker(Germany), Peter Winkler (Germany), Thomas Wirth (Germany)


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Purpose: Chronic non-bacterial osteomyelitis is an aseptic form ofosteomyelitis with manifestations in children, adolescents andadults. There are several synonyma such as CRMO (chronicrecurrent multifocal osteomyelitis) and SAPHO-Syndrom(‘‘synovitis, acne, pustulosis, hyperostosis, osteitis’’) describing aninflammatory disorder of unspecified origin. Clinical appearanceand symptomatic therapy modalities suggest the association torheumatoid diseases. The aim of the study is to develop an effi-cient way to correctly separate nonbacterial from bacterial chronicosteomyelitis cases at an early stage.

Methods: Over the period from 1997 to 2004 in the orthopaedicand paediatric department of the Olgahospital Stuttgart 338children were treated due to manifestations of non-specifiedosteomyelitis. The cases were retrospectively evaluated, 238 casescould be classified as chronic osteomyelitis. Since 2005 full-bodyMRI was used instead of skeletal scintiscan.

Results: In 48 cases (e.g. 20 % of chronic osteomyelitis) thediagnosis of a non-bacterial osteomyelitis, e.g. CRMO, could bemet following the strict criteria under exclusion of bacterialinfection or other tumorous lesions. In 31 % of these cases furtherextraosseous manifestations were associated, some of which couldonly be detected by the use of a full-body MRI-scan. In 8 casesarthritis (in 3 cases chronic affection), in 5 cases pulmonaryinfiltration, in 4 cases skin manifestations (acne), in 3 casessplenomegaly, in 3 cases kidney lesions (haematuria, nephrocalc-inosis), in 2 cases intestinal manifestations (M. Crohn), in 1 caseunspecified ascites were found.

Conclusions: The initial differentiation of a possible bacterialorigin or the exclusion of a possible tumor may cause first diag-nostic and then therapeutic problems. The variety of possibleassociated lesions is wide and may be misleading in finding acorrect diagnosis. For detecting all possible osseous and extraos-seous lesions full-body MRI is most helpful, since it is minimallyinvasive and also reproducible, it can be used for follow-ups andcontrol of therapeutic efficiency. The strategy in diagnosing andtreating chronic osteomyelitis should include biopsy with histo-logical and microbiological examination and, in case of signs ofnonbacterial origin, a full-body MRI-scan to detect lesions whichmay be not (yet) symptomatic. Full-body-MRI is superior toscintiscan in detecting the osseous lesions, it is radiation-free andreduces the need for further screening methods.

Significance: Since every 5th case (48 of 238 cases) in our collectiveis according to strict criteria classified as nonbacterial osteomy-elitis, the arising problems in false or prolonged treatment aresignificant. The early detection of extraosseous or multiple ‘‘silent’’osseous lesions is an important factor in establishing a correctdiagnosis and thus may avoid prolonged and maybe unnecessaryantibiotical treatment and/or further surgical interventions.

23

Neonatal skeletal infection caused by group B streptococci

agalacticae

Author: Karin Schara (Slovenia)

Co-Authors: Natasa Berden (Slovenia), Arabella Leet (UnitedStates)

Purpose: Group B streptococcal osteomyelitis in the neonatepresents with few inflammatory signs, a mild clinical picture andextensive bony destruction. In the last ten years we treated threeneonate surgically because of acute bone or joint infection causedby group B Streptococci agalacticae (SA).Causes of infection,clinical symptoms, diagnostic methods, and outcome of treatmentwere evaluated.

Methods: 45 children were treated for bone and joint infections inour dept. during the last ten years (1995–2005). We report onthree neonate (2 boys and 1 girl) 3 weeks of age that were treatedsurgically in our department. One hip, one knee and one shoulderjoint were involved. Laboratory blood tests, ultrasound, x-raysand MRI were performed in order to confirm the diagnosis. Bloodcultures and aspirates were examined. Surgical incision, drainageand antibiotic treatment followed. Intraoperative cultures wereanalyzed. Clinical examination and x ray were performed one yearafter the event.

Results: Recognition of the disease was difficult, clinical symp-toms were vague, and the babies had no fever. No risk factors likeprematurity or respiratory distress syndrome were present. Twomothers were treated for mastitis a week after delivery. The firstidentified sign was lack of limb movement and later moderateswelling of the involved joint. White cell counts and sedimentationrate were normal. In one baby we isolated SA from the bloodcultures and in two babies the same organism was aspirated fromthe joint. Ultrasound showed periosteal reaction in the distal fe-mur in one baby. X ray of the shoulder joint showed distension ofthe joint space while the studies of the knee and hip joints werenormal and MRI was necessary to make the diagnosis. The delaybetween the onset of symptoms and diagnosis was from 2 to4 days. The treatment consisted of surgical incision and drainage.From intraoperative cultures SA was isolated in all three babies.The same bacteria serotype was isolated from the milk of twomothers. Babies and mothers received antibiotic therapy withpenicillin. Breastfeeding was temporarily suspended. On clinicalexamination full range of motion of the involved joint was ob-served. X rays one year later showed no changes when comparingto the uninvolved side.

Conclusions: The diagnosis of osteomyelitis or septic arthritis inthe neonate is difficult. Loss of limb movement presents animportant early sign. In order to isolate the causative agent bloodcultures and aspirates may be required. Mastitis and intrauterineinfection should arouse suspicion. With early diagnosis andtreatment we can avoid destruction of bone or joint that can resultin severe deformities.

Significance: In neonatal period Streptococcus B infection can betransmitted from mother to the child. The outcome depends onearly recognition as well as on surgical and antibiotic treatment.

24

Pyogenic Sacroiliitis in the Infance. Review of 6 Years.

Author: Schaufele P. (Chile)

Co-Authors: Cerna C. (Chile); Ibieta A. (Chile), Pineda D. (Chile)

Introduction: Pyogenic sacroiliitis (PS) is one of the less frequentlocalizations among joint infections, near the 1,5% . It is habit-ually presented between the 7 and 14 years, usually unilateral. Alate diagnosis generally exists.

Material and method: A retrospective study of 20 records wascarried out, 17 with diagnosis of entrance of PS and 3 withdiagnosis of another pathology that turned out to be a PS, amongthe years 1999 and 2005 in our unit.

Results: 11 only fulfilled the requirements to be classified as PS(Clinic features of infection and sacroiliac localization, laboratoryexams and Tc-99 bone scintigraphy alterations). 7 males and 4females (64% males), 55% left sacroiliac joint, 4 had clinicallypredisposing conditions (trauma), aged between 3 and 14 years(average 10.2 years). The half time of clinical evolution foresaw todiagnosis it was of 6,5 days (range between 5 and 10 days). Themain symptom that motivates the consultation was fever (100%)


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accompanied by FABER test positive (82%) and by limping,negative to walk and buttock pain (36% each one). Laboratoryexams : WBC count was normal in 5 cases and elevated in 5 casestoo and only in 1 case with left deviation (PMNs elevated); CRPhigher than 55 mg/dl in all patients, ERS with value average of62 mmHg/hour (27–111). Blood cultures were positive in 75%and the Staphylococcus aureus was the only bacteria founded(100%). No radiological alterations were found initially. TheTc-99 bone scintigraphy showed in all the cases pathologicalaccumulation of radiofarmaco in one of the sacroiliac joints. Allpatients had a 7 to 12 days course of intravenous antibiotics(oxacillin + amikacina) and then completed 6 weeks with oraloxacillin. All patients recovered without sequel.

Conclusions: Blood cultures may be obtained prior the adminis-tration of antibiotics. The Staphylococcus aureus is for far the mostfrequent germ involved in this process, and may guide the empiricantibiotic therapy. The precocious antibiotic treatment solves thecase without sequels. The PS is an uncommon pathology in childrenthat makes that it’s often not recognized initially. Wrong diagnosissuch as appendicitis, transient synovitis of the hip, discitis, etc. canbe avoided if PS is sought in a systematic way.

25

Puncture wounds in children’s foot complicated

with osteomyelitis

Author: George Tagaris (Greece)

Co-Authors: George Christodoulou (Greece), George Sdougkos(Greece), George Protopapadakis (Greece), Sotirios Koukos(Greece)

Purpose: This study determines the clinical picture and laboratoryfindings of osteomyelitis of the foot following puncture woundsand evaluates the results of the applied treatment.

Methods: We studied 14 children with osteomyelitis of the footfollowing puncture wounds during a period of 15 years. Involvedbones were calcaneum in 6 cases, metatarsal bones in 2 cases,phalanges in 2 cases, navicular bone in 1 case, cuboid bone in1case. The mean age of patients was 10 years. The averageobservation period was 9 years. 13 of the children were treatedsurgically and 1 conservatively. In 11 cases the wound was causedby a metallic object (usually nail), whereas in 3 cases by a woodenone. All patients had previously received oral antibiotics. Thepresentation and diagnosis was delayed for an average of 14 days(4 days - 2 months).

Results: Three of the patients were presented with fever >38 o.The local symptoms were mild, involving pain, redness andswelling. ESR was elevated in all cases while CRP in 50%, andWBC in 28% of cases. Pus cultures were positive in 80%, dem-onstrating Pseudomonas aeruginosa as the main causativeorganism. At follow-up, all but one were asymptomatic apartfrom residual radiographic lesions in 3 cases of calcaneous oste-omyelitis (widening, shortening, early closure of the physis), 1 caseof metatarsal bone synosteosis and 1 case of spontaneousarthrodesis of the metatarsophalangeal joint. These findings weremore common among younger children and those who receiveddelayed treatment (more than 15 days post-traumatically).

Conclusions: In studied cases of osteomyelitis following puncturewounds of the foot the symptoms were mild, leading to delayeddiagnosis and treatment. The preferred treatment is extensivesurgical debridement and appropriate antibiotic therapy.

Significance: In all cases of puncture wounds of the foot, closefollow up with a warning to the family about the danger ofosteomyelitis is required.

26

One-step treatment of chronic bone infection by continuous

intraosseous lavage-drainage system

Author: Gheorghe Burnei (Romania)

Co-Authors: Dana Vasilescu (Romania), Costel Vlad (Romania),Dan Cosma (Romania), Ileana Georgescu (Romania), StefanGavriliu (Romania), Daniela Dan (Romania)

Purpose: Infection of bone is one of the most serious complica-tions in the field of orthopedic and trauma orthopedic surgery. Itcan result from a variety of etiologies but most often is a conse-quence of trauma to a long bone. In children the most commoncause of chronic osteomyelitis is the incorrect treated acute oste-omyelitis. This paper presents the results of one-step treatment ofchronic bone infection using the continuous intraosseous lavage-drainage system.

Methods: Our series included 287 patients with 325 foci of chronicbone infection treated in our departments during 1988–2005.Excepting the cases with fistulisation our treatment protocolstarted with broad-spectrum antibiotics after cultures were takenat operation and were changed to organism-specific therapy whenculture results were available. Parenteral antibiotics were contin-ued for a mean of five weeks. We proposed a one-step surgicaltreatment including fistulectomy, sequestrectomy, opening of theproximal and distal intramedullary canal and placement of thecontinuous intraosseous lavage-drainage system with antisepticfluids. When large bone defects or fracture risk resulted after se-questrectomy the external fixation devices were used. The evolu-tion during the treatment was monitored by inflammatoryparameters, C-reactive protein and fluid cultures. When fluidcultures were sterile the system was removed.

Results: In our series of 287 patients we noted the following forms:161 monofocals, 53 mono-osseous multifocals, 44 chronic withacutization, 21 with fistulae and 8 with soft tissue loss. In post-operative follow-up evaluation, none of the patients have hadevidence for recurrent osteomyelitis or osteitis.

Conclusions: Our results indicate that this challenging disease canbe solved by a one-step procedure that provide sterilization of theseptic foci and provide second-healing of the skin defectsexcluding bony and soft-tissue reconstruction.

Significance: 3b.

27

Septic Arthritis in Children: a One Centre-based experience

of 40 years

Author: Cosimo Gigante (Italy)

Co-Authors: Giorgia Martini (Italy), Cristian Berton (Italy),Cristina Vallongo (Italy), Sisto Turra (Italy), Francesco Zulian(Italy)

Purpose: Retrospective overview of 40 years experience concern-ing the treatment of septic arthritis in children.

Methods: The study includes the overall period between 1965 and2005. The patients were divided in 3 groups on the basis of thedifferent clinical and therapeutic approach. Group A (1965–1978)includes 62 children (26 new-borns) with 72 joints (knee 50%; hip19%); the treatment was mostly conservative (72%). In Group B(1979–1998) there are 25 children (4 new-borns) with 32 joints(knee 38%; hip 38%); the treatment was mostly surgical (84%). InGroup C (1999–2005) are collected the most recent patientstreated by a dedicated team of a paediatric orthopaedicsand rheumatologist. On admission x-ray, ultrasound and joint


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aspiration were performed. All patients were treated emergentlywith i.v. oxacillin/cefotaxime with the addition of gentamicin forhigh risk neonates. In Group C there are 21 children (4 new-borns) affected by septic arthritis (knee 43%; hip 24%); thetreatment was mostly conservative (71%). Surgical drainage wasperformed in all but one septic arthritis of the hip and in twoosteoarthritis of the knee. Staphylococcus aureus was the mainpathogen in both Group A and B but the causative organismremained undiagnosed in 64% of Group A and in 63% of GroupB. Also in Group C only 7/21 joint aspirates (33%) had positivecultures (Streptococcus pneumoniae was the main pathogen). In aprevious report the patients of Group A and B were respectivelyreviewed at an average follow-up of 3,2 years (range 1–6 yrs) and9,7 years (range 6 mo–20 yrs). The patient of Group C were re-viewed at an average follow-up 4,5 years (range 9 mo–7 yrs). Theresults were classified as good, fair or poor according to thefunctional and radiological Rigault classification.

Results: In Group A the outcome was good in 73%, fair in 7%,poor in 20% of the joints. In Group B the outcome was good in90%, fair in 3% and poor in 7% of joints. In Group C the out-come was good in 90%, fair in 5% and poor in 5% of joints.

Conclusions: In the two oldest series of patients, the outcome ofGroup B (mostly surgical patients) was significantly better than inGroup A (mostly conservative patients). In the most recent series(Group C) the same good outcome observed in Group B wasobtained with a more conservative treatment performed by adedicated team of specialists on the basis of a new establishedalgorithm.

Significance: An appropriate algorithm for the prompt diagnosisand medical treatment of septic arthritis can lower the need forsurgery and guarantee the same good functional outcome ofextensive surgery. Surgical joint drainage remains the first choicein the septic arthritis of the hip and in all the resistant osteoar-thritis.

28

Treatment of sequelae of infantile septic arthritis of the hip

Author: Klaus Parsch (Germany)

Co-Authors: Jana Schiering (Germany)

Purpose: Sequelae of infantile septic arthritis can cause lifelongmajor handicaps. Early reconstruction of the subluxed or dislocatedhip and correction of the femoral neck malposition are recom-mended, leading to satisfactory results in the majority of cases.

Methods: Retrospective evaluation of surgical reconstructions in18 children with 19 involved hips with type II, III, and IVdeformities following Choi’s (1990) classification.

Results: In 8 children with type II A and B surgical leg lengthequalization in prepuberty helped to overcome LLD. In 5 childrenwith type III A and B: Valgusosteotomy with anterotation waseffective. Additional leg length equalization was necessary in allcases 4 children had unilateral Type IV A or B destruction, 1 childhad bilateral type IV B deformity. In 3 children open reduction ofthe residuum of the femoral head was done within the first12 months, followed by valgus osteotomy at a later stage. Allchildren needed later an epiphyseodesis to overcome LLD. 1 childhad trochanteric arthroplasty with a satisfactory result over morethen 10 years. Later THR is facilitated by the preservation of theacetabulum.

Conclusions: All 5 type III sequelae were treated by valgus andanterotation osteotomy with satisfactory results. 3 out of 4 typeIV sequelae profited from reconstructive surgery. The procedure isadvised as early as with 12 months. The residual head is placedinside the joint. In two hips secondary valgus ostetomy aligned the

femur in a weight bearing position. Trochanteric arthroplastyhelps out for a limited time.

Significance: This small and heterogenic series does not allow tostate significance.

29

Harmon Reconstruction for Severe Sequelae of Infantile Septic

Arhtritis of the Hip

Author: Magdy El-Batouty (Egypt)

Co-Authors:

Purpose: This paper describes our experience with an old tech-nique described by Harmon (1942) for reconstruction of the hip inchildren in whom the femoral head and neck had been destroyedby septic arthritis.

Methods: This operation was carried out in eight children aged 14– 53 months (average 25 months) with severe late sequelae ofinfantile septic arthritis of the hip. Two hips were classified asChoi Type IIIB, four as Type IVA, and two as Type IVB. All ofthem had problems of hip instability and leg length discrepancy.

Results: When reviewed at an average of 17.8 months (range 15 –22 months), radiographs showed that the upper end of the femurhad reshaped into a rounded medial shadow contained in theacetabulum that looked like a femoral head, and a lateral shadowthat looked like a greater trochanter.

Conclusions: All children had a stable hip, a satisfactory range ofpainless movement. All could walk and run for long distances withonly a slight abductor lurch.

Significance: Early reconstruction is recommended to stabilize thehip joint and restore the anatomy of the hip to as near to normalas possible.

30

The Graft has Fallen to the Floor!!!

Author: Federico Fernandez-Palazzi (Venezuela)

Co-Authors: Manuel Guzman (Venezuela)

Purpose: To demonstrate the effectivenes of different antisepticson a possible infected graft.

Methods: In 17 samples taken from patients subjected to differentsurgical procedures such as fractures, hip degeneration or herni-ated discs, bone fragments were taken to be exposed to contam-inating suspension of E. Coli, Staphylococcus coagulasa positiveand to floor dust, and later to the effect of antiseptics 3 differentantiseptics Benzalconium Clorhide, Iodopolivinilpirrolidona andlaurildimetilbencil-amonio for 15 min. and, then they were ana-lyzed from the laboratory point of view.

Results: Except in 2 samples treated with iodopolivinilpirrolidona,in all the rest the bacterial growth persisted. The bacterial growthin the exposed bone fragments to antiseptics allows to evaluate thelittle effectiveness of these. The sterilization markers (0-1-2-3)demonstrated the different degrees of effectiveness of the anti-septic used. Data was statistical significant.

Conclusions: None of the antiseptics used was effective, neitherdid they cover the sterilization expectation to decontaminate thebone implant that had fallen to the floor. In one of the controlssample of the antiseptic there was bacterial growth, even indifferent lots.

Significance: Has just the immediate rinse with sterile water thesame effect as the use of antiseptics when a graft falls to thefloor?


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Session 6: Foot & Ankle

31

Comparison of two different surgical techniques in severe

flexible pes planovalgus: calcaneal lengthening

and Dennyson-Fulford subtalar extra-articular arthrodesis.

Author: ahmet dogan (Turkey)

Co-Authors: Yunus Akman (Turkey), Ismail Mumcuoglu(Turkey), Gazi Zorer (Turkey)

Purpose: To compare the results in realigning the foot after cal-caneal lengthening and Dennyson-Fulford subtalar extra-articulararthrodesis performed in patients with severe flexible pes plan-ovalgus (PPV) deformity due to a variety of etiologies.

Methods: Two patient groups with similar spectrums of etiologicdistribution who had randomly underwent calcaneal lengthening(Group I) or Dennyson-Fulford extra-articular arthrodesis(Group II) were constituted. In Group I, 25 feet of 13 patients(mean age 130 months; mean follow-up period 23 months, range13–75 ), in Group II 27 feet of 15 patients (mean age 115 months;mean follow-up period 41.8 months, range 17–82) were includedin the study. Clinical and radiographic evaluations were done.Mann-Whitney U test and repeated measurments from generallinear models were used to evaluate statistical results.

Results: Clinical results were excellent in 19 feet (76%), good in 3(12%), moderate in 2 (8%), and poor in 1 (4%) in Group I andexcellent in 19 feet (70%), good in 5 (19%), moderate in 2 (7%) andpoor 1 (4%) inGroup II. Radiological results were excellent in 6 feet(24%), good in 14 (56%) and moderate in 5 (19%) in Group I pa-tients, and good in 7 feet (26%),moderate in 18 (67%), and poor in 2(7%) in Group II patients. Pre-operative values of AP talocalcanealand AP talonavicular angles were worse (p < 0.05) in Group IIwhen compared with Group I. All other parameters were alike be-tween the two groups preoperatively (p > 0.05). Post-operativevalues of lateral talocalcaneal, AP and lateral talonavicular angles inGroup I were worse than that of Group II (p < 0.05) and calcanealpitch angle in Group II was worse (p < 0.05) than that of Group I.All parameters, except for AP naviculometatarsal angle in Group I(p > 0.05), showed significant correction within each group post-operatively when compared with preoperative values. By using re-peatedmeasures from linearmodels, a better correctionwas obtained(p < 0.05) inAPand lateral talocalcaneal,medial longitudinal arch,lateral talonavicular and AP naviculometatarsal angles in Group II.

Conclusions: Although significant (p < 0.05) correction of thedeformity was obtained with both techniques, Dennyson-Fulfordextra-articular arthrodesis technique showed significant(p < 0.05) superiority over calcaneal lengthening on reduction ofthe talo-calcaneo-navicular joint complex, correction of the fore-foot supination in relation to the hindfoot, and reconstruction ofthe medial longitudinal arch.

Significance: Although both Dennyson-Fulford and calcaneallengthening techniques are efficient in obtaining satisfactory cor-rection, the former technique is superior than the latter techniquein the surgical correction of flexible PPV.

32

Calcaneal lengthening osteotomy for talocalcaneal tarsal

coalition

Author: Vincent S. Mosca (United States)

Co-Authors: Wesley Bevan (New Zealand)

Purpose: Surgical resection of the persistently painful talocalca-neal tarsal coalition has not been shown to reliably relieve

symptoms in patients with coalitions that are large (33–50% of thearea of the subtalar joint) and have associated hindfoot valgusand subtalar arthrosis. It has been recommended that these pa-tients undergo triple arthrodesis, a procedure that has been shownto lead to premature arthrosis of the ankle joint. To avoid addi-tional stress on this important joint, treatment of this group ofpatients using the calcaneal lengthening osteotomy (CLO), with orwithout resection of the coalition, has been performed at ourinstitution over the last 16 years.

Methods: A retrospective review of all patients with talocalcanealcoalitions who had undergone CLO was performed. Clinical andradiographic records were reviewed. Demographic data, preop-erative and postoperative pain and function were recorded. Preand postoperative radiographs and CT scans were reviewed andmeasurements performed. Computed tomography was used tocalculate the degree of hindfoot valgus and the size of the coali-tion. Patients were recalled for interview, clinical examination,and radiographs.

Results: Sixteen feet in eleven patients with foot pain related totalocalcaneal coalitions underwent CLO. Follow-up averaged6.9 years, with a range from 1 year to 16 years. Seven patientswith 11 feet underwent CLO without resection of the coalition tocorrect deformity associated with a large middle facet coalition,with or without arthrosis, but with severe hindfoot valgus defor-mity. All patients report improved comfort and function. Onepatient reported improved comfort and function following bilat-eral simultaneous resections and CLOs. Two of three patients hadimprovement in comfort and function in a foot that had residualpain and deformity after a prior talocalcaneal resection. Theappearance of the feet was improved in all. All patients required aconcurrent Achilles or gastrocnemius lengthening for contracture.

Conclusions: CLO, usually accompanied by a heel cord length-ening, is a useful operation both in the failed middle facet resec-tion where there is persistent pain and deformity, and also in thevery large talocalcaneal tarsal coalition with associated valgusdeformity and/or arthrosis that is not appropriate for resection. Itcorrects the foot deformity, improves comfort and function,maintains motion in Chopart’s joints and, unlike triple arthrod-esis, avoids creating additional stresses in the ankle joint.

Significance: Calcaneal lengthening osteotomy appears to solvethe problem of the unresectable, painful middle facet talocalcanealtarsal coalition.

33

The Severe Flexible Flatfoot : A Combined Reconstructive

Procedure with Rerouting Of The Tibialis Anterior Tendon

Author: Hazem Mossad El Tayeby (Egypt)

Co-Authors:

Purpose: To present a new reconstructive procedure for the severeflexible flatfoot adressing all the components at fault.

Methods: A combined procedure starting by an Evan’s CalcanealDistraction wedge osteotomy to lenghten the lateral column willcorrect the heel valgus and forefoot abduction + A Cuneiformwedge resection osteotomy (Based medial and plantar) willshorten and reshape the collapsed medial arch. This is augmentedby reconstruction and plication of the lengthened plantar liga-ments. Besides, shifting the tibialis anterior pull proximally byrerouting its tendon to attain an L course, the vertical limb ofwhich will act as a sling to the talar head, while its horizontal limbwill augment the supporting plantar ligaments. Z-Plasty of theconcealed tight tendo-Achillis is always needed.

Results: 29 feet in 15 patients were the subject of this study. Theage ranged from 12–16 years (average 13.9 years). The period of


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the follow up ranged from 6–8 years. The results were assessedaccording to the relief of foot strain and calf pains, improvementin shoe ware, general activity and foot shape. The children andparents were satisfied with the final results in 26 feet (13 patients).Improvement of the radiological measurements was evident andwas statistically significant.

Conclusions: The described procedure proved to be an excellentreconstruction for the severe flexible flatfoot.

Significance: An easy procedure that can be applied for the severedisabling flexible flatfoot.

34

Minimal invasive ‘calcaneo – stop’ method in cases

of pes planovalgus in childhood with ‘‘Bone Star�’’ implant

Author: Sandor Roth (Croatia)

Co-Authors:

Purpose: To improve better results in Calcaneo-Stop Method withspongious screw, we managed to construct a new canulated tita-nium implant for per cutem implatation.

Methods: We have operated on 218 cases from 1997 to 2005 with theCalcaneo-Stop Method using the spongious screw. We have a mini-mumof five year follow-up period in 94 cases. In 92%of the cases wehad excellent and good results. Complications showed : breakage ofscrews (8), wrong positioning of the screws (7). In 8 % we did notachieve correction postoperatively, therefore we constructed a newtype of a screw, which would bring better results. We reinforced thescrew’s dimensions and shape, and changed the material (titaniumalloy) to make it more flexible and resistant to breakage. Further on,we canulated it to make the placement easier by means of Kirschnerwire. We placed the apex-thread and the conical smooth body withspongious coil. We need to place the implant the Kirschner –wire,fluorograph control, canulated Imbus key, the titaniumscrew (‘‘bonestar�’’), scalpel, scissors and two stiches.

Results: From July 1995 till September 2006, we operated on 42cases of patiens with planovalgus gradus III/IV, and up to now wedid not have neither wrongly positioned screw nor breakages ofthe screw. There was no surgical complications whatsoever. Wethink that we have improved the Calcaneo-Stop Method with thisimplant.

Conclusions: Despite of short follow up we have proven minimalinvasive effect of the new screw as well as security and highereffeciency.

Significance: childhood, surgical treatment of flat foot, arthro-ereisis, canulated titan implant.

35

A comparison of physician and physiotherapist run clubfoot

clinics using the ponseti method

Author: Joseph A. Janicki (Canada)

Co-Authors: Unni Narayanan (Canada), Anvesh Roy (Canada),Barbara Harvey (Canada), James Wright (Canada)

Purpose: The Ponseti method of the treatment of idiopathicclubfeet was introduced at The Hospital for Sick Children, Tor-onto in 2002. In 2003, a physiotherapist (PT) trained in thePonseti method was appointed to run the serial casting programand post-tenotomy/abduction bracing protocol for all childrenwith idiopathic clubfeet. Surgeons completed the initial assess-ment, performed the percutaneous tendoachilles tenotomy (TAT),and were available for patient review as needed. This study

compares the results of the PT directed Ponseti casting with thatof surgeons’ casting (MD) in order to evaluate the success of thePT clubfoot clinic.

Methods: A retrospective review from 2002 until 2005 was com-pleted. Patients were excluded for a diagnosis other than idiopathicclubfoot, if treated by surgeons without Ponseti training, or had<1 yr follow up. 2 Ponseti trained surgeons treated 30 childrenwith 42 clubfeet prior to the establishment of the PT ClubfootClinic. 149 patients with 220 clubfeet were treated by the PT from2003–2005. Outcomes evaluated included the number of casts, the% of patients requiring TAT, % of recurrences and secondaryprocedures.

Results: The mean age at presentation was 9.3 (0–68) weeks inthe PT group & 22 (0–130) weeks in the MD group(p < 0.01). The mean follow up was 28 months (12–46) in thePT group and 46 months(23–60) in the MD group. Number ofinitial casts was 4.8 casts (2–11) in the PT group and 4.5 casts(2–7) in the MD group (p = NS). Percutaneous TAT wasnecessary in 142/220 (65%) feet in the PT group and in 33/42in the MD group (85%)(p < 0.05). Recurrence during main-tenance phase requiring additional treatment occurred in 17/220(8%) in the PT group and in 9/42 (21%) in the MD group(p < 0.05). In addition to repeat serial casting, additionalprocedures included second percutaneous TAT (5 PT & 3 MD),limited posterior/posterior medial release (5 PT, 6 MD) totaling10/220 (4.5%) in the PT group and 9/42 (21%) in the MDgroup (p < 0.01).

Conclusions: Although the children in the PT group were youngerand have been not been followed for as long as the MD group, theearly results show that the PT directed Ponseti management is atleast as effective as the treatment by Surgeons alone. There werefewer TATs, recurrences and additional procedures in the PT group.

Significance: One of the advantages of the Ponseti method is itssimplicity, allowing physician extenders such as physiotherapistsboth learn and implement this technique. Our institution is a largetertiary children’s hospital that services a large volume of patients.The introduction of a PT run Clubfoot clinic has been a veryefficient model of effective delivery of quality care. The physio-therapist has more time to educate families and to monitor postcorrection maintenance protocol with abduction orthoses. Thismodel can run without compromising, but possibly contributingto improved, outcomes.

36

Aplication of ponseti method for relapses after posteromedial

release in clubfoot

Author: Anna Maria Ey Batlle (Spain)

Co-Authors: Jose Illobre Yebra (Spain), Laia Sabate Cequier(Spain), Marta Vallverdu Pujol (Spain), Diego Gutierrez de laIglesia (Spain)

Purpose: We want to show the utility of Ponseti’s method forrelapsed cases after PMR.

Methods: We include in the study all the patients received in thehospital from September 2001 to June 2006,with clubfoot relapseafter PMR. (we have excluded isolated posterior release cases andneurologic deformities).

We apply the same management as Ponseti’s method for relapses :

# < 2 years old : correction casts+ abduction brace +/– percuta-neous Achilles tenotomy and fasciectomy.# 2–3 years old: Depending on the case# > 3 years old : Correction casts to get at least 40� abduc-tion + anterior tibial tendon transfer( using a titanium anchor) +/–percutaneous Achilles tenotomy and fasciectomy


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Results:

Patients :

• N: 43 feet in 29 patients / Age : from 16 m-14a (average 5,3) /Male18-Female11

Previous surgery:

• 1 Surgery: 27feet / > 1 Surgery: 16 feet (12f -2S / 3f-3S /1f-4S)

Treatment aplicated :

• Casts+Brace: 14cases . (in 3 cases Achilles tenotomy was neces-sary)

• Anterior tibial transfer 29 cases.(Achilles-22 cases, Fasciectomy-29cases,Other procedure-1 case)

• Number of casts: 0–3 feet;1–20 feet; 2–10 feet; 3–8 feet; 4–2 feet

Treatment results :

We have evaluated previous and post treatment the followingparameters :

Cavus .- PRE: 43 POST:10Heel Varus.- PRE: 43 POST:12Equinus.-PRE: 33POST: 8AdductusPRE: 43POST: 5SupinationPRE: 43POST: 3Skin ThickeningPRE: 43POST: 1PainPRE: 18POST: 0Special shoesPRE: 38POST: 2The first 5 parameters have been valoratedusing 3 degrees, and the last 3 parameters using presence-absence.

All the residual deformities after the treatment are mild and doesn’taffect the normal function of the feet. Improvement of scars havebeen observed in young patients.

But all of them are rigid at the beginning we have observed animprovement after the casts.

None of the patients has developed recurrence of the previousdeformity.

Complications: 1 Pseudoaneurism of plantar artery, 1 Intoleranceto anchor suture.

Conclusions

– We can confirm that Ponseti’s management for recurrences is alsoan effective treatment for PMR relapse of clubfoot.

– The anterior tibial tendon transfer corrects the foot balance andavoids the possibility of relapse.

– We improve foot support and appearance using Ponseti’s man-agement without using extensive corrective surgeries.

– The obtained results should make reconsider orthopaedic surgeonsthe approach to PMR relapse

Significance: Relapse after PMR (posteromedial release) has beenusually treatted using extensive joint and ligaments operations,sometimes associated to tendon transfers or bone surgeries. Pons-eti’s management has been described as an elective technique forcongenital clubfoot ; the accepted patients to use this method are:untreated, recurrent, resistant and atypical clubfeet. The use of thistechnique for PMR relapses has never been reported.

37

Comparison of patient-based outcomes in clubfoot treatment:

a long term follow-up study

Author: Joshua Ethan Hyman (United States)

Co-Authors: Hiroko Matsumoto (United States), SamuelDellenbaugh (United States), Jose Morcuende (United States),Michael Vitale (United States)

Purpose: The treatment of patients with Talipes Equinovarus,commonly known as clubfoot, has been controversial due to thedifficulty of assessing their long-term outcomes. The purpose ofthis study is to compare patient-based measures of long termoutcomes in two cohorts of patients, one treated with Ponsetimethod, and the other treated with the open surgical method.

Methods: The study population consisted of 24 patients whounderwent open surgical repair and 16 patients who were treatedwith Ponseti method for their idiopathic clubfoot deformity. Thepatients with the open surgical method were treated at the Divisionof PediatricOrthopaedics atMorganStanleyChildren’sHospital ofNew York-Presbyterian. The patients with Ponseti method weretreated at the Department of Orthopaedics at University of Iowa.The Child version of the Child Health Questionnaire (CHQCF-87)17wasutilized in this study.Themeans of all domains of theCHQ inthe two patient cohorts were compared using independent samples ttests.

Results: There were no significant differences between twogroups in gender, race and age at treatment; however, there wassignificant difference in age at follow up (p < 0.001). Mean agefor the surgical patients were 16.4 ± 1.5 years old while Ponsetipatients were 26.6 ± 5.1 years old in average. The patientstreated with the Ponseti method patients had significantly higherpain than the patients with open surgical method (p = 0.036).The patients treated with the Ponseti method also scored sig-nificantly higher in General Health and Family Cohesion do-mains (ps = 0.027) and significantly lower in Mental Healthdomain (p = 0.047) on the CHQ than the patients treated withthe open surgical method.

Conclusions: Surprisingly, the patients who were treated withPonseti method reported higher pain than the patients who hadopen surgery. This differencemay be due to the fact that the patientswith Ponseti method had the follow-up 10 years longer on averagethan the patients with open surgical method. Psychosocial out-comes might attribute to environmental factors rather than thetreatment methods.

Significance: The patients treated with the Ponseti methodpatients had significantly higher pain than the patients withopen surgical method. The patients treated with the Ponsetimethod also scored significantly higher in General Health andFamily Cohesion domains and significantly lower in MentalHealth domain) on the CHQ than the patients treated with theopen surgical method.

38

Long-term results of posteromedial release in congenital

clubfoot treatment

Author: Harjanneke Van Gelder (Netherlands)

Co-Authors: Jan Visser (Netherlands), Patrick Maathuis(Netherlands)

Purpose: Short-term follow-up studies show good results in footfunction, after surgical treatment of idiopathic clubfoot. Long-term follow-up studies are rare and probably represent a mixtureof experience of the different treating orthopaedic surgeons. It isthe aim of this study to present the long-term results of the Pos-tero-Medial-Release (PMR) in congenital clubfoot treatment ofone treating surgeon.

Methods: Thirty-eight patients with fifty-eight clubfeet had aPMR, a la carte, performed by one experienced pediatric ortho-paedic surgeon before the age of two. This group had a meanfollow-up of sixteen years (range thirteen to twenty-four years).All patients were interviewed and examined and standing


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anteroposterior and lateral radiographs of the feet were made.The results of treatment were graded according to the system ofLaaveg and Ponseti. With the radiographs the grade of osteoar-thritis was determined and those results were compared with thecontralateral normal feet, in case of unilateral clubfoot.

Results: In fifty-three feet, the mean rating was 80.6 points (range43 to 97), according to the system of Laaveg and Ponseti. Therewere fifteen excellent, seventeen good, thirteen fair and eight poorresults. The majority of patients had limitation of foot functionwith a significant decrease in dorsiflexion of 31% and a significantdecrease of pronation-supination of 24%. The grade of osteoar-thritis was consistently higher in the clubfeet than in the contra-lateral normal feet. Five feet (9%) needed an additional bonyprocedure because of pain and overcorrection of the clubfeet. Thiswas considered to be a failure of the surgical treatment.

Conclusions: We conclude that in our hands, PMR has a highchance of leading to stiff and therefore not fully functional feetafter a follow-up of sixteen years. We expect our results to dete-riorate in the next fifteen years as is suggested in literature. Werecommend to classify all clubfoot before and after treatment toan accepted classification system, like the DiMeglio- or Pirani-score.

Significance: The long term functional outcome of this group ofoperative treatment of clubfoot can serve as a control group.Against this historical background, it will be possible to comparethe influence on long term outcome of new techniques in futureresearch concerning the treatment of clubfeet. Standard classifica-tion is a prerequisite for reliable and objective comparison.

39

Iatrogenic Rocker Bottom Deformity in Congenital Idiopathic

Clubfoot. A report of 36 cases

with 15 years follow-up.

Author: Georgios Koureas (France)

Co-Authors: Philippe Wicart (France), Alice Fassier (France),Raphael Seringe (France)

Purpose: The purpose of this study is to analyze the evolution ofRocker Bottom Deformity (RBD), find out the age of its mani-festation, localize the articulation where the apex of the deformityoccurs, and evaluate the final outcome.

Methods: Inclusion criteria: Patients hospitalized from 1975 to1996, full term gestation, Clubfoot (CF) treated as early as onemonth of age, plantar convexity demonstrated radiologically. 1120CF, 36 feet in 23 patients were identified presenting RBD. All feetwere initially treated by manipulations, muscular stimulations, andfixation of the foot on a sole with non elastic strapping followed byan above knee plaster splint immobilization. 33 feet out of 36 withRBD were operated. A postero medial release associated to ante-rior tibialis lenghtening ± calcaneocuboid lateral release was per-formed. The v2 test, the Student t-test and the Pearson’s correlationcoefficient (r) were applied for the statistical analysis.

Results: Follow-up was 15.4 ± 3.7 years. RBD was apparentradiologically at 3–6 month period (p = 0.028). The age of sur-gery was 12 ± 6.8 months. RBD increases the risk for surgicaltreatment 2.76 times. Two third of the feet presenting RBD werebelonging to either Dimeglio D or C group. In 34 feet the con-vexity was located in the Chopart joint. The calcaneo-cuboidalsubluxation improved significantly post-op (p < 0.001). Hind-foot equinus also improved significantly post-op (p = 0.035).There were not observed any immediate post-operative compli-cations. The final functional result according to Ghanem &Seringe classification was excellent or good in 70% of surgically orconservatively treated feet while fair or poor in 30%.

Conclusions: The Chopart joint locates the apex of this sagittaldeformity early after birth. A convex talo-metatarsal I angle andan increase of the clinical measured dorsal foot flexion with aresistance of hind-foot equinus are early diagnostic factors ofRBD. RBD represents a risk factor for surgical treatment. Tibialisanterior lengthening is very important in the correction of theplantar convexity. Roentgenographic control before six months ofage should be carried out for early diagnosis.

Significance: This study clarifies the evolution of RBD and dem-onstrated the exact location of the deformity which is veryimportant for the surgical procedure.

40

Scarf Osteotomy in Adolescent Hallux Valgus

Author: Leroy Anthony James (United Kingdom)

Co-Authors: Harvey George (United Kingdom), Deepak Shiva-rathre (United Kingdom), Alfie Bass (United Kingdom), ColinBruce (United Kingdom)

Purpose: To determine whether Scarf osteotomy is a safe andeffective treatment option in adolescent patients with symptom-atic Hallux Valgus deformity.

Methods: Data was collected retrospectively from a tertiary referralchildrenhospital betweenApril 2001and June 2006.Thepre andpostoperative intermetatarsal angle (IMA), hallux valgus angle (HVA)and distal metatarsal articular angle (DMAA) were determined. Inaddition, any complications were recorded and the hallux meta-tarsophalangeal interphalangeal scale developed by the AmericanOrthopaedic Foot and ankle society (AOFAS) score calculated.

Results: 23 scarf osteotomies were perfomed in 16 patients with amean age of 14.3 years (12–18). The mean pre operative IMA of14.4 degrees was improved to a post operative value of 9.3 de-grees, p < 0.0001. The mean HVA angle was improved from34.7 to 16.5 degrees, p < 0.0001. The DMAA was improvedfrom 13.1 to 8 degrees, p < 0.0001. There were 2 cases ofsuperficial wound infections successfully treated with oral antibi-otics. One patient developed a complex regional pain syndromethat resolved with physio and analgesia. One patient complainedof a prominent suture in the wound. The AOFAS score averaged91.4 at six weeks and improved to 100 at final follow up.

Conclusions: In the adolescent age group, the Scarf osteotomy hasconsistently achieved a significant improvement in the intermeta-tarsal angle, hallux valgus angle and distal metatarsal articularangle with few complications and good patient satisfaction.

Significance: Scarf osteotomy is a safe and effective treatmentoption in adolescents with symptomatic bunions.

41

The paradoxic effect of alendronate on osteoblasts

in osteogenesis imperfecta

Author: Arabella Iris Leet (United States)

Co-Authors: Tamara Kazarian (United States), Edward McCar-thy (United States), Jain Alka (United States), Jay Shapiro(United States), Neal Fedarko (United States)

Purpose: Bisphosphonates, used to treat children with osteogen-esis imperfecta (OI), have not been shown to have an effect onnormal osteoblasts (1). However, there have been recent clinicalreports that raise suspicion for an osteoblastic effect of this drugclass: some children with OI have gone on to non-union aftersurgical osteotomy and bisphosphonate treatment (2). Our re-search examines the possibility of an osteoblastic effect ofalendronate (ALD) on normal and OI osteoblasts.


123

Methods: Proliferation assay: 48 wells were seeded with cells froma normal patient as well as 4 different OI patients with differentages and phenotypes. 8,000 cells per well were allowed to attachfor 24 hours than media was changed exposing half of the plate togrowth media, the other half of the plate to 2 · 10–5 M alendro-nate. Cells were fixed with glutaraldehyde at day 0 and at 3 dayintervals thereafter for 3 weeks. Crystal violet staining as de-scribed by Fedarko (3) allowed quantification of cell growth. Invivo transplantation: An ossicle system as described by Mankani(4) was utilized to study bone formation. Over 2 millions cells werecombined with 1 cc of HA-TCP and allowed to attach via cen-trifugation and incubation. The pellet was placed into the sub-cutaneous tissue of nude mice for 12 weeks. Normal osteoblasts aswell as two OI cell lines were compared.

Results: Normal osteoblasts exposed continuously to drugdemonstrated a favorable response to alendronate with an in-crease in maximal cell growth at confluence (1.4 v 1.8,p < .008); however, the OI cell lines were adversely effected bythe same drug conditions: in one sample of the 12 year old withtype 3 OI the maximal cell growth declined (1.37 v. 1.02,p = .001); the remaining cell lines exhibited not only a declinein proliferation, but eventual loss in cell number compared withthe original number of cells seeded.

The in vitro results were seen in vivo. In the normal osteoblastsbone formation was promoted by drug from a bone score of 0 to4. While the opposite effect was seen in the type 3 OI cells wheredrug exposure prior to formation of the implants caused adecrease in the bone score from 2 to 1.

Conclusions: We report a direct osteoblastic effect of a bis-phosphonate and find that the presence of a gene defect in CO-LIAI changes the response of the osteoblasts to drug. Whilenormal osteoblasts appear to have improved proliferation andbone formation under drug effect, OI cells show the opposite re-sponse.

Significance: Our study supports further in vivo studies of the roleof bisphosphonates and fracture healing in children with OI.

42

WITHDRAWN

43

Significance of fever post multilevel surgery

in neuro-orthopaedic patients

Author: Eduardo Daniel Segal (Argentina)

Co-Authors: Juan Couto (Argentina), Eduardo Samara (Argentina)

Purpose: Fever following orthopaedic operation in children is acommon event. The presences of fever usually generates conster-nation and worry by patient’s parents, physicians and nursingstaff Our purpose: Identify risk factors, complications. To suggesta guide to follow.

Methods: Fifty consecutives paediatrics orthopedic surgeries withmultiple procedure at the same stage were analyzed, 35 includebone proceedings and conform Group A. 15 involved only softtissue procedures, Group B. Duration of surgery, anesthesia, ap-proaches, transfusions, temperature records, supplementarystudies and complications were analized. Fever was defined as atemperature > 38�C.Results: Considering both groups 42% (21/50) of patients hadpostoperative fever. Group A. 51% (18/35) and Group B 20%had fever (3/15). Patients with myelomeningocele presented higherfever incidence 71% (10/14) Only 3 from 21 patients with fever

had any complication, a pressure heel sore, one otitis and oneatelectasia. This complications were diagnosed as a result of theexamination of the patients.

Conclusions: Our results suggest that a meticulous general physicalexamination should be the appropriate response to fever atpostoperative.

Significance: Routine septic work-up should not be undertakenmerely on the basis of fever, and fever should not necessarily delayhospital discharge.

Session 7: Trauma

44

Interventions for treating wrist fractures

in children – a Cochrane Systematic Review

Authors: Alwyn Abraham (United Kingdom) and Tahir Khan

Co-Authors:

Purpose:

Background: The epidemiology of fracture in children has beenreported in detail by other authors. The most common mechanismin their study was a fall in or around the house onto an out-stretched hand causing a fracture of the distal radius and ulna.These injuries accounted for 35.8% of all fractures in this agegroup and the annual incidence was estimated to be 16 per 1000children in the UK. The controversial issues in the management ofdistal radius fracture involve what constitutes a degree of fracturedisplacement and angulation likely to be compensated byremodelling with growth over time, indications for fracture sta-bilisation with wires or other invasive methods compared withplaster casting alone, details of the position of the arm duringimmobilisation in a cast, and whether the cast should immobilisethe wrist alone or both, the wrist and the elbow. The managementof buckle fractures of the distal radius is relatively uncontrover-sial, involving splintage for symptomatic relief from pain. Someauthors have advocated removable wrist supports, with discon-tinuation of splintage at the parents’ discretion. We performed asystematic review of all areas of the management of distal radiusmetaphyseal fractures in children. Growth plate injuries were notincluded for analysis.

Methods: Any randomised or quasi-randomised controlled trialswhich compared types of immobilisation and the use of wire fix-ation for distal radius fractures in children were included.

Types of outcome measures

• Radiological deformity

• Effect of cast index

• Complications of k-wiring

• Remanipulation rates

• Compliance with splintage

• Cost of various forms of splintage

• Effect of intact ulna

• Upper limb function while immobilised

• Wrist and elbow ROM

10 studies complied with the inclusion criteria and were analysed usingReview Manager software provided by the Cochrane Collaboration.

Results: Regarding displaced metaphyseal fractures:

• K wire fixation reduces redisplacement

• There is no proven increase in complications with k wires


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• Intact ulna favours redisplacement

• Long casts do not reduce displacement

• Short casts allow better early function Regarding stable compres-sion fractures

• Removable splints are not associated with displacement

• Patients prefer removable splints for buckle fractures

Conclusions: Distal Radius metaphyseal fractures should bestabilised with k-wires if the ulna is intact. A below elbow cast willprovide sufficient stability for such fractures treated non opera-tively. Soft removable splintage is the most convenient form ofsplintage for stable compression fractures.

Significance: K-wires or short forearm casts are recommendedfor metaphyseal fractures and removable splintage for bucklefractures.

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Cast index following closed manipulation of distal forearm

fractures in children

Author: Sreejib Das (United Kingdom)

Co-Authors: Ujjwal Kanti (United Kingdom), Rachit Shah(United Kingdom), Abhijit Ranjan (United Kingdom)

Purpose: To assess the relevance of cast index as a predictor of redisplacement.

Methods: 174 consecutive paediatric patients (124M : 50F), with amean age of 9.8 years (range 2–15 years), presenting with forearmfractureswere analysed radiologically. 156 patientswere included inthe study who had manipulation for either distal radius alone orcombined distal radius and ulna fracture. All patients weremanipulated in OR and a moulded above elbow cast was applied.Patients were followed up with radiographs in the first and thirdweeks. The cast index was measured on immediate post manipula-tion radiographs.

Results: Displacement of the fracture within the original plastercast occurred in 32/174 patients (18.4%), 24/124 males (19.4%); 8/50 females (16%). The cast index in the 32 patients requiring asecond procedure (mean 0.92, sd .081) was significantly more thanthe cast index (mean 0.78, sd .08) in the others (p < .001).

Conclusions: Cast index is a valuable tool to assess the quality ofmoulding of the cast following closed manipulation of distal ra-dius fractures in children. A high cast index in post manipulationradiographs indicates increased risk of re-displacement of thefracture and these patients should be kept under close review.

Significance: Higher cast index in the post-manipulative X-raysfollowing distal radius fractures in children should raise the suspi-cion of redisplacement. The patients in the ages below five andabove ten should be carefully monitored. All children undergoingmanipulation for angulated distal radial fractures should be treatedwith a well moulded cast and cast index should be measured in thepost manipulation X-rays.

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Stiffness in displaced pediatric both-bone forearm fractures

Author: Charles T. Mehlman (United States)

Co-Authors: Mike Greiwe (United States), Eric Wall (UnitedStates), Alvin H (United States)

Purpose: Both-bone forearm fractures are common pediatricinjuries. Displaced forearm fractures are notoriously difficult tomanage because of their inherent instability. Two philosophies

exist regarding the management of these fractures: casting andintramedullary (IM) fixation. Unforunately, the two techniqueshave not been researched in head-to-head prospective, random-ized controlled trials. The purpose of this paper was to comparerange of motion and complication data in IM and closed reduc-tion using a meta-analysis.

Methods: A literature search was employed for IM fixation andclosed treatment techniques. Studies were limited to the modernEnglish literature (1970-present). Papers were excluded if they hadless than 20 patients, poor range of motion or complicationreporting, other fracture sites included in the data, if they fixedonly one bone, or if they compared ORIF to IM fixation. Ninepapers concerning IM treatment and six papers regarding closedtreatment were identified. Range of motion and complicationswere tabulated for each group. Pronation and supination loss wasdivided into mild (15–35�), moderate (36–59�) and severe loss(> 60�). Complications were separated into minor and majorcategories. Data analysis was performed by the chi-squared test.

Results: Mild (40/219 vs. 14/278) and moderate (9/219 vs. 0/278)range of motion loss was present in the closed treatment groupwith more frequency (p < 0.05). Although there was a trend,severe (5/219 vs.1/278) range of motion loss was not statisticallysignificant between the groups. In addition, IM fixation had moreminor complications (21.15% vs 6.4%) (p < 0.05), but majorcomplications were similar IM 2.9% vs. closed 2.3%.

Conclusions: Our meta-analysis identified that pronation andsupination losses are more prevalent using a closed reductiontechnique. IM fixation is associated with more minor complica-tions, but major complications were similar.

Significance: IM fixation is a viable treatment option for both-bone forearm fractures.

47

Associated Ipsilateral Elbow Fractures in Paediatric Elbow

Dislocations

Author: Bulent Daglar (Turkey)

Co-Authors: Onder Delialioglu (Turkey), Ertugrul Gungor(Turkey), Bulent Tasbas (Turkey), Kenan Bayrakci (Turkey),Ugur Gunel (Turkey)

Purpose: Elbow is a frequent site of injury in paediatric agegroup. However, elbow dislocations are not seen that oftenduring childhood. Because of the weak link between metaphysisand epiphysis, dislocations frequently associated with fracturesaround the elbow in children. Aim of this study is to determinethe incidence of fractures associated with paediatric elbow dis-locations in our hospital and to evaluate functional results afterthese injuries.

Methods: We retrospectively reviewed our database and looked fordiagnosis of elbow dislocation, elbow epicondylar, condylar, radialhead and olecranon fractures, Monteggia and equivalent fracturedislocations in patients with ages lower than 18 years. During5 years period, between January 2000 and December 2005, 482patients were identified. Within these 32 elbow dislocations andassociated injuries were detected. Patients’ demographic and trau-madata besides treatment and follow-up results were noted. Elbowswere evaluated by using QuickDASH and Mayo scores.

Results: 23/32 patients were males. Dominant elbow injury wasdetected in 26/32. Most common injury mechanism was sportsinjuries (12 of 32) followed by playground accidents (6 of 32).All but one elbow dislocations were associated with fracturesaround elbow. 23 medial epicondyle, 4 lateral condyle, 3 radialhead and 1 olecranon fractures were concomitant injuries


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detected ipsilaterally. Medial ulnar collateral ligament injurywas detected associated with medial epicondyle fracture dislo-cation in a 17 years old girl, who is an elite level Olympicweight lifter. All associated fractures except 9 medial epiconylar,were treated surgically. All but 3 patients were symptom free atsixth month after injury. Mean Mayo elbow score was 90points in this series. Patients treated conservatively with closedmanipulation and posterior splint had slightly higher Mayoscores (93 versus 88, p = 0,025).

Conclusions: Elbow dislocations were infrequent injuries in chil-dren. When occurred, one must be very careful not to overlookassociated ipsilateral bony injuries around the elbow since dislo-cations are rarely seen as isolated injuries at this age group.Depending on the mechanism of injury open reduction and softtissue repair might be indicated also in paediatric patients.

Significance: Elbow dislocations in children frequently associatedwith fractures around the ipsilateral elbow. These associatedinjuries might change the treatment strategy and should be lookedfor at initial presentation of the paediatric patients.

48

Avascular Necrosis of the Trochlea of the Humerus Revisited –

Long Term Follow-up

Author: Kaye Wilkins (United States)

Co-Authors: Erik V. Nott (United States), K. Sri Ram (India)

Purpose: To review fracture patterns associated with avascularnecrosis (AVN) of the trochlea of the humerus as well as deter-mine if any long term complications exist.

Methods: We retrospectively reviewed the x-rays of thirty fourpatients who were thought to have AVN of the trochlea. Thesecases and films had been collected over a thirty year period. Manyof these cases had been included in a previous report on AvascularNecrosis of the Trochlea presented at the EPOS meeting in Pra-gue, Czech Republic in 1986. The initial fracture patternsinvolving the distal humerus were analysed on most of the filmscollected. In addition, the patterns of AVN were characterizedusing on the current classification system into two types. The TypeA patterns presented with dissolution of the lateral crista of thetrochlea producing the typical ‘‘fishtail’’ deformity. The Type Bpatterns were manifest as dissolution of the entire trochlea. Thepatient record information was reviewed prior to contacting thepatients for follow-up interval history, physical exam and radio-graphs.

Results: AVN of the trochlea was observed to occur with everytype of distal humerus fracture/elbow fracture to include:supracondylar humerus fractures, lateral condyle fractures, distalhumeral physeal separations, medial condyle fractures, andosteomyelitis. We were able to characterize the fracture patternsin 27 patients. There were 17 with Type A and 10 with Type B.Follow-up was achieved in five patients from the senior author’scase series, as well as two cases provided to the senior authorwhile visiting India. Average time of follow-up was 16 years(range 10–22 yrs). All patients had cubitus varus. 3/5 patientshad pain with prolonged use, especially with heavy lifting. Allpatients were functional with activities of daily living and work,but none were heavy laborers. 4/5 patients were unable to fullyextend their elbows. The average flexion was 131 deg (range 100–150), average extension was 17 deg (range –25–40), averagesupination was 92 deg (range 90–100), average pronation was 77deg (range 60–90), average arc of flexion/extension was 113 deg(range 60–175). No cases of delayed motor or sensory deficitswere found.

Conclusions: Type A AVN of the trochlea can result in minimalradiographic changes and minimal functional changes.Type BAVN of the trochlea can result in drastic radiographic changeswith collapse of the medial joint and sometimes subluxation of theelbow joint. There is often significant loss of function of the elbowjoint with this pattern of necrosis.

Significance: In a review of the literature to date, this appears tobe the only report describing the long term functional andradiographic results in patients with AVN of the trochlea. thedisability acquired depends upon the pattern of necrosis thatdevelops.

49

Fracture neck of radius in children – factors affecting outcomes

and complications.

Author: Arjandas Mahadev (Singapore)

Co-Authors: B Lim (Singapore), E Lee (Singapore)

Purpose: The aims of this study are to determine the local inci-dence and demography and identify the factors that affect out-comes of the treatment of radial neck fractures. Based on these,we aim to suggest a possible algorithm for treatment of thesefractures.

Methods: A retrospective case note and Xray review of 108consecutive radial neck fractures treated at the KK Women’sand Children’s Hospital Singapore from 1997 to 2001 wascarried. The treatment was classified as cast immobilisa-tion without any further manipulation (CI), closed manualmanipulation and reduction (MR), percutaneous K-wireassisted manipulation and reduction (PKWR) and open reduc-tion (OR). All patients included in the study were then re-quested to return for a clinical evaluation to ascertain treatmentoutcome. Xrays were independently assessed. The angular dis-placement was measured as the angle made by the perpendic-ular of the axis of the displaced radial epiphysis and the axis ofthe radial shaft.

Results: Of the 108 patients, 54% were boys with an average ageof 8.7 years, ranging from 2 years to 14 years. 86 patients weretreated by CI alone. 8 had MR, 7 had PKWR and 7 were had OR.They were followed up for an average of 2.7 years. 86% patientshad excellent clinical outcome, 4% had fair and none had pooroutcome. One patient had heterotropic calcification and anotherhad proximal radio ulnar synostosis. The factors associated with apoorer outcome and increased rates of complications include age,degree of angulation, associated fractures and, interestingly, opensurgery.

Conclusions: Although relatively less common, radial neckfractures can produce significant poor outcomes and complica-tions which are dependent on age, degree of angulation,associated fractures and interestingly open surgery. We proposea step-wise approach to surgical reduction of radial neck frac-tures with angulation more than 30 degrees. Closed reductionshould be attempted in all radial neck fractures with unac-ceptable angulation. Failing which, percutaneous reductionshould be attempted followed by open reduction if an accept-able reduction of less than 30 degrees angulation cannot beachieved.

Significance: The above study has one of the larger series of radialneck fractures treated. Treatment protocols proposed so far canbe confusing and as such, the above study proposes a treatmentplan stressing on a stepwise approach with open surgery as a lastresort as it has been shown to be an independent factor for pooroutcome.


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50

Do proximal femoral fractures result from high energy trauma?

analysis of causes and severity of injury in 1299 cases

of pediatric proximal femoral fractures

Author: Brian Grottkau (United States)

Co-Authors: Gleeson Rebello (India), Wouter Willems (Nether-lands)

Purpose: Proximal femoral fractures (PFF) make up less than 1 %of all pediatric fractures. The severity of injury causing thesefractures in children is not accurately documented in the litera-ture. The aim of our study was to recognize the mechanisms ofinjury and to measure the severity of trauma resulting in theinjury.

Methods: Injured children bearing ICD-9 codes 820.0–820.9,registered in the National Pediaric Trauma Registry (NPTR)between 1988 and 2001, were included in the study. 1299 patientswere stratified into age groups <1 yr, 1–4 yrs, 5–9 yrs, 10–14 yrsand 15–19 yrs. External Cause of Injury Codes were used toobtain mechanisms of injury, grouped into nine functionallydescriptive categories. The location of the injury and additionalinjuries were also noted. The Injury Severity Score (ISS) was usedto determine the severity of trauma. Bonferroni’s multiplecomparisons tests were used to determine differences amongsubgroups of patients.

Results: Falls (33%), MVA (30%), pedestrian versus motorvehicle crashes (16%), bicycle accidents (7%), struck by an object(6%), intentional abuse (2%) and firearm injuries (1.6 %) were theleading causes of injury. The leading cause of injury in those<1 year was abuse (35%) while children 1–4 yrs (37%) and 10–14 yrs of age (40%) most frequently suffered falls. 5–9 yr olds(30%) and 15–19 yr olds(54%) were most frequently injured inmotor vehicle accidents. 47% of the injuries occured on the roadand 26% at home. Major additional injury occured in 23% of thechildren. ISS scores were < 9 in 57%, 10–18 in 28% and 19–75 in14% of the injured children. Children <1 yr, 1–4 yrs and 10–14 yrs had a median ISS of 9. Children 5–9 yrs and 15–19 yrs ofage had a median ISS of 10.

Conclusions: Overall, falls (33%) were the leading cause of PFF inchildren. The median ISS in all age groups were 9 or 10. Severelyinjured children made up 14 % (ISS > 18) of the study popula-tion. We conclude that proximal femoral fractures are not asfrequently associated with severe high-energy trauma as has beenpreviously reported.

Significance: Proximal femoral fractures in children are notnecessarily the result of high energy trauma with 86% of our studypopulation suffering low to moderate energy trauma as measuredby the ISS.

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Complete Distal Femoral Metaphyseal Fractures:

A Harbinger of Child Abuse

Author: Lawrence Wells (United States)

Co-Authors: Jared Friedman (United States), Alexandre Arkader(United States), William Warner (United States)

Purpose: We contend that metaphyseal femur fractures are also apotential indicator of child abuse in children less than one year old.

Methods: This retrospective study was performed at two level-1United States pediatric trauma centers. Query of a trauma data-base revealed a complete distal femur fracture from 1995–2005 in117 pediatric patients; 29 (24.8%) sustained metaphyseal fractures

with 20 (69%) one-year-old or younger. The average age for the14 males and 6 females was 6 months, 10 days. All radiographs,mechanisms of injury and associated injuries were evaluated bythe respective Suspected Child Abuse or Neglect (SCAN) proto-cols at each institution.

Results: Ten cases (50%) were confirmed to have a history ofabuse, whereas another five cases (25%) were suspected of abuse.In all, 15 (75%) cases of complete distal femoral metaphysealfractures indicated child abuse after a SCAN team evaluation ateach hospital.

Conclusions: With 50% of our cases confirmed to be caused bychild abuse and another quarter suspected, complete distal fem-oral metaphyseal fractures occurring in children before walkingage should prompt further inquiry for possible etiology of childabuse.

Significance: Health care workers are advised that in addition toepiphyseal corner fractures, complete metaphyseal fractures of thefemur are highly associated with child abuse in children beforewalking age.

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Acute Patellar Dislocation in Children and Adolescents

Author: Sauli Palmu (Finland)

Co-Authors: Pentti Kallio (Finland), Aarno Nietosvaara (Finland)

Purpose: The aims of this prospective population based study wereto evaluate the natural history of acute patellar dislocation (APD)in the pediatric patient population, to compare the outcome ofprimary surgical repair to conservative treatment and to assess theprognosis in patients with intra-articular osteochondral fractures(OCF).

Methods: 74 consecutive primary patellar dislocations in 51 girlsand 20 boys (<16 years old) were treated in Aurora Hospital,Helsinki during 1991–92. Arthroscopy revealed damage of thejoint surfaces in 41 % of the knees (chondral lesions 16 andOCF 14). Knees without OCF larger than 15 mm in diameterwere treated randomly either by immobilization (29) or bysurgery (35). All patients were followed up at 2 years and atmean 6 years. The last follow-up (68 patients, 92 % of theknees) was conducted by an independent observer at mean14 years (11–15) after the injury. Recurrent instability (redislo-cations and subluxations), reoperations, subjective and func-tional results (Kujala score, Hugston VAS and Tegner activitylevel) were recorded.

Results: The subjective result at the final follow-up was eithergood or excellent in 75% of the patients with conservative treat-ment, 66% in operatively treated patients and in 54% of the pa-tients with OCF. Recurrent patellar dislocation (RPD) occurredin 69% and recurrent patellar instability in 90% of all patientswith insignificant differences between the different study groups.Two-thirds of RPD occurred within 3 years of the primary injury.Half of the patients experienced contralateral patellar instability.The mean Kujala score was 84 after conservative treatment, 83after operative treatment and in patients with OCF. Hugston VASscores were 91, 84 and 85 respectively. The median Tegner activityscore of all patients was 5 before the injury and at the last follow-up. Positive family history was a risk factor for RPD andcontralateral patellar instability. Girls had significantly lowerfunctional scores and activity level than boys.

Conclusions: The majority of pediatric patients with APD aresatisfied with their knees in young adulthood despite the very highrecurrent instability rate. Primary repair of the torn medial reti-nacular structures is not advocated. OCF in association with APDis a risk factor for poor subjective result.


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Significance: The knowledge of the prognosis of APD in thepediatric patient population concerning the subjective result,recurrent instabilityand function is very useful for patient infor-mation and treatment decisions.

53

Excision Of Partial Physeal Arrest Followed To Skeletal

Maturity; A Report of 100 Lower Extremity Cases

Author: Anthony Stans (United States)

Co-Authors: Rudolph Klassen (United States), William Shaugh-nessy (United States), Hamlet Peterson (United States)

Purpose: The purpose is to determine the outcome of partialphyseal arrest excision and insertion of polymethylmethacrylateinterposition material in lower extremity long bones of 100 pa-tients followed to skeletal maturity.

Methods: A prospective study of 100 patients followed to skeletalmaturity following partial physeal arrest resection was performed.Partial arrest occurred in the distal femur in 45 patients, proximaltibia in 18, and distal tibia in 37 patients. Surgical excision andinterposition of polymethylmethacrylate (Cranioplast) were per-formed in all cases. Sex, age, etiology, limb length, angulardeformity, growth, and percent physeal involvement were re-corded.

Results: Compared to the normal contralateral limb, averagephyseal growth following physeal arrest resection was 78 percentin the femur, 88 percent in the proximal tibia, and 93 percent inthe distal tibia. Area of physeal arrest was greater than 45 percentin 16 patients, greater than 30 percent in 17, and less than 30percent in 65 patients. Additional operations included epiphy-seodesis in 40, osteotomies in 37, lengthening in 13 and physealarrest recurrence excision in 16 patients, for an average of 1.1additional surgeries per patient. Two patients fractured throughresection sites.

Conclusions: Following partial physeal arrest resection, the af-fected physis grows at a slower rate and matures earlier than thenormal physis. Virtually all patients will require additional sur-gery to correct length and alignment.

Significance: Patients and families should be counseled regardingthe inevitable need for additional surgery following partial physealarrest resection, and appropriate treatment and follow-up plansmade to provide optimal care.

Session 8: Legg-Calve-Perthes Disease

54

Legg-Calve-Perthes Disease with Onset before Age Six;

a retrospective review

Author: John Anthony Herring (United States)

Co-Authors: Scott Rosenfeld (United States)

Purpose: To evaluate the outcome of Legg Perthes disease relativeto the Lateral Pillar classification in untreated hips with onsetbefore age six.

Methods: We retrospecetively reviewed 190 hips in 173 patientswho had the onset of Legg Perthes disease before age six. Allpatients were seen at Texas Scottish Rite Hospital for childrenbetween 1949 and 1998 and had not had specific treatment.Classifications were confirmed by two observers.

Results: In the entire group there were 7 lateral pillar A, 101lateral pillar B, 27 B/C border, and 29 C hips. There were 131

Stulberg I-II, 14 III, and 19 Stulberg IV results. The group B hipshad Stulberg I-II outcome in 95 of 101 hips while only 14 of 29group C hips had a Stulberg I-II result and 10 of 29 had a StulbergIV outcome (p < 0.0001). In a logistic regression with the B hipscompared to the B/C border and C hips, both age and lateralpillar classification were significant predictors of outcome. Wefound a unique group of 12 patients who had simultaneous onsetof bilateral Perthes-like radiographic changes and symmetricevolution through the stages of fragmentation and reossification.Radiographs of other joints and spine revealed no evidence ofepiphyseal dysplasia. There were 7 lateral pillar B, 4 B/C border,and 13 lateral pillar C hips. At final followup there were 21Stulberg I-II and 3 Stulberg III results, and only one patient haddifferent results between the two hips.

Conclusions: Children who have the onset of Legg-Calve-Perthesdisease prior to age 6 have a high probability (80%) of a goodresult without treatment. Lateral pillar classification is predictiveof outcome, but the infrequent group C hips will have a StulbergIV outcome about 1/3 of the time. Bilateral simultaneous onsetdisease may represent a variant of Legg Perthes, with somecharacteristics of Meyer’s dysplasia, or may represent some otherunknown abnormality.

Significance: This work which reviews a large number of untreatedhips reinforces the concept that children with Legg Perthes withonset before age six should not routinely have major treatment oractivity restrictions. Treatment programs should focus on group Chips, but the efficacy of treatment for these children remains to bedemonstrated.

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Comprehensive Range of Motion Treatment of Perthes Disease

Author: Perry Lee Schoenecker, MD (United States)

Co-Authors: Margaret Rich, MD (United States)

Purpose: The goal of containment treatment of Perthes disease is tominimize permanent deformation of the femoral head. In mostcenters this method of treatment includes femoral and/or pelvicosteotomy (ies) or acetabuloplasty. A femoral varus extensionosteotomy decreases hip abduction and flexion. Innominate oste-otomy potentiates acetabular retroversion which may exacerbatefemoral-acetabular impingement. Combined proximal femoraland acetabular osteotomy produces an additive loss of motion.The optimal treatment of Perthes disease, which is a biologicalprocess more than a problem of instability, should be functionalcontainment of the deformable femoral head as the healing processevolves. This requires dynamic not static containment, which isdesigned to and promotes optimal physiologic range of bothfemoral head and acetabular remolding and congruence.

Methods: From 1985 through 2001, 316 patients have been treatedfor Perthes disease solely with a comprehensive range of motionapproach. Protocol treatment for these patients included anexamination under anesthesia, adductor release as needed, appli-cation of an abduction cast, and subsequent dynamic contain-ment, using an A-frame orthosis and progressive weight-bearing.

Results: This preliminary report presents the outcome of 251patients (291 hips) whose age at presentation was 6 years (range2–12). Herring classification of 12 hips were A, 121 B and 158 C.Coxa magna was noted, but with less proximal femoral deformity(coxa breva). Two hundred three hips were mature enough forStulberg classification. Average age at Stulberg classification was12.1 years; 73 hips were class I, 78 class II, 43 class III, 9 class IVand no class V.

Conclusions: An analysis of our experience to date with thistreatment approach strongly suggests that a satisfactory radio-


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graphic outcome will occur and is superior to the results of thePerthes study group. Assessment of passive hip motion (abduc-tion) is used as the determinant factor for treatment in stages ofthis disease. The need for soft tissue release, additional abductioncasting and progressive weight-bearing are based on the adequacyof hip abduction which is necessary for physiologic containment.

Significance: This method of dynamic containment which focuseson hip range of motion acts to minimize deformity of the recov-ering femoral head, encourages acetabular remodeling and fem-oral/acetabular congruence which is critical. The outcome ofdynamic containment is as good as and often better than withosteotomy and avoids secondary problems associated withosteotomy.

56

MR-Based Volumetric Analysis of the Femoral Head

and the Acetabulum in Perthes’ Disease

Author: Ludwig Meiss (Germany)

Co-Authors: Sintje Singerhoff (Germany), Christian Habermann(Germany)

Purpose: Coxa magna is well known in Perthes’ disease but aquantitative evaluation of the early, in particular cartilaginous,enlargement of the femoral head and the necessary adaptivechanges of the acetabulum (widening and/or growth) does notexist. We would like to present MR-based volumetric data.

Methods: We measured the volume of the femoral head and theacetabulum in MRI by means of a software established for thesizing of tumours before therapy and the determination of liverlobe volume prior to transplantation. We evaluated MRI exams in47 children with Perthes’ disease and 72 normal children from 4 to9 years and present data of the affected hip in comparison to theunaffected hip and to normal hips.

Results:

Femoral head:

1. On the average the affected head had a volume that was 47%(range 42–57%) larger than on the unaffected side and 44 %(range 13–59%) larger than in hips of healthy children.

2. Cases with serial exams showed that the volume of the affectedhead increased in the course of time.

Acetabulum:

1. On the average the acetabular volume was 21% (range 13 to 30%)larger on the affected side than on the unaffected side and 20%(range 10 to 29%) larger than in healthy children.

2. In patients who underwent surgery (pelvic osteotomy, alone ortogether with intertrochanteric varus osteotomy) the acetabularvolume was 24% larger (range 9–33%) on the affected side thanon the unaffected side. In patients without surgery the acetabularvolume was 16% larger (range 10 to 33%) on the affected side.

3. In cases with serial exams there was a definite increase of theacetabular volume after surgery.

Conclusions:

1. We found that Perthes’ disease is associated with an average in-crease of femoral head volume of 47% in comparison to theunaffected side and of 44% in comparison to healthy children.

2. There was an average increase of the acetabular volume of 21% incomparison to the unaffected side and of 20% in comparison tohealthy children.

3. These data may allow a better understanding of the disease and areappraisal of current forms of treatment.

Significance:

Given a chronic disproportion between the size of the femoralhead and the acetabulum therapy should aim at:

A. Retardation of the (cartilaginous) enlargement of the femoralhead

B. Promotion of widening or growth of the acetabulum.

We believe that current conservative modes of treatment areeffective through rationale A and B.

Operative modalities, in particular pelvic osteotomies and /or in-tertrochanteric varus osteotomy, seem to be mainly effectivethrough rationale B. By reorientation of the acetabulum and/orthe proximal femur they should favour a better distribution offorces through the hip joint allowing for a gradual widening of theacetabulum. In addition, the operative trauma in the vicinity ofthe triradiate cartilage should have a stimulating effect on ace-tabular growth.

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Legg-Calve-Perthes-Disease –The Role of the Acetabulum

Author: Andreas Schreiner (Switzerland)

Co-Authors:

Purpose: Stulberg pointed out the significance of the acetabularmorphology for the prognosis in Legg-Calve-Perthes disease. Sincethen some studies have delt with the effect of acetabular pathologyin the different stages of the disease on the outcome. And yet, thereare contradictory observations andmany remaining questions as tothe role of the acetabulum within the Perthes process.

Methods: Longstanding X-ray evolutions of patients in two majorpaediatric orthopaedic centres in Austria and Switzerland werestudied. There were 45 hips fulfilling the criteria of a completeddisease process. The observation protocol included the sphericityof the femoral head as a matter of course, but also the inclinationof the acetabular roof, the reasons for salvage operations and thenature of these operations.

Results: In 22 of those 45 hips an operation was done forsequelae of the disease. 12 of those operations consisted in apelvic osteotomy in order to correct an increased inclination ofthe acetabular roof in cases of Stulberg III, which means that thefemoral head was not spherical, but not flat. In 2 hips differentoperations were used for the same reason and end. For 4 oper-ations an extreme shortening of the femoral neck was the indi-cation. Only in 4 cases the lost sphericity of the femoral head wasthe essential pathology. Furthermore there are observationssuggesting independent acetabular phenomena within the diseaseprocess.

Conclusions: In the majority of outcomes requiring an operation itwas not the loss of cephalic sphericity to give rise to the inter-vention, but the increased inclination of the acetabular roof. Thisis astonishing, because according to Stulberg’s findings those hipshave a very good prognosis. And yet, it can be shown, that inthese cases the operation was reasonable and achieved for themost its goal to save the hip from major osteoarthritis. The gen-erally speaking good prognosis in these cases is not reallyunderstandable anyway before the background of Pauwels’ insightin the adverse biomechanical effect of an increased inclination ofthe acetabulum. So, there is a lot of confusion about the role ofthe acetabulum in Legg-Calve-Perthes disease. This confusion canbe dissolved by the point of view that the acetabulum is a site ofpathology in its own right, which plays an innate part in theevolution of a Perthes hip.


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Significance: This study adds genuine new aspects to the under-standing of the pathogenesis of Legg-Calve-Perthes disease.

58

Hinge Abduction in Perthes’ disease: Pathomechanism

of Out-toeing and In-toeing

Author: In Ho Choi (Korea, Republic of)

Co-Authors: Won Joon Yoo (Korea, Republic of), Chin YoubChung (Korea,Republic of), Tae-JoonCho (Korea,Republic of),KiSeokLee (Korea,Republic of),DongYeonLee (Korea,Republic of)

Purpose: The purpose of this study was to investigate the rela-tionship between the femoral head deformity and the abnormalgait pattern in the transverse plane, i.e. out-toeing (n = 4) and in-toeing (n = 4).

Methods: Three-dimensional computed tomography (3D-CT)scans and three dimensional (3D)-gait analysis were performed in8 patients with late-presenting unilateral Perthes’ disease. Spatialfeatures, i.e. location, size and shape, of the ‘hump’ on the femoralhead were determined using 3D-CT. Gait parameters includedfoot progression angle, hip rotation, and pelvis rotation in thetransverse plane; hip flexion and extension in the sagittal plane;hip adduction and abduction in the coronal plane.

Results: In out-toeing patients, all hips were externally rotated inthe CT gantry as compared to the contralateral normal side. Andthe most protruded ‘hump’, when seen from above, faced theanterolateral aspect of hip joint, implying that the ‘hump’ waslocated relatively anteriorly. On the other hand, all hips wereinternally rotated in in-toeing patients, and the most protruded‘hump’ faced the anterolateral aspect of hip joint, implying thatthe hump was located at relatively laterally. Gait laboratory dataconfirmed abnormal foot progression angle, decreased hip flexionin all out-toeing patients and increased downward pelvic obliquityin all in-toeing patients.

Conclusions: Three-dimensional CT and instrumented gait analysiswere helpful to delineate the pathomechanism of abnormal gaitpatterns in the transverse plane in late-presenting Perthes’ diseasewith hinge abduction. Out-toeing and in-toeing gaits are apparentlycaused by compensatory rotation of proximal femur in an attemptto avoid impingement by placing the ‘hump’ to the relatively defi-cient anterolateral aspect of hip joint.

Significance: The results of this study support our opinion thathinge abduction is a complex manifestation of the hinge move-ment which occurs in the continuum between lateral impingementand anterior impingement.

59

Gait characteristics in perthes disease during the florid stage

Author: Bettina Westhoff (Germany)

Co-Authors: Andrea Petermann (Germany), Marcus Jager(Germany), Rudiger Krauspe (Germany)

Purpose: The final outcome of Perthes disease is dependant on thedeformity of the femoral head and the congruity of the hip joint.Parameters influencing the severity of head-involvement and thefinal outcome are poorly understood. Follow-up-evaluations areanalyzing only subjective results, clinical parameters and radio-logical changes. No studies are evaluating the functional impair-ments during gait.

Methods: 21 children (16 #, 5 $, average age 6,9 ys.) were included.Inclusion criteria were: 1. unilateral hip involvement in initial or

fragmentation stage 2. age > 6 ys. 3. no previous surgical treatmentat the hips 4. no other disorder leading to gait deviations. All childrenwere investigated clinically and radiographically. 3D-gait-analysiswas performed with a VICON 512 system. Spatiotemporal, kine-matic and kinetic parameters were evaluated and compared to agroup of normal children (n = 30, 14#, 16 $, average age 8,1 ys.). Amodified ‘‘hip flexor index’’ (HFI) according to Schwartz afterrepeating principal component analysis with the data of our normalpopulation was applied to our study group for quantifying hip flexorfunction during gait. The gait patterns in frontal plane were catego-rized according toWesthoff et al.. Statistical analysis was performedby the Wilcoxon-test, a p-value of less than 0,05 was considered toindicate statistical significance.

Results: Spatiotemporal parameters: Stance phase on the soundside was significantly prolonged, on the affected side single stancephase was shortened, the step length was reduced on both sides;gait velocity was not significantly altered. Kinematics: Majordeviations in sagittal plane kinematics were found at the pelvis(increased anterior tilt and ROM) and at the level of the hip(elevated minimum flexion, reduced ROM). In frontal plane only8 (38%) children showed a normal gait pattern, 42,8% showed atype 2 pattern (similar to Duchenne gait), 14,3% a type 1 pattern(Trendelenburg). Kinetics The hip abductor moment as aparameter of hip loading was significantly reduced during singlestance on the affected side (0.32 + 0.13 Nm/kg, control0.40 + 0.08 Nm/kg, p = 0.008). Power generation was reducedas well. The modified HFI was significantly increased(4.36 + 2.99, control 0.00 + 1.17, p < 0.001).

Conclusions: There are significant changes of the spatiotemporalparameters and of the gait pattern in the sagittal and frontalplane. These deviations are mainly part of an unloading mecha-nism. The changes at the pelvis can be interpreted as compensa-tion mechanisms of altered hip joint kinematics.

Significance: Further studies will show in which way these devia-tions will alter the final outcome in Perthes disease.

60

Gait Changes after Greater Trochanter Transfer in Patients

with Unilateral Legg-Perthes Disease

Author: Sun Young Joo (Korea, Republic of)

Co-Authors: Hui Wan Park (Korea, Republic of), Hyun WooKim (Korea, Republic of)

Purpose: To examine the results of distal and lateral transfer of thegreater trochanter in patients with unilateral Legg-Perthes diseasecomplicated by relative overgrowth of the greater trochanter.

Methods: 9 hips in 9 patients were included in the study. Clinical,radiological examinations and three dimensional gait analysiswere performed to examine the postoperative gait changes.

Results: Fatigue pain on walking and limping gait were improvedand Trendelenberg sign was disappeared in all cases. Radiologicparameters such as articulotrochanteric distance were also im-proved. In coronal plane, pelvic obliquity was decreased postop-eratively, and there was no change in the hip abduction angle.However, the abduction moment decreased in affected hips afterthe operation especially in patients with decreased center-edgeangle and limb length discrepancy more than 1 cm preoperativelyand patients classified as Stulberg III or IV at the latest follow up.

Conclusions: Distal and lateral transfer of greater trochanter im-proved limping gait and fatigue pain in patients with unilateralLegg-Perthes disease complicated by relative overgrowth of thegreater trochanter. However, the abductor moment was not in-creased in patients with dysplastic and/or subluxated hip and limblength discrepancy.


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Significance: Distal and lateral transfer of greater trochanter im-proves clinical and radiological parameters, however the abductormoment does not increase in patients with dysplastic and/orsubluxated hip and limb length discrepancy more than 1 cm.

61

The outcome of patients with hinge abduction in severe Perthes’

disease treated by shelf acetabuloplasty

Author: Robert Freeman (United Kingdom)

Co-Authors: Yasser Kandil (Egypt), Andrew Wainwright (UnitedKingdom), Tim Theologis (United Kingdom), Michael Benson(United Kingdom)

Purpose: To assess the value of shelf acetabuloplasty in childrenwith hinge abduction in severe Perthes’ disease.

Methods: Twenty seven consecutive patients with severe Perthes’and arthrographically proven hinge abduction treated with shelfacetabuloplasty were reviewed radiographically and clinically. Theseverity of the disease was assessed according to Catterall’s,Salter-Thompson’s, and Herring’s lateral pillar classification.Radiological measurements included head size, sphericity, andhead coverage. Measurements were made at presentation, pre-operatively and at serial follow up, with final grading by theStulberg classification.

Results: The mean post-operative follow-up was 57 months (26–125 months). No patients were lost to follow up. All patientswere Catterall grade III or IV, lateral pillar grade B or C andhad arthrographically proven hinge abduction at the time ofoperation. At final follow-up 15 patients (56%) were gradedStulberg 1 or 2; nine hips Stulberg 3; two hips Stulberg 4 andone hip Stulberg 5. The percentage acetabular cover increasedfrom 82% preoperatively to 98% postoperatively. A strikingfinding was the swift relief in pain together with the improvedrange of movement early postoperatively. At final follow uptwenty three patients were pain free, but four patients felt mildoccasional pain.

Conclusions: For children with severe Perthes’ disease who dem-onstrate progressive subluxation with hinge abduction the ante-rolateral shelf acetabulaplasty may improve outcome. Theprocedure is relatively simple, pain relief follows swiftly and atmean follow-up of 57 months the outcomes appear better than inhistorical reports.

Significance: The role of surgery in the management of childrenwith severe Perthes’ and uncontainable hips with hinge abductionhas been questioned. This paper supports the use of shelf ace-tabuloplasty in this group of patients.

62

Treatment of Severe Late Onset Perthes’ Disease with Soft

Tissue Release and Articulated Hip Distraction

Author: Eitan Natan Segev (Israel)

Co-Authors: Michael Fishkin (Israel), Moshe Yaniv (Israel),Yoram Hemo (Israel), Eli Ezra (Israel), Shlomo Wientroub(Israel)

Purpose: To evaluate the clinical and radiographic results of softtissue release and hip joint distraction for severe late onset Per-thes’ disease.

Methods: Nineteen patients, 10 of whom at skeletal maturity, whohad undergone soft tissue release and articulated hip distractionfor late onset Perthes’ disease were included in the study.

Distraction was discontinued when Shenton line was corrected (4–5 months). All patients completed the Oxford hip questionnairefor pain and function. In patients at skeletal maturity, we assessedthe Harris hip score for pain, function, daily activities, as well asthe hip range of motion, and limb length discrepancy.

Results: Surgery was performed at an average age of 12.5 years(range 9.4–16.0). At the last follow-up, the average pain score on ananalog scale dropped from a preoperative 7.0 to 1.6 and Shentonline breakage improved from 7.6 mm to 2.1 mm. An improved hiprange of motion was found in all patients. Epiphyseal index im-proved from 0.69 to 0.8. In the skeletally mature group, the meanage at surgery was 12.3 years (range 9.4–15.1 years) and the meanduration of follow-up was 5.7 years (range 4.3–7.8). The mean ageat last follow up was 18.0 years (range 15.2–22.8). The averageHarris hip score was 86.7/100 (range 48.5–96). Average Oxford hipscore was 17.2/60 (range 12–31). Some limitation of hip abductionand internal rotation compared to the normal side was present.Three patients had short leg limp and one had positive Trendelen-burg sign. Three patients had no limb length discrepancy, while 4had 1 cm. Two patients with 3.5 cm of shortening and one with4 cm of shortening used shoe lifts. X-rays of the hip joint at lastfollow up showed that most femoral heads were coxa magna and ofspherical shape with good congruency to the acetabulum.

Conclusions: Soft tissue release and hip joint distraction for severelate onset Perthes’ disease resulted in clinical and radiographicimprovement for the hip joint. The positive effect was continuousand became significant at skeletal maturity.

Significance: The above techniques can be regarded as a salvageprocedure for this severe hip pathology, without eliminatingfuture interventions such as osteotomies and total jointreplacement.

63

Exact indications of femoral varus osteotomies for severely

involved Perthes’ disease

Author: Makoto Kamegaya (Japan)

Co-Authors: Takashi Saisu (Japan), Junnichi Nakamura (Japan),Hideshige Moriya (Japan), Tomonori Kenmoku (Japan), ChikatoMannoji (Japan)

Purpose: To confirm the efficacy of our surgical strategy for se-verely involved Perthes’ disease. Based on our analysis of thesurgical outcomes, we tried to identify the exact indications for afemoral varus osteotomy (FVO).

Methods: The number of patients who underwent FVOs due totheir severity was 38 (39 hips) out of a total 113 Perthes’ pa-tients from 1990 to 1999. The operation rate was 33.6%, whichcoincides with the generally accepted rate of poor outcomestreated conservatively in Perthes’ disease. Thirty-three weremale and 5 were female. Thirty-one patients were unilaterallyaffected and 7 were bilaterally affected. One of the 7 patientsunderwent FVOs in both sides. The remaining 6 had FVO inone side. The average age at operation and followup were 8.4and 17.0 years respectively. Our surgical indication was decidedon the following conditions before the healing stage: the age of8 years or more at the onset with Herring’s class B (Catterall’sIII) with more than two risk signs and/or persistent limitationof the range of hip motion, or all ages with Herring’s C(Catterall’s IV). Retrospectively, pre-operative arthrography wasinvestigated to find exact indicators for obtaining good surgicaloutcome of FVOs. All arthrography was performed undergeneral anesthesia. The Caput Index, Subluxation Indices inboth neutral and maximum abduction defined as the ratio of


123

tear drop distance to acetabular depth, and Epiphyseal Slip-inIndex (ESI) defined as the ratio of the distance from the ace-tabular rim to the tip of the epiphysis slipped into the ace-tabulum in maximum abduction to acetabular depth weremeasured in the arthrography. Final outcome was radiologicallyevaluated with the modified Stulberg’s classification, Slope ofAcetabular Roof (SAR) and Acetabular Head Index (AHI).

Results: An acceptable result was shown in 23 hips (59%).According to the stepwise multiple regression analysis, the ESIwas the most reliable arthrographic indicator for acceptableoutcomes of FVOs (p < 0.0001). Based on this fact, 20% ormore ESI was at least required to have better sphericity of thefemoral head, better acetabular cover and better acetabularconfiguration.

Conclusions: Our surgical outcomes were not satisfactory inresolving 41% of the hips. However, this study has clarified exactindications for obtaining good surgical outcomes of FVOs, basedon the findings of pre-operative arthrography.

Significance: The surgical indication for Perthes’ disease whichhad been given poor prognosis has been shown in many worksof literature. However, it has not been indicated which surgicalmethod would be the most effective for which patient. There-fore, we propose certain indications for FVOs, while, at thesame time, we suggest the necessity of a new procedure forpatients whose outcomes would be predicted as unacceptableeven with FVOs.

Session 10a: Spine I

64

The effect of early anterior spinal fusion on spinal canal size

in an immature porcine model

Author: G Yilmaz (Turkey)

Co-Authors: M Pekmezc_ı (Turkey), K Daglioglu (Turkey),A Alanay (Turkey), ER Acaroglu (Turkey), CF Oner, M Yazici(Turkey)

Purpose: Neurocentral cartilage (NCC) is located at the posterior2/3 of vertebrae and responsible for the growth of the pedicles andposterior vertebral body. NCC moves posteriorly during thegrowth of spinal column. Injury to the NCC or disruption ofposterior movement of NCC can result in spinal stenosis. The aimof this study is to evaluate the effect of anterior spinal instru-mentation and fusion on the development of vertebral body in aporcine model.

Methods: Twelve 8 week-old domestic pigs had CT scans preop-eratively and underwent anterior circumferential discectomy ofthe L3-L4 and L4-L5 discs . Anterior spinal instrumentation wasperformed between L3 and L5 (L4 skipped). When they reachskeletal maturity, their vertebrae were evaluated with CT scan forthe presence of anterior fusion and the size of the vertebral canal.The canal area was calculated by using the sections passingthrough pedicle level. The average area of vertebral segmentsadjacent to the proximal and distal instrumented segments wasused as control level area (AC), average area of L3 and L5 wasused as the area change in the instrumented levels (AI), and thearea of L4 was used as the area change at the arthrodesis level(AA). The percent increases in the canal area, as well as total canalarea were compared among groups.

Results: One subject was lost during the immediate postoperativeperiod. All subjects had documented anterior fusion. There wasno difference in the average canal diameters of the three groupsin the preoperative period (AA: 0.70 cm2; AI: 0.70 cm2 and

AC: 0.68 cm2) (p > 0.05). At the end of 6 months the averagecanal diameter was significantly lower in the arthrodesis andinstrumentation groups when compared to the control group (AA:1.20 cm2, AI:1.24 cm2 vs AC:1.41 cm2) (p < 0.001). There wasno difference between the average canal diameters of thearthrodesis and instrumentation groups (AA: 1.20 cm2 vs AI:1.24 cm2) (p > 0.05). The average percent increase in the canalarea in the arthrodesis segment and the instrumented segmentswere significantly lower than the control levels (AA: 72.6%, AI:77.1% vs AC: 110.1%) (p < 0.001). There was no difference inthe percent increase in the canal area between the arthodesissegment and instrumented segment (AA: 72.6% vs AI: 77.1%)(p > 0.05).

Conclusions: This study demonstrated that anterior spinalarthrodesis or instrumentation in the immature spine may result iniatrogenic spinal stenosis. The growth of the neurocentral carti-lage might be either disturbed by the tethering effect of the ar-thodesis or secondary to direct destruction by the anterior screws.Destruction of NCC or blocking of posterior movement of NCCmight result in iatrogenic spinal stenosis.

Significance: Early anterior instrumentation and fusion in childrenmay cause iatrogenic spinal stenosis leter in life.

65

Posterior or dorsal arthrodesis of the thoracic spine

in pre pubertal rabbits and effects on thoracic cavity growth

Author: Federico Canavese (Italy)

Co-Authors: Alain Dimeglio (France), Fabiano Cavalli (Italy),Francois Bonnel (France), Donatella Volpatti (Italy), J-P Daures(France), Marco Stebel (Italy), Eugenio Pittioni (Italy), Bartolo-meo Canavese (Italy)

Purpose: Can a posterior (or dorsal) arthrodesis influence thethoracic growth pattern,the length of the sternum and the thoraciccavity volume in pre pubertal rabbits?

Methods: 12 pre pubertal female W NZ rabbits (r.) were subjectedto surgery for posterior arthrodesis of the upper thoracic spi-ne.Two ‘‘C’’-shaped titanium bars,measuring 10 cm inlength,were placed with metal wire beside the spinous processes ofthe first 6 thoracic vertebrae that were immobilized.Three CTscans were performed under general anesthesia 10(T1),55(T2) and139(T3) days after surgery.All the CT scans were analyzed by anexpert in radiology to avoid inter-observer errors.The dorsal-ventral (DV) and lateral-lateral (LL) thoracic diameters at thefused levels,the length of the sternum (SL) as well as the lungvolumes (LV) were measured by means of the Myran Pro� pro-gram.The dorsal and ventral length and diam. of all thoracicvertebral bodies (D1-D12) were measured with the same computerprogram.

Results: 3 groups (G.) of r. were identified - G.1: 6 r.,complete fu-sion;G.2: 3 r.,incomplete fusion;G.3: 3 sham-operated r. as controlgroup.The average DV/LL thoracic diam. ratio at fused levels was0.953 atT1, 0.931 atT2 and 0.894 atT3 inG.1, and 1.026 atT1, 1.031at T2 and 1.048 at T3 inG.3 (p < 0.005).The average growth of thesternum between T1 and T3 in G.1 was 19.75 mm (SL atT1:75.37 mm–SL at T3:95.12 mm) and 26.70 mm in G.3 (SL atT1:81.87 mm–SL at T3:107.57 mm) (p < 0.005).The LV growless in G.1 compared to G.3:+1.83 cm3 vs +8.33 cm3 onaverage.D1-D6 length was smaller in G.1 compared to G.3(48.69 mm vs. 54.40 mm) whereas no differences were observedbetween the two groups in the D7-D12 segment (79.81 mm and81.30 mm respectively).

Conclusions: Posterior arthrodesis in prepubertal rabbits changesthoracic growth patterns.In operated rabbits the DV thoracic


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diam. grows more slowly than the LL thoracic diam. and leads toan asymmetrical growth of the thorax which becomes almostelliptical and thinner.The sternum and the lung volume growless.These changes reduce sternum growth and lung develop-ment.The crankshaft phenomenon is evident at the fused vertebrallevels where there is a reduction of the thoracic kyphosis due toanterior vertebral growth.Posterior surgery directly influences thegrowth pattern of the ribs which are connected posteriorly to thefused vertebral bodies (D2-D6) and to the sternum in front(sternal ribs).However,lower ribs,which are connected neither tothe sternum nor to fused vertebral bodies (non-sternal ribs), alsogrow less under the influence of the reduced growth of the uppersternal ribs.The thorax as a whole grows,and a substantial mod-ification of the upper part has effect on the lower part.Posteriorsurgery can directly influence the growth of sternal ribs andindirectly of non-sternal ribs,but has no influence on the growth ofunderlying vertebral bodies.

Significance: experimental study.

Basic Science

66

Intervertebral Disc Adaptation to Wedging Deformation

in Scoliosis

Author: David D Aronsson (United States)

Co-Authors: Ian Stokes (United States), Katherine Clark (UnitedStates), Maria Roemhildt (United States)

Purpose: The scoliosis deformity includes vertebral and discwedging. Although wedging of vertebrae is reported to be causedby asymmetric growth, little is known about the discs, and whe-ther disc wedging is caused by mechanical influences on growthand/or remodeling.

Methods: Percutaneous pins inserted into vertebrae were attachedto an Ilizarov-type external fixator that applied compression and15 degrees angulation to each of two adjacent immature ratcaudal intervetebral discs for 5 weeks (4 animals), or 10 weeks (4animals). Micro-CT scans were performed each week to docu-ment the in vivo wedging of the discs. After euthanasia, thevertebral segments were excised and the disc flexibility wasmeasured over a range of lateral bending. The angle of maxi-mum flexibility was recorded. The discs were then fixed in situ,with the external fixator in place, and sectioned for polarizedlight microscopy.

Results: Disc wedging averaged 15 degrees initially, 20 degreesafter 5 weeks, and then reduced to 10 degrees after 10 weeks. Thedecreased disc wedging after 5 weeks was interpreted as beingsecondary to steadily increasing vertebral wedging. The lateralbending flexibility showed a distinct maximum at an average of1.1 degrees from the in vivo position in the 5-week animals,indicating structural remodeling of the discs almost to the de-formed geometry. The 10-week animals had a maximum flexibilityof 1.4 degrees from the in vivo position. There was no significantdifference between the 5 and 10-week animals. The collagen crimpangles were not significantly different between the convex andconcave sides, indicating that remodeling had occurred.

Conclusions: A mechanically induced scoliosis deformity in askeletally immature rat model caused intervertebral disc wedgingthat demonstrated remodeling within 5 weeks.

Significance: This indicates that this animal model is suitable forstudying adaptive wedging changes in human scoliosis.

67

Lung Function Asymmetry in children with congenital

and infantile scoliosis

Author: Kit M Song (United States)

Co-Authors: Greg Redding (United States), Steven Inscore(United States), Eric Effman (United States), Robert Campbell(United States)

Purpose: We evaluated right and left lung function in chiildrenwith progressive infantile scoliosis. We aimed to see if progressiveincreases in Cobb angle would correlate with increasing lungfunction asymmetry.

Methods: 39 children ages 20–186 months and diagnosed withinfantile or congenital scoliosis without chest wall abnormalityand being considered for VEPTR placement had preoperative V/Q or Q scans with Tc99M-radiolabeled albumin microaggregatesand Tc99M-labeled DTPA, and spine radiographs. Normal dis-tribution is 55% right and 45% left. Asymmetry in lung functionwas correlated with Cobb angles using non-parametric Pearsoncorrelation coefficient. P < 0.05 was considered significant.

Results: Two-thirds of the 25 children with congenital scoliosis hadfused ribs; 13 children had infantile scoliosis. Cobb angles rangedfrom30–112 degrees in the group (median value = 71 degrees) withthe concave lung being the left lung in 61% of cases. Lung functionrelations between the right and left lung were abnormal (>+/–5%from the normal 55%right/45%left) in 21 (54%) of patients. Right-left contributions to lung perfusion ranged from 86%R-/14% L to26%R-74%L among the 39 children. Lung function in the concavelung was reduced below the normal proportion in 20 children(51%), and increased above predicted proportion of function in 17children (44%). Lung function asymmetry, measured as the devia-tion from the normal contributions of the right and left lungs, didnot correlate with Cobb angle values. (r = .12, p > 1.0) Ventila-tion asymmetry and perfusion asymmetry were concordant andcorrelated closely (r = .79, p < .001).

Conclusions: Asymmetric ventilation and perfusion between theright and left lungs occurs in more than half of children withsevere congenital and infantile thoracic scoliosis. However, theseverity of lung function asymmetry does not relate to Cobb anglemeasurements.

Significance: Asymmetry in lung function is an important physi-ologic impairment. It is influenced by deformity of the chest wallin multiple dimensions, and cannot be ascertained by chestradiographs alone.

68

The effect of early thoracic fusion on pulmonary function

in non-neuromuscular scoliosis

Author: Kiril Mladenov (Germany)

Co-Authors: Lori Karol (United States), Charles Johnston(United States)

Purpose: To determine the effect of early thoracic fusion on pul-monary function at intermediate follow-up.

Methods: Patients who had thoracic spine fusions before age 8 yrswith minimum 5 yrs follow-up underwent pulmonary functiontesting (PFT). Patients with neuro-muscular disease, skeletaldysplasias, or preexisting pulmonary disease were excluded, whilethose with rib malformations were included.

Results: No patient died of pulmonary insufficiency. Twenty-eightpatients reported for PFT. Twenty of them had congenital scoli-


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osis, three had neurofibromatosis, three idiopathic scoliosis, onesyndromic scoliosis and one congenital kyphosis. Twenty six pa-tients underwent anterior and posterior surgery as their primaryinitial surgery, one had isolated posterior surgery and one isolatedanterior surgery. Eleven of the 28 patients underwent revisionspinal surgery. Age at surgery averaged 3.3 yrs (range 4 mo to8.4 yrs), age at follow up averaged 14.6 yrs (range 7.3 to 22.8 yrs),the lenght of follow-up averaged 11.2 yrs (range 6.4 to 20.5 yrs).

PFT results: The forced vital capacity (FVC) averaged 57.8%(range 27% to 99%)of age matched normal values. FVC was lessthan 50% of normal in 12 of 28 patients implying significant lungdisease in 42.9% of the study group. The average FEV 1 was54.7% of age matched normal values (range 23% to 91 %). FEV 1was less than 50% in 12 of the 28 patients. Obstructive lung dis-ease (FVC /FEV 1 less than 85%) was noted in 35.7% of thepatients. Age at fusion and PFT were not significantly re-lated(r = 0.28, p = 0.15). The % FVC did strongly correlatewith the per cent of the thoracic spine fused at the index procedure(r = –0.46, p = 0.01). There was a highly statistically significantcorrelation between the proximal level of the thoracic spine fusedand %FVC (r = 0.62, p = 0.0004). Proximal fusions deterio-rated PFT’s most, since 8 from 12 patients (66.7%)with fusionbeginning at T1 or T2 had FVC less than 50%, while only 4 out of16 (25%) with fusions beginning below T3 had FVC less than50%. None of the 7 patients with fusions below T6 had FVC lessthan 50%. There was no correlation between revision surgery and% PFT (p = 0.15).

Conclusions: Significant restrictive lung disease (FVC and FEV 1less than 50%) was present in 43 % of the patients. Poor pul-monary function correlated with extensive thoracic fusion andwith fusions beginning proximally at T1 or T2. Obstructive lungdisease was diagnosedin 35.7% of the patients. Young childrenwho require extensive fusions of the thoracic spine are most at riskfor thoracic insufficiency syndrome, and alternative treatmentsshould be considered in this group of patients.

Significance: Retrospective study.

69

Correlation of plain radiographic measurements

and CT lung volumes in early onset scoliosis

Author: Charles E Johnston (United States)

Co-Authors: Salah Fallatah (Canada)

Purpose: To correlate chest, spine and pelvic dimensions onradiographs with CT lung volumes in patients with early onsetscoliosis (EOS).

Methods: Spine radiographs and chest CT of 21 patients with EOSwere reviewed. Age range: 9 mo - 8 + 9 yr at time of CT, with nopatient having had surgery. T1- T12 length, coronal chest width atT6 and pelvic width were measured from the PA radiograph.Sagittal chest depth T6- sternum was measured on the lateral.These measurements were correlated with CT lung volumes of theright, left and both lungs.

Results: There were 7 congenital, 4 idiopathic, 3 congenital MD,and 7 syndromic/miscellaneous deformities. Main curve Cobbangles averaged 53o (range 24–108). Coronal chest width at T6(13.4 cm, range 10.2–18.4) had a significant correlation(r = 0.72,p = 0.0008) with each of the three CT lung volumes. Pelvic width(mean 7.4 cm, range 5.5–9.1) had a modest correlation (r = 0.5,p = 0.03) with the three CT volumes. T1-12 length and T6-ster-num sagittal depth did not correlate with CT volumes. Multiplelinear regression indicated that chest width at T6 and tolesser extent pelvic width were predictors of CT lung volumemeasurements.

Conclusions: T6 chest width and to a lesser extent pelvic width arepredictors of CT lung volumes (right, left and combined) and maybe used to assess lung development in EOS patients at risk forTIS, possibly providing an objective indication for commencingprophylactic treatment.

Significance: Patients with EOS are at risk to develop chest walldeformity with pulmonary hypoplasia. Current treatment strategies(expansion thoracoplasty, growing rods, etc) focus on the preven-tion of thoracic insufficiency syndrome (TIS). However, objectivecriteria defining TIS and indications for treatment are incomplete.A method to predict lung volumes and by implication risk for TISfrom standard chest and pelvic measurements would be invaluableto establish objective indications for prophylactic treatment. Thisstudy confirms the value of the pelvic width data from Emans et al(SRS 2004).

70

A Retrospective Cohort Study of Pulmonary Function,

Radiographic Measures and Quality of Life in Children with

Congenital Scoliosis: An Evaluation of Patient Outcomes after

Traditional Spine Surgery.

Author: Michael Guy Vitale (United States)

Co-Authors: Hiroko Matsumoto (United States), Michael Bye(United States), Joshua Hyman (United States), Jaime Gomez(United States), Whitney Booker (United States), David Roye(United States)

Purpose: Children with congenital scoliosis are at an increased riskfor severe progression of their spinal curvature, which will even-tually impact their pulmonary function. Recently, new surgicaloptions have become available to treat these conditions byexpansion of the thoracic cavity without early fusion. It is impor-tant to evaluate the outcomes of children who were treated withtraditional methods before any comparative studies can be con-ducted. The purpose of this study is to evaluate pulmonary function(PFT) and quality of life (QOL) of children who were treated withgrowing rods and/or fusion for progressive congenital scoliosis andto compare them to healthy children. The relationships betweenradiographic measures, PFT and QOL will also be examined.

Methods: Twenty seven patients (13.7 ± 4.9 years old) with aprimary diagnosis of congenital scoliosis who were treated withgrowing rod/fusion and subsequent fusion were evaluated usingradiographs, (PFT) and QOL surveys using Child Health Ques-tionnaire Parent Form (CHQ). They were, on average, 6.8 yearspost definitive fusion. Average age at initial surgery was 6.7 years.

Results: Forced vital capacity (FVC) (p < 0.001), forced expira-tory volume in one second (FEV1) (p < 0.0001), total lungcapacity (p = 0.001), and vital capacity (p < 0.001) were signifi-cantly lower than those in healthy children. The CHQ scores in ourstudy patients were significantly lower than healthy children inphysical function (p = 0.001), general health (p = 0.001), andphysical summary (p < 0.001) and significantly higher in bodilypain (p < 0.001) and impact on parent time (p = 0.036). Patientswith larger thoracic curves had lower FVC (r = –0.467, p = 0.04)and FEV1 (r = –0.466, p = 0.04). Patients with larger cervico-thoracic curves were likely to present lower FEV1 (r = –0.435,p = 0.03). Patients with larger kyphotic angels had lower selfesteem (r = –0.462, p = 0.02) and patients with larger thoracol-umbar curves had higher impact on parental time(r =–0.511, p = 0.01). Patients who had lower FEV1 obtainedhigher scores on parental impact on time (r = –0.408, p = 0.04).

Conclusions: Compared with healthy peers, patients with con-genital scoliosis treated with a growing rod technique and/or


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subsequent fusion have significantly worse pulmonary functionand quality of life scores when assessed at an average of 6.8 yearsfollowing initial surgery. Children with larger curves present lowerPFT and CHQ results and show higher burden of care.

Significance: PFT scores were significantly lower than those inhealthy children. Quality of life physical scores are significantlylower but psychological scores are similar to those found inhealthy peers. Children with larger curves present lower PFT andCHQ results, they also show higher burden of care.

71

Surgical Treatment of High-Grade Spondylolisthesis

in Children and Adolescents- Results of One-Stage Posterior

Surgical Reduction

Author: Monica Elena Ursei (France)

Co-Authors: Jerome Sales de Gauzy (France), Aziz Abid(France), Jorge Knorr (France), Jean-Philippe Cahuzac (France)

Purpose: The main purpose of this study was to analyze the resultsof this reduction technique in patients with high-grade spondyl-olisthesis, presenting sagittal spinopelvic imbalance, gait abnor-malities and neurological signs.

Methods: 15 patients with high-grade spondylolisthesis (Meyer-ding III, IV and spondyloptosis) were retrospectively evaluatedwith an average follow-up of 52 months(range, 25–129). Mean ageat surgery was 12 years (range, 9 to 16). Indication for surgeryconsisted in low-back pain, radicular pain and progression of theslippage. Surgical technique consisted in posterior decompression,reduction by pedicle instrumentation and circumferential fusionby a single-stage posterior approach. During surgery evokedpotentials were routinely used. Postoperative all patients wereimmobilized in a lumbar cast prolonged over one thigh for3 months, followed by a lumbar brace for another 3 months.Clinical and radiographic evaluation were performed.

Results: Clinical evaluation showed complete pain relief and noactivity limitation in 14 patients. One patient accused intermittentpain. Radiographic analysis: L5–S1 slippage averaged 71% pre-operatively (52–100) and 35% postoperatively (8–95). Slip anglemeasured preoperatively averaged –14 degrees( range, –30 to –5).Postoperatively it had a mean positive value of 3 degrees (range,–30 to +20). In 14 patients the slip angle improved after surgeryand in one it remained the same. Pelvic incidence: meanpreoperative value of 85 degrees (65–100) and 74 postoperatively( 50–92). We report 9 postoperative complications: one woundinfection, 6 cases of broken or pullout screws, 2 cases of pro-gression of the slippage. No neurological deficit was noted.

Conclusions: Surgical treatment of high-grade spondylolisthesisusing this one-stage posterior reduction technique provides goodclinical and radiographic results. The major indication of thisprocedure is high-grade spondylolisthesis, with trunk imbalanceand gait abnormalities.

Significance: Reduction of spondylolisthesis using pedicle screwsistem represents a technically challenging method, that requiresspinal surgical experience and exposes to neurological risks, likeother reduction techniques. It provides sufficient spinal stabilityand restores spinopelvic alignment.

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Single Stage Posterior Vertebral Resection Osteotomy

for Correction of Paediatric Spinal Deformities

Author: Nanjundappa Somasekhar Harshavardhana (UnitedKingdom)

Co-Authors: Mihir Bapat (India), Vinod Laheri (India), SatyajitMarawar (India), Prashanth Deshmane (India), Harish Patni(India), Siddarth Badve (India)

Purpose: To define the role and analyse the results of Single StagePosterior Vertebral Resection Osteotomy in the management ofPediatric Kyphotic / Kypho-scoliotic deformities.

Methods: 42 children (35 primary and 7 revision cases) aged 5to 16 yrs with severe post-tuberculous spinal deformities oper-ated between 1999 to 2004 formed the study group. The ky-phosis (Ko) angle ranged from 66o to 128o (av 76o). Thedeformities were grouped as cervico-dorsal (2), upper dorsal (5),dorsal (17) and dorso-lumbar (18). 11 patients had pre-opera-tive neurological deficits [2 ambulatory and 9 non-ambulatory].Positive sagittal imbalance ranged form + 7 to + 32 mm. Thenumber of vertebrae at the apex varied from 2 to 6 (av 2.7).The apex was grouped as soft (wet) in 12 and rigid (dry) in 30based on the nature of tuberculous lesion on MRI. 9 had sig-nificant coronal plane deformity (i.e Scoliosis) ranging from 97oto 134o with coronal imbalance of 10 to 55 mm. 4 patients hadAnaconda Spine (i.e the apex of kyphosis being cranial to themost distal vertebra in the compensatory curve). In this smallgroup of patients, a pre-operative traction was employed toasses the correction / flexibility of the curve. In 7 patients, aprevious surgery had failed to achieve desired correction / fu-sion.

Results: A single stage posterior vertebral resection osteotomy wasperformed in all patients. The average follow-up was 2 years. Theaverage correction achieved was 64.77% with an averageimprovement in sagittal balance of 15 mm. 1 had post-operativetransient neurological deficit. All patients with neurodeficit at-tained independent ambulation. There were 4 deep and 2 super-ficial infections. Implant failure and loss of kyphosis correctionoccurred in 4 cases warranting a revision surgery of which 1 haddural injury during the revision procedure. 1 patient was detectedto have multi-drug resistant tuberculosis (MDR-TB). 1 died dueto pulmonary complications 2 mo after the surgery and 2 othersrequired ventilatory support for post-op pneumonia. The averagecorrection achieved in revision procedure was 60.86% as com-pared to primary procedures. In kyphoscoliotic deformity, ky-photic correction was 57.88% while scoliotic correction averaged42.10%. 1 patient required 2 revision procedures to achieve fu-sion.

Conclusions: A prospective analysis of correction of severe ky-phosis / kypho-scoliosis in children is sparse in literature. A singlestage posterior vertebral resection osteotomy provides excellentcorrectionwith column shortening. Application of this technique tothe paediatric spine is challenging & difficult owing to weak bonyelements that impedes application of corrective forces to the spine.

Significance: The single stage posterior vertebral resection oste-otomy is a safe & excellent mode of restoring the sagittal / coronalbalance in axial immature skeleton but has a steep learning curve.

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Spondylo-costal dysostosis treated by costal distraction

without thoracostomy.

Author: Yan Alfred Lefevre (France)

Co-Authors: Franck Launay (France), Elke Viehweger (France),Jean Luc Jouve (France), Gerard Bollini (France)

Purpose: The spondylo-costal dysplasia (SCD) consists of unilat-eral and asymmetric costal and spinal malformations combiningcostal anomalies, with different vertebral anomalies leading to


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spinal curvature. We studied a series of patients who presentedwith SCD with spinal curvature without major rib fusions butmajor rib deficiency, proposing an expandable device to maintaindistraction on the concave side of the curve in order to limit itsprogression. The purpose of this preliminary study was to inves-tigate the efficiency and complications of the treatment of SCDwith partial rib-cage aplasia (PRCA) by mainly using rib dis-traction.

Methods: We studied six cases of patients SCD with PRCAwithout major extended rib fusion treated by rib distraction alone.Surgery was indicated after an increase of the curvature greaterthan seven degrees in six months. The side of distraction wasdecided according to the limits of the thoracic curvature and theposition of the aplasia in relation to the side of the concavity.Clinical examination and radiographs were performed every sixmonths according to the case evolution. Surgery to increase dis-traction was performed according to the deformity progression ifthe Cobb angle increased more than 7 degrees.

Results: Six patients were treated, four girls and two boys.Mean age at the initial operation was 15,3 months (1 month to31 months). None of them presented with a neurologic defi-ciency. Mean follow up was 36,2 months (24 to 49 months).The mean number of surgeries (including initial placement ofthe device) and its expansion to increase the distraction wasthree (one to six). The mean Cobb angle of thoracic curvesbefore surgery was 33,3�, and mean Cobb angle of thoraciccurves at the last follow up was 33,8�. In 18 operations, therewere three complications, two fractures of an upper rib, and aninfection of the operative site.

Conclusions: The distraction concave device was effective in so faras there was no progression greater than 3,5� per year after theonset of treatment with new distraction necessitated by any curveprogression. Our complication rate was similar to others methodsusing costal or vertebral distraction. We feel that those cases withmainly rib aplasia with curve progression are indications for ribdistraction without thoracostomy. On the other hand, we agreethat SCD with significant rib fusions need opening wedge thora-costomy to allow a rib distraction. In conclusion, preliminaryresults of rib distraction treatment to control scoliosis associatedwith a form of spondylo-costal dysostosis in which rib aplasia is apredominant feature, demonstrated satisfactory outcomes with anacceptable complication rate. The use of this method for the SCDform with predominant aplastic ribs must be differentiated fromcases of SCD with spinal anomalies and major rib fusions whichrequire thoracostomy as well.

Significance: Retrospective study.

Session 11a: Spine II

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Surgical treatment of scoliosis associated

with myelomeningocele

Author: Stella Gilberto (Italy)

Co-Authors:Marco Carbone (Italy), MariabeatriceMichelis (Italy)

Purpose: A longer life expectancy for patients with myelomenin-gocele increases a number of patients with progressive spinaldeformities. Deformity may present at 2 to 3 years of age,becoming severe before 10 years of age. A main factor that needsto be considered in the surgical treatment of these patients is thehigh infection rate and pseudoarthrosis.

Methods: Twenty-seven patient(13 male, 14 female; mean age13,3 years) with severe(average 100�, angle range 80�–160� Cobb)

thoraco-lumbar and lumbar scoliosis due to myelomeningocelewere treated by spinal fusion.1 by posterior arthrodesis withinstrumentation, 1 by anterior arthrodesis with instrumentation,25 by combined anterior and posterior fusion extended to thesacrum and with double instrumentation. Number of surgicalprocedures: 52. The anterior fusion and instrumentation should bedone first. The most utilized instrumentation in posterior ap-proach was CDH. In anterior approach the instrumentation wasmainly TSRH and Colorado2. For pelvic fixation we preferDunn-McCarthy technique. This kind of pelvic fixation with newvertebral implant allows a deep contact of the instrumentation tothe spine. This allows suitable muscle-skin coverage and allows avery good laminar decortication of the lumbo-sacral junction; itefficently opposes the torsional and bending forces of the trunk.An excellent alternative is ileo-sacral screw of Dubousset.

Results: Mean period of follow-up was three years and eightmonths. The final average curve correction was 60%. Correctionof pelvis obliquity was 65% at follow-up. Complications: 5 infec-tion( 3 superficial, 2 deep infection) after posterior instrumenta-tion; 1 stress ulcer; 1 sore due to sacral rod requiring partial rodremoval; 1 lumbo-sacral pseudoarthrosis; 1 instrumentationloosening in posterior approach; 1 screw pull-out in anteriorapproach (no operative reinsertion was necessary).

Conclusions: Only thoracolumbar and lumbar curves under70�–80� with normal spine in sagittal plane and without ormoderate pelvic obliquity need only anterior fusion and instru-mentation with standard thoracolumbar approach. Almost everypatients requiring surgery needs both anterior and posterior fu-sion and instrumentation. In these children the combined anteriorand posterior instrumentation and fusion gave the best correctionof the deformity and reduced the rate of pseudoarthrosis. Infec-tion after posterior approach was the most serious problem.

Significance: A longer life expectancy for patients with myelome-ningocele increases a number of patients with progressive spinaldeformities that needs surgical treatement.

75

The surgical treatment of scoliosis in Duchenne Muscular

Dystrophy

Author: Francesco Turturro (Italy)

Co-Authors: Antonello Montanaro (Italy), Luca Labianca (Italy),Marco Spoletini (Italy), Fortunato Mangiola (Italy), FedericoSciarra (Italy), Sonia Messina (Italy), Andrea Ferretti (Italy)

Purpose: Scoliosis is observed in approximately 90% of patientswith Duchenne Muscular Dystrophy (DMD), after stop walking.The main consequences of the progression of scoliosis are: 1) theimpossibility of remaining in a comfortable sitting position; 2)back pain; 3) pressure sores; 4) difficulties in nursing care; 5)worsening of the respiratory deficiency. Several data indicate thatconservative treatment with braces or spinal supports is unable tocontrol the progression of the scoliosis, while surgical treatmentappears to be the only effective way of treating such a pronouncedand rapidly-evolving deformity. The goal of our study was toevaluate the results of surgical treatment of scoliosis in DMDpatients.

Methods: We retrospectively reviewed the records of 33 DMDpatients who underwent spinal surgery between 1991 and 2006. Aspinal fusion from T2 or T3 as far as the sacrum and trans-iliacpelvic fixation was always performed. The surgical instrumenta-tions used were: Luque in 25 patients and Plus in 8 patients.Postoperative support with a plaster cast or brace was not used inany patient. The patients underwent the first clinical and instru-


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mental re-examinations (spirometry and echocardiography)3 months after the operation and then every 6 months; an X-rayof the spine in toto in a sitting position was done 3 months, 1 yearand 2 years after the operation. As control group to evaluatepulmonary function, we analysed 20 age-matched DMD patientswho refused surgical treatment.

Results: At the time of surgery, the mean age was 13.1 yrs (range12–17) and the mean Cobb angle was 45� (range 20–95�). Themean postoperative angle was 16� (range 0–32�). The mean loss ofcorrection at follow up was 10� (range 0–15�). We observed 3major complications: 3 deep infections requiring the removal ofthe hardware 2 months after its insertion. All patients achievedthe sitting position within 7–10 days after surgery. Discomfort insitting position or prolonged back pain were observed in 3 out of33 (10%) patients. No significant differences in the respiratoryfunction were observed between surgically-treated and controlpatients. When asked, the majority of patients and their parents(80%) would give again the consent to surgery.

Conclusions: Surgery successfully corrected the curve and thepelvic imbalance of DMD patients with scoliosis. This also causeda more comfortable sitting position, an easier application ofrespiratory aids and a simpler nursing care. All these aspectssignificantly ameliorated the quality of life for these patients, asalso acknowledged by patients and their parents. However,respiratory function was not affected by surgical correction.

Significance: We describe the outcomes of spinal surgery inpatients with Duchenne Muscular Dystrophy and scoliosis, add-ing new evidences on the efficacy of the surgical strategy, espe-cially on the quality of life of these patients.

76

Upper cervical fusion in children with Morquio’s disease:

long-term results

Author: William Mackenzie (United States)

Co-Authors: Mihir Thacker (United States), Aaron Littleton(United States), Mohan Belthur (United States)

Purpose: Children with Morquio’s syndrome have a high inci-dence of upper cervical instability, which can lead to compressionof the spinal cord resulting in progressive neurological deteriora-tion, quadriplegia and death. Upper cervical fusion has beenadvocated to arrest this instability and prevent neurologicaldeterioration. However, long term results of this procedure in thisselect population have not been reported. The purpose of thisstudy is to evaluate the long-term clinical and radiological out-come of upper cervical fusion in children with Morquio’s disease.

Methods: The charts and radiographs of 13 patients with Mor-quio’s type A disease who had undergone upper cervical fusion toarrest upper cervical instability were reviewed for evidence ofbony fusion, instability of the subaxial spine, sagittal alignment ofthe cervical spine, neurological improvement and complications.

Results: The average follow up was 105 months (range 44–148).All 13 patients achieved solid fusion at final follow up. 12 (92%)achieved fusion by 6 months after the index procedure. Theremaining patient developed a symptomatic pseudarthrosis, whichhad to be revised. Four patients had minor complicationsincluding halo pin site infections and a pressure sore under thehalo body jacket. Three patients (23%) developed symptomaticsubaxial instability below a successful fusion and had to have thefusion extended. The average time to revision surgery was64 months (range 43–113) Of 5 patients with preoperative neu-rological involvement, 4 (80%) experienced improvement. Thesagittal alignment of the cervical spine was lordotic in 8 (69%),neutral in 3 (23%) and kyphotic in 1 patient respectively.

Conclusions: Upper cervical arthrodesis is a safe and effectiveprocedure in children with Morquio’s disease to arrest uppercervical instability and neurological deterioration. Long-termfollow up is recommended for early detection and management oflate subaxial instability after successful upper cervical fusion inthis patient population.

Significance: Upper cervical arthrodesis is a safe and effectiveprocedure in children with Morquio’s disease, and patients shouldbe followed long-term for subaxial instability after successfulupper cervical fusion.

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Limited Atlantooccipital and Cervical Range of Motion

in Patients with Familial Dysautonomia

Author: David Feldman (United States)

Co-Authors: Eric Henderson (United States), Mark Schweitzer(United States), Felicia Axelrod (United States)

Purpose: Familial Dysautonomia (FD) is a neurological diseaseseen in Ashkenazic Jews. Severe kyphoscoliosis occurs in 85–90%of FD patients. Surgical scoliosis correction is often followed byproximal junctional kyphosis; proximal end screw pullout is notuncommon. These patients appear to have limited cervical flexion,which may facilitate their junctional kyphosis. A retrospectiveradiographic study of cervical spine flexion-extension in FD pa-tients was undertaken to verify this clinical finding and investigatea causal relationship between deficient flexion and instrumenta-tion failure.

Methods: Active cervical flexion and extension lateral radiographsof fifteen pediatric FD patients were measured. Intervertebralflexion-extension was measured. Measurements of the FD popu-lation were compared to normal values available in the literature.

Results: Flexion-extension in the FD patients was significantlylower than the control population at all intervertebral levels ex-cept C1–C2. Atlantooccipital motion was reduced more than atother interspaces. Similar motion was seen in the FD and controlpopulations at the remaining interspaces, however, motion in theFD patients at all levels was considerably less than in published,age-matched normal values.

Conclusions: Decreased cervical flexion, particularly at occiput-C1,is a common finding in patients with FD. Proximal junctionalthoracic kyphosis following scoliosis surgery may be compensationfor fixed upward gaze secondary to deficient flexion of the cervicalspine. Bone quality is often low in FD patients and risk of proximalinstrumentation failure is increased if the thoracic spine is correctedbeyond a point of possible compensation. These findings warrantconsideration in planning scoliosis surgery for FD patients.

Significance: The significantly decreased cervical flexion that wasfound in patients with Familial Dysautonomia may contribute tothe development of proximal junctional thoracic kyphosis afterscoliosis surgery.

78

The Role of Amicar in Same-Day Anterior and Posterior Spinal

Fusion in Idiopathic Scoliosis

Author: George H. Thompson (United States)

Co-Authors: Ivan Florentino-Pineda (United States), Connie Poe-Kochert (United States), Douglas A Armstrong (United States)

Purpose: A retrospective study of the effectiveness of Amicar indecreasing perioperative blood loss and the need for transfusion in


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same-day anterior (ASF) and posterior spinal fusion (PSF) withsegmental spinal instrumentation (SSI) in idiopathic scoliosis.

Methods: Amicar is administered at 100 mg/kg over 15 minutesnot to exceed 5 grams at induction of anesthesia. Maintenance is10 mg/kg until wound closure. There were three study groups:Group 1, (n = 15), no Amicar; Group 2, (n = 27), Amicarfor PSF only; and Group 3, (n = 16), Amicar for both ASFand PSF.

Results: The total perioperative blood loss (estimated intraoper-ative blood loss for the ASF and PSF, measured suction and chesttube drainage) and the transfusion requirements (autologous andbank blood) were: Group 1, 3807 +/– 105 ml and 3.1 +/–1.5units; Group 2, 2080 +/–659 ml and 1.9 +/– 0.9 units; andGroup 3, 2183 +/– 851 ml and 1.0 +/– 0.8 units.

Conclusions: Amicar is effective in decreasing perioperative bloodloss and transfusion in same-day ASF, PSF with SSI in idiopathicscolosis. It is most effective in decreasing intraoperative PSFblood loss and chest tube drainage. It had little effect on ASFblood loss since it was relatively low in all three groups.

Significance: The use of Amicar results in less preoperativeautologous blood donation, blood transfusions, lowers costs, andreduces the potential for transfusion related complications.

79

What is the role of the autonomic nerve system in etiology

of idiopathic scoliosis? – A prospective electronmicroscopic

and morphometric study.

Author: Martin Repko (Czech Republic)

Co-Authors: Drahomır Horky (Czech Republic), Martin Krbec(Czech Republic), Richard Chaloupka (Czech Republic), IrenaLauschova (Czech Republic)

Purpose: Prevalent scoliotic deformities have been classified as anidiopathic one. The real etiology is still unknown. Trunk and ribcage developmental asymmetry seems like one of possible etiologyof the adolescent idiopathic scoliosis (AIS). This deformities canbe induce by asymmetrical intercostal vascular nutrition due tochanges in autonomic nerve system (ANS). The changes in sym-pathetic ANS seems like one of the possible cause of AIS. Somestudies have shown that the left breast of girls with right convexthoracic AIS is significantly more vascular than the right one. Thisexpression can produce an asymmetry of the breast and conse-quently it can leads the origin of the spinal deformity. The mainpurpose of this study is to search the possible causation of AIS indevelopment changes of the ANS. In our prospective study wehave been followed up the changes in autonomic nerve structure,as well as discrepances between concavity and convexity of thescoliotic curve.

Methods: We evaluated 9 patients with diagnosis idiopathic sco-liotic deformities and control set of 3 patients without scolioticdeformity between period March-November 2005. We took thesamples of peripherial autonomic nerves from convexity andconcavity of the scoliotic deformity during the surgical correctionof them using the transthoracal approach. We examined thesamples by using the electronmicroscopic method. Then we usedthe morphometric statistical evaluation in comparison with con-trol samples which has been taken during the surgical tretament ofnon-scoliotic patients.

Results:

1. scoliotic convexity: 23,71% of myelinised nerve fibres (MNF),12,21% of unmyelinised nerve fibres (UNF) and 5,0% of Schw-annscells (SC) by morphometric measurements.

2. scoliotic concavity: 17,36% ofMNF, 5,82% of UNF and 5,27% of SC.

There were the main morphological abnormalities expressed asdegenerated nerve fibres with massive lesion and separation of themyelin vagina. Also the vacualization of the Schwanns cells cy-toplasma and condensation of the cytoblast are abnormal.

3. control non-scoliotic samples: 29,9% of MNF, 19,9% of UNFand 16,7% of SC.

Conclusions: There were statistically significant diferences betweenboth sides of scoliotic deformity (convexity and concavity), as wellas discrepancies between scoliotic samples and non-scolioticcontrol samples. Significant morphologic changes were in allscoliotic samples mostly in myelin vaginas with abnormalities andcompression of the axon fibre. All these changes had been notfound in control set of patients without scoliotic deformities.

Significance: This findings can help us in search of the scolioticetiology. The abnormalities in the myelinated fibers may be originby the primary genetic lesion and in this way they can influencethe development of scoliosis.

80

Pedicle Screw Versus Hook Versus Hybrid Instrumentation

in Posterior Spinal Fusion for Adolescent Idiopathic

Scoliosis – a Minimum 2 Year Follow Up Comparative Study

Author: Battugs Borkhuu (United States)

Co-Authors: Aaron Littleton (United States), Mohan Belthur(United States), Dan Mason (United States), Peter Gabos (UnitedStates), Suken Shah (United States)

Purpose: The purpose of this study was to comprehensivelycompare the 2-year postoperative results of posterior correctionand fusion with segmental pedicle screw instrumentation versusthose with hook and hybrid constructs in adolescent idiopathicscoliosis (AIS) treated at a single institution.

Methods: A total of 105 patients with AIS at a single institutionwho underwent a posterior spinal fusion with segmental pediclescrew (35), hook (35) or hybrid (35) instrumentation were sortedand matched according to the following criteria: similar age atsurgery, identical Lenke curve types, curve magnitude and Rissergrade. Patients were evaluated before, immediately after, and at 2-years post surgery for radiographic parameters, complications,and outcome.

Results: The preoperative Cobb angle of the major curve in thescrew (58.1%), hybrid (55.4%), and hook (55.6%) groups werecomparable (F = 1.49, p = 0.23). The groups also showed nostatistical difference in age (F = 0.54, p = 0.58) or number oflevels fused (F = 0.58, p = 0.56). The correction rate of themajor curve was significantly better in the screw (78.5) and hybrid(70.0) groups as compared to the hook group (56.8) (F = 16.9,p = 0.00). Repeated measures ANOVA showed that techniquehad a significant effect on Cobb angle over time (F = 8.27,p = 0.00). There was no loss of sagittal plane alignment or ky-phosis in either the thoracic spine over time in any of the groups.Lumbar lordosis was well preserved. All screw constructs pro-vided significantly more correction of the compensatory curvecompared to the hook group (F = 3.99, p = 0.022). Better apicalvertebral translation was achieved in the screw group as comparedto the hook group (p = 0.00). Better horizontalization of the lastinstrumented vertebra was achieved in the screw group as com-pared to the hybrid and hook groups (F = 8.42, p = 0.00). Therewere no neurologic or visceral complications in any group. Hookdislodgement was seen in 2 patients in the hook group by 2-yearfollow up; both patients had loss of correction, needing revisionsurgery. SRS-22 outcomes scores were similar for all groups.


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Conclusions: Pedicle screw instrumentation for AIS offers signifi-cantly better major and compensatory curve correction, apicalvertebral translation and horizontalization of the lowest instru-mented vertebra without an increased complication rate overhook and/or hybrid spinal instrumentation. SRS-22 outcomeswere similar for all groups.

Significance: Pedicle screw instrumentation for AIS offers signifi-cantly better major and compensatory curve correction, AVT andhorizontalization of the LIV over hook and/or hybrid spinalinstrumentation.

81

Use of the vertical expandable prosthetic

rib for management of spinal deformity in non-ambulator spina

bifida patients

Author: John M. Flynn (Puerto Rico)

Co-Authors: Norman Ramirez-LLuch (Puerto Rico), RobertCampbell (United States), John Smith (United States), RandalBetz (United States)

Purpose: The purpose of this report is to evaluate the patients withmyelodysplasia and spinal deformity treated with the VerticalExpandable Prosthetic Titanium Rib (VEPTR) and included inthe FDA Request For Approval Of Humanitarian DeviceExemption For the Synthes Vertical Expandable Prosthetic Tita-nium Rib Indicated For The Treatment Of Thoracic InsufficiencyIn Children.

Methods: The FDA report includes 247 patients with surger-ies performed at 8 centers. Twenty patients were myelodysplas-tic none ambulatory. Six patients had less than 4 monthsfollow up and were excluded from this report. Data from theremaining 14 patients was extracted from the FDA report andanalyzed.

Results: The average age at the time of the first surgery was5 years (range 1 – 14 yrs). The average time of follow up was47.3 months (range 5.0 to 106.4 mo). The main indication forsurgery was a hypoplastic thorax in three children, rib fusion in 7patients, progressive scoliosis in 5 patients and flail chest in 1patient. In nine patients the Cobb angle was decreased an averageof 14.4 degrees; in five patients the Cobb angle increased anaverage of 12.6 degrees. Thoracic spinal height was increased intwelve patients an average of 3.2 cm. and there was a loss spinalheight in two patients an average of 0.8 cm. Twelve patients im-proved in ventilator function. Two patients did not improveventilatory function: one went from supplemental oxygen preop topart time use of ventilator and the other went from room air tonight time use of ventilator. Implant lengthening was done on theaverage of every sixth months and device exchange every30 months. Complications in five patients were due to the severityof the decreased pulmonary capacity and not directly relatedto the surgery. Implant failure and skin breakdown occurred in sixpatients. During the study period two patients died from cardio-pulmonary problems at 20 and 65 months post the initial surgery.

Conclusions: The rate of complications reported in this group ofpatients lies within the range reported for spinal fusion using theposterior or combined anterior and posterior approaches. Thenumber of surgical procedures increases due to the need forexpanding the implants as the child grows.

Significance: The advantages of the VEPTR are: surgical incisionsare away from the midline avoiding the scarred tissue from pre-vious myelomeningocoele closure and avoiding a spine fusionallowing growth of the spinal column with improved spaceavailable for the lung.

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WITHDRAWN

83

SpineScan-aided school screening significantly improves positive

predictive value in detecting idiopathic scoliosis

Author: Dror Ovadia (Israel)

Co-Authors: Michael Fishkin (Israel), Orna Filo (Israel), AdiShechtman (Israel), Shlomo Wientroub (Israel)

Purpose: School screening for scoliosis aims to prevent the needfor surgery by detecting curve changes in children at an earlystage, at which bracing may be effective in halting the progressionof the deformity. American Academy of Orthopaedic Surgeons(AAOS) and Scoliosis Research Society (SRS) continue to supportschool screening, even though the effectiveness of the currenttechniques has not been established yet and a low positive pre-dictive value (PPV) have been reported (Wong HK et al. Spine2005;30:118–96, 40%;Karachalios T et al. Spine 1999;24:2318–24,17%). The major criticism focuses on the cost-ineffectiveness ofthe process, as too many students are unjustifiably referred tospecialists for radiographs/treatment. Moreover, examiner’s skillsand experience are important factors in screening outcome. Anongoing, large-scale study of school screening is conducted toassess the reliability of a new, hand-held computerized device(SpineScan) that was designed to measure the ‘‘angle of trunkinclination’’ (ATI), and is less dependent on examiner’s level ofmedical training.

Methods: In a first phase of the study, 375 children (195 boys,180girls) aged 12 to 14 years were screened. Each child underwent‘‘blinded’’ examinations by two examiners with different skills (apediatric orthopaedic surgeon and a physiotherapist), each ofwhom using a different tool (a scoliometer and SpineScan,respectively). Screening was performed in examination positionsspecific for true scoliosis (standing and sitting forward bending)and ATI measurements were compared. Children with anATI = /> 7� measured with either tool at both positions werereferred to undergo a standard full spine X-ray in standing posi-tion, on which an experienced pediatric orthopaedic surgeonmeasured the Cobb angles. Curves =/>10� were considered truepositive findings for scoliosis. Statistical analysis included speci-ficity, sensitivity and predictive value estimates of both methods.Comparison of proportions of false positives and false negativesbetween the methods was carried out using the Exact Binomialtest.

Results: Referral rate for scoliometer was 3.7% and for Spine-Scan 3.5%. We assumed that all the children who were notreferred to radiological evaluation were true negatives. Althoughthe specificity values of both methods were almost simi-lar (99.2% with 95% CI [98.2–99.9%] and 99.7% with 95%CI [97.4–99.8%], respectively), SpineScan achieved a signifi-cantly higher PPV (91%), compared to that of the scoliometer(73%).

Conclusions: The high PPV and specificity value achieved usingSpineScan in the preliminary phase of the study show that the newdevice can be considered a reliable tool. Over-referral and lowPPV, which have been reported in the available screening proto-cols, were absent.

Significance: The new method can significantly improve positivepredictive value of results of school screening for idiopathicscoliosis.


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Session 12a: Limb reconstruction

84

Morphological changes in dorsal root ganglia and spinal cord

after limb-lengthening

Author: Gyorgy Szoke (Hungary)

Co-Authors: Sandor Kiss (Hungary), Zita Puskar (Hungary),Tamas Shisha (Hungary), Karoly Pap (Hungary)

Purpose: Nerve injury is one of the most serious complications ofthe limb lengthening. As a result, pain, sensory loss and motorweakness are the most frequent symptoms in patients who hadthis type of operation. Despite of the fact that this is a commonpractice, the precise etiology of nerve injury is still unknown. Inthis study, we examined the morphological and neurochemicalchanges in the dorsal root ganglia and spinal cord segmentsassociated with the limb lengthening in rabbits.

Methods: Three groups of rabbits were operated and differentlengthening protocols were used. In group A (5 rabbits) the sur-gery was followed by 7 days compression. 1 mm distraction oncea day was applied for 20 days, to achieve 120% length in com-parison of the contralateral leg. In group B (5 rabbits) thelengthening was started after 7 days compression (three times1 mm per day for 10 days, to achieve 130% length in comparisonof the contralateral leg). Group C was the control containing onlyuntreated animals. Using immunohistochemistry and confocalimage analysis, the portion of the Substance P (SP) immunreactiveneurons was determined in dorsal root ganglia (DRG) and thechanges in SP immunoreactivity were detected in the spinal cord.The Datas was analysed with the help of logistical regressionanalysis.

Results: In group A and B, huge vacuoles appeared in largeganglion cells in the ipsilateral side of the operation. The mor-phological appearance of the vacuoles was very similar to thoseexisting after nerve transsection in rats. However, the number ofthe SP immunoreactive cells in the DRGs decreased (by 10%),while the total number of DRG neurons was not changed. SP,CGRP and IB4 immunoreactivity also decreased in the operatedside of the spinal cord.

Conclusions: Our results suggest that vacuolisation and changes inpeptide expression in DRGs and in the spinal cord could result indifferent pain symptoms in patients during limb lengthening.

Significance: This animal model could be an important step tounderstand the pain, sensory loss and motor weakness during limblengthening.

85

Unexpected Absence of Effect of rh-BMP-7 (OP-1)

on Distraction Osteogenesis

Author: Frederic Sailhan (France)

Co-Authors: Franck Chotel (France), Roger Parrot (France), EricViguier (France), Aygulph Chousta (French Guiana), JeromeBerard (France)

Purpose: We asked whether locally applied rh-BMP-7 with a TypeI collagen carrier could enhance the consolidation phase in dis-traction osteogenesis.

Methods: We performed unilateral transverse osteotomy of thetibia in 28 immature male rabbits. In 1/2 of the animals (14 rab-bits), 70 lg of rh-BMP-7 (28.5 mg of rh-BMP-7/CC, OP-1) waslocally applied on the day of osteotomy; the control group (14

rabbits) had no local application. After 7 days, 3-weeks of dis-traction was begun at a rate of 0.5 mm/12 hours. Starting Week 2of distraction, we assessed radiographic, ultrasonographic, anddensitometric parameters once per week. Animals were sacrificedafter 3 weeks of distraction, and after 1, 2, and 3 weeks of furtherconsolidation. Histologic analysis was performed after sacrifice ofthe animal and harvensting of the callus.

Results: Radiographic evaluation revealed a tendency for in-creased bony union and bone differentiation in the control groupcompared with the rh-BMP-7/CC group. The bone mineral con-tent was higher in the control group at each time point. Ultr-asonographic evaluation revealed the development of a cyst withinthe regenerate in 92% of the animals in the rh-BMP-7/CC groupversus 0% in the control group. Ultrasonography and histo-morphometry showed delayed regenerate development in the rh-BMP-7/CC group.

Conclusions: Rh-BMP-7 with collagen carrier did not enhanceconsolidation in this rabbit model of tibia lengthening. We suggestthe poor results related to the relatively large bulk of the solidcarrier of the OP-1 that might have acted as a mechanicalobstacle.

Significance: A single local application of 70 lg (30 lg/kg) solidrhBMP-7/CC (OP-1) before distraction delayed the consolidationof the callus. We suggest the cyst developed in the regenerates ofthe treated animals because of the solid consistency of the BMP.Solid BMPs should probably not be used as interposition materialin a distraction osteogenesis procedure.

86

Effect of Local Growth Factors on Muscle Regeneration

in Distraction Osteogenesis

Author: Hyun Dae Shin (Korea, Republic of)

Co-Authors: Kwang-Jin Rhee (Korea, Republic of), Ho-SeopSong (Korea, Republic of)

Purpose: Our aim was to assess the distraction rate-related effectof the growth factor on muscle regeneration after bone distrac-tion.

Methods: We measured the effects of distraction on the tibialisanterior and soleus of rats. We used IGF-•, PDGF, and bFGFdevelopment for markers. 6 month-old Sprague-Dawley rats wereused. The right tibia was distracted, contralateral limbs werecontrol. We divided two group into six 0.35 mm/24 h(2 times) andsix 0.7 mm/24 h(2 times) distraction rate.

Results: In tibalis anterior, IGF-• expression at lengthening sitecompared with nonlengthening site significantly increased(p < 0.001), at group that lengthening rate was 0.7 mm/daycompared 0.35 mm/day group significant decreased (p < 0.01),but in soleus muscle, there was no significant change (p > 0.05).PDGF expression in tibialis anterior although in lengthening0.7 mm/day group compared 0.35 mm/day group increased butnot statistically change (p = 0.145). In soleus, lengthening0.7 mm/day group compared 0.35 mm/day group decreased, butnot significant change (p > 0.05).

Conclusions: Bone distraction promotes growth factor release, butthe growth factor release in mature muscle is decreased dependenton distraction rate. The bFGF is not related myoblast cell pro-liferation and differentiation and The faster distraction of themuscle growth dose not adapt to muscle lengthening.

Significance: The growth factor release in mature muscle is de-creased dependent on distraction rate. So We can reduce thecomplication during distraction osteogenesis with local growthfactor.


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87

Staged lenghtening in preventing deformities and correcting

achondroplasic children. 25 years experience

Author: Giovanni Peretti (Italy)

Co-Authors: Antonio Memeo (Italy), Fabio Verdoni (Italy),Omar De Bartolomeo (Italy), Walter Albisetti (Italy)

Purpose: The Authors review their 25 years long experience incorrecting the achondroplasic dwarves. We already presented in1994 our preliminary report of staged lengthening in the preven-tion of dwarfism in achondroplasic children. The aim of theoperation is not only to increase the height of the patients, butalso to correct limb deviations, to ameliorate their function and totransform a disharmonic in an harmonic individual. Our methodconsists in performing the lengthening in different stages (twooperations on the tibiae and two operations on the femurs; up to1996 we lengthen also humeruses.

Methods: With our method we treated 97 patients, 53 males and44 females, lengthening a total of 572 segments. The operation bymeans of metaphyseal corticotomy and, in few cases, by means ofepiphyseal distraction and applying a circular fixation for tibiaand an axial one for femur and humerus; only in 4 femurs we usedthe intramedullary lengthening nail. The distraction was carriedout at a rate of 0.5 mm every 12 hours, after an average waitingperiod of 4 days.

Results: Among our patients 19 of have completed the stagedprogram obtaining an average lengthening of 31,5 cm (range 28 to36) and 13 underwent also the lengthening of upper limbs.Complications are very frequent during and at the end oflengthening and have been examined in this paper; the patient andhis family implication is very important, but all patient are sat-isfied of the result and are glad to have spent a so long time toobtain a result.

Conclusions: The lengthening in dwarfism has become a standar-dised procedure with good prognosis, however there is a certainrisk and many complications.

Significance: With new lengthening devices we believe now to canreduce complication and to make easer the operations.

88

Bone lengthening in symmetric pathological short stature: long

term follow up.

Author: German Garcia-Llaver (Argentina)

Co-Authors: Eduardo Stefano (Argentina), Gabriela Martinez(Argentina), Nestor Vallejos-Meana (Argentina)

Purpose: The purpose of this study is to perform a therapeuticprotocol of lengthening for patients with symmetric pathologicalshort stature.

Methods: We review the long term functional and cosmetic resultsof 260 bone lengthenings in symmetric short stature between 1987and 2003. There were 81 patients included in the study with amean of 3.2 lengthening per patient. The etiology of the deformityincluded 35 achondroplasias, 19 hypocondroplasias, 8 rickets, 7Turner syndrome, 5 pseudoachondroplasias, 3 multiple epiphysealdysplasia and 4 non-classified dysplasias.

Results: The operated on bone include 116 femurs, 132 tibias and12 humerus. The average age at the time of frame application was10.2 years old. The mean follow up was 10.8 years. The functionaland cosmetic results were analyzed using a satisfaction scale, aradiographic assessment and a clinical test one year and 3 years

after frame removal. We found that 100% of the patients fellbetter after the lengthening, the average length gained per segmentwas 8.2 cm, and the bone healing index was in average 32. 2 days/cm. There also was a proof improvement in the activities of dailylife.

Conclusions: In developing countries severe short stature is notonly a cosmetic problem, these patients have multiples impedi-ments to perform regular activities of the daily life that’s why werecommend to lengthen patients with final predicted height of130 centimeters or less.

Significance: After more than 250 lengthening in patients withpathological short stature we perform a therapeutic protocol oflengthening depending on the final predicted height that consist in1 or 2 bilateral tibia and successive bilateral femur lengthening,and sometimes 1 bilateral humerus lengthening at the end of thelower limbs lengthening.

89

Development of Genu Varum in Achondroplasia: Its relation to

Fibular overgrowth

Author: Hae-Ryong Song (Korea, Democratic People’s Republic of)

Co-Authors: Seok-Hyun Lee, Jae-Hyuk Yang, Sameer Desai,Gautam Shetty, Harry Matta

Purpose: Development of genu varum in achondroplasia has verycomplex and multifactorial origin with little mention in literatureabout the role of fibular over growth. The purpose was to ob-serve the contribution of fibular length to tibial length (F:T)ratio, a measure of fibular overgrowth, to the development ofgenu varum.

Methods: Standing full length AP radiographs of 53 patientsof achondroplasia were analyzed. 30 patients were skeletallyimmature and 23 were skeletally mature. Fibular length, and tibiallength was measured and their ratio (F:T ratio) was used asmeasure of fibular overgrowth. Regression analysis was done tofind out the causal relation between the fibular overgrowth on thevarious indices of lower extremity alignment.

Results: Analysis showed that FT ratio had significant effect onmedial proximal tibial angle and mechanical axial deviation inskeletally immature group.

Conclusions: We thus conclude that, fibular overgrowth is signif-icantly related to the development of genu varum in achondro-plasia in the skeletally immature age group.

Significance: Fibula Overgrown contributes significantly todevelopment of gunu varum in achondroplasia and hence earlyprevention of overgrowth of fibula will probably prevent thedevelopment of deformity.

90

Massive bone lengthening in short stature patients

Author: Dalia Sepulveda (Chile)

Co-author: Juan Carlos Hernandez Bueno (Chile); SepulvedaMatıas (Chile)

A retrospective study was performed in 21 patients undergoingmassive long bones lengthening, between January 1994 toDecember 2006 at the Reconstruction Surgery Unit of the Ro-berto del Rio Hospital and University of Chile in Santiago,Chile.


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The series is conformed by 21 patients; 2 of whom were notavailable for study, 8 out of 21 are female (42%) and 11 are males(58%), mean age at the first surgery was 10 years and 8 monthsold, (range 7 to 16), the initial mean height was 105 cm (range 85to 125 cm) and the mean projected height at maturity beforelengthening was 127 cm. Mean follow up 63,3 months.

The achondroplasia group, representing the biggest one, iscomposed by 11 patients (57, 9%); 3 other patients hadconstitutional short stature (15, 8%) and 3 had other skeletaldysplasias; 1 has a Turner Syndrome (5, 25%) and 1 had anunclassified etiology.

72 bone segments wee lengthened : 12 femur (17%), 44 tibias(61%), and 16 humerous (22%).;16 patients undergone conven-tional bone lengthening technique with unilateral external fix-ators, (54 segments, 75% of the surgeries).; 5 patients, 14 bonesegments (20%) were converted to a blocked endomedulary nailonce the lengthening was finished; only in 2 patients, 4 bonesegments (6%) the bone lengthening technique was done over anendomedulary nail since the beginning of the procedure. All thedevices were monolateral external fixators.

Evaluation in this study includes statistical demographic results inextensor but overall we emphasize: bone segments lengthened, timein frame and consolidation index to meet the goal, complicationsduring lengthening and the patients and doctors’ satisfaction.

91

Functional outcome after 8 years follow up following

the treatment of Congenital Pseudarthrosis of the Tibia

By Ilizarov Technique

Author: Hani Mohamed Elmowafi (Egypt)

Co-Authors: Barakat Elalfy (Egypt),MohamedRefai (Afghanistan)

Purpose: Congenital pseudarthrosis of the tibia remains one of themost controversial pediatric entities in treatment and prognosis.In this study, we reported our results in the treatment of con-genital pseudarthrosis of the tibia by Ilizarov technique.

Methods: Twenty legs in 20 patients (15 boys and 5 girls) withCPT were treated in the Orthopaedic Department, MansouraUniversity Hospital, Mansoura, Egypt from 1997 to 2005 (TableI). The average age at time of Ilizarov application was 6.8 yearsold (range 4 to 15 years). Patients were classified as Crawford’sclassification into 9 patients type II and 11 patients type IV. 15patients underwent excision of the affected part of the tibia.Excision of the affected part of both tibia and fibula was achievedin 5 patients (3 type IV and 2 Type II). Type IV patients asCrawford’s classification was treated with excision of affected partof the tibia and acute shorting with insertion of the distal part ofthe tibia into the proximal part of the tibia by the mouth fishtechnique. Out of 11 patients type IV 3 cases treated with mouthfish technique and periosteum graft and 2 cases treated with thesame technique with excision the affected part of the fibula. 9cases with type II treated with excision of the affected part of thetibia, 2 of them treated with excision of the affected part of bothtibia and fibula. If the defect after excision was less than 4 cm,acute shortening was followed by bone lengthening (5 patients). In4 patients the gap was more than 4 cm (6 cm and 10 cm), andbone transport was preferred.

Results: The mean duration of follow up period was 4.2 years.Bony union at pseudarthrosis site of the tibia was achieved inall patients. Leg length discrepancy was occurred in 3 patients,refracture in 2 patients. Genu valgus deformity and foot valgusdeformity was occurred in 14 patients. The deformity wasdeveloped with patients treated with excision of the affected

part of the tibia only. All patients with deformity underwentcorrection.

Conclusions: The Ilizarov method has been shown to be effectivein achieving union at pseudarthrosis site, correcting any associ-ated angular deformity and lengthing of the tibia if the affectedpart of both tibia and fibula is excised.

Significance: The Ilizarov method has been shown to be effectivein achieving union at pseudarthrosis site, correcting any associ-ated angular deformity and lengthing of the tibia if the affectedpart of both tibia and fibula is excised.

92

Lengthening Reconstruction Surgery for Treatment

of Fibular Hemimelia

Author: Dror Paley (United States)

Co-Authors: Said Saghieh (Lebanon), Baek Song (Korea, Republicof), M Young (United States), John Herzenberg (United States)

Purpose: Fibular hemimelia presents a problem with limb lengthdiscrepancy and equinovalgus foot deformity. Our protocolsimultaneously treats both problems, with the goals of equalizinglimb length and achieving a plantigrade, painless, functional foot.

Methods: Seventy-eight patients with fibular hemimelia underwent92 lengthenings and foot deformity correction. Equinovalgus footdeformity was corrected by four different methods in 67 cases:distraction, soft tissue release, release plus supramalleolar and/orsubtalar osteotomy, and fibular transport.

Results: Goals of lengthening and foot deformity correction wereachieved in all cases. Foot deformity recurred in 19 patients andwas retreated. Foot deformity recurrence occurred in nine (56%)of 16 distraction cases, four (22%) of 18 soft tissue release cases,two (7%) of 28 release plus osteotomy cases, and four (80%) offive fibular transport cases. Genu valgum developed in many caseswith no or partial anlage resection. Genu valgum did not developin any cases with complete anlage resection. Final results based onfunctional and radiographic evaluation: 46 excellent, 28 good, and18 fair. Final result did not correlate with number of rays in foot.

Conclusions: Limb length discrepancy and foot deformity can besuccessfully treated by simultaneous lengthening and foot defor-mity correction. Soft tissue release plus osteotomy and completeanlage resection yielded best results.

Significance: Lengthening reconstruction surgery is an excellentalternative to ablative surgery and prosthetic fitting for patientswith all severities of fibular hemimelia.

93

The Metaphyseal Arc System to Correct Epiphyseal, Physeal

and Metaphyseal Deformities– 5 year Experience.

Author: Alfred D Grant (United States)

Co-Authors:

Purpose: The Metaphyseal Arc System has been in use forapproximately 5 years to treat deformities in the proximal tibia,the distal femur and the distal tibia/fibula. There have been 56cases at our hospital of which all have been reviewed through tothe end of correction. Of these 47 were proximal tibia varus cor-rections, 7 were ankle valgus deformities and two were distalfemoral recurvatum deformities (sagital plane deformities). Therewere 43 cases of proximal tibial deformity properly corrected. Thefailures were due to not finding the plane of deformity (3 cases),over correction (1 case) and under correction because of improper


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mounting of the device (1 case). One of the ankle cases was undercorrected, leaving the ankle in 10 degrees of valgus. Both distalfemoral deformities, recurvatum were corrected. Problem of pintract infections have been managed with frequent and/or longterm use of antibiotics. One fibula prematurely consolidatedrequiring re-osteotomy and separate correction with a small raildevice. Mounting maneuvers have allowed one stage correction ofprocurvatum/recurvatum and rotation (which can also be cor-rected gradually with use of an attachable rotation arc).Addi-tional cases have been able to benefit from the miniaturization ofthe device such that it can be used for the younger and/or smalldysplasia child. Recently the Multiaxial Correction system(M.A.C.) has been used for diaphyseal corrections.

Methods: (Please refer to purpose field)

Results: (Please refer to purpose field)

Conclusions: (Please refer to purpose field)

Significance: (Please refer to purpose field)

Session 10b: Hip/Lower Extremity I

94

Current practice acute/unstable SUFE in the United Kingdom

and the Netherlands

Author: Melinda Witbreuk (Netherlands)

Co-Authors: P Besselaar (Netherlands), Deborah Eastwood(United Kingdom)

Purpose: Traditionally, a slip of the upper femoral epiphysis(SUFE) is classified into preslip, acute, acute-on-chronic andchronic phases. More recently a stable/ unstable classificationrelating to weight-bearing ability has become more prognostic.The management of acute unstable SUFEs remains controversialas noted in a recent questionnaire sent to POSNA (PediatricOrthopaedic Surgeons of North America) members. Agreementexisted on method of patient evaluation, but discrepancies re-mained in classification and fixation methods. Our goal was tocompare management strategies in two European countries withthose identified by the POSNA survey.

Methods: A questionnaire similar to the POSNA survey was sentto all members of the British Society of Children’s OrthopaedicSurgery (BSCOS) and the Werkgroep Kinder Orthopaedie(WKO). Only 33.1% (263 of 794) of POSNA members respondedwhereas our overall response rate was 65% (142 of 220).

Results: Amongst responders, the mean duration of consultantpractice was 12.9 years. 63% had >50% paediatric workload.Overall, 68 % use both acute/chronic and unstable/stable classi-fication methods but the use of both systems is significantly morecommon in surgeons with a higher paediatric workload. All use X-rays in two planes; 30 % also use dynamic fluoroscopy, CT, MRIand bone scans. 88% operated <24 hours. 69% use a tractiontable. 88% perform percutaneous fixation; 79% using a singlescrew. 66% never reposition the slip. Others reposition gently oraccept an ‘accidental’ reposition prior fixation. Only 29%decompress the capsule and 26% routinely pin the contralateralside. 33% always remove metal work.

Conclusions: In all three countries, agreement exists on evaluation.TheUKhas significantly better agreement on classification and pre-operative positioning. Interestingly, those with <15 years experi-ence tend to use percutaneous single screw fixation techniques. Thesurvey engendered discussion regarding the gentle repositioning ofunstable slips and within what time this should occur.

Significance: Level 5?

95

Analysis of the hip at risk in the slipped capital femoral

epyphisis

Author: Gilberto Waisberg (Brazil)

Co-Authors: Claudio Santili (Brazil), Miguel Akkari (Brazil),Susana Braga (Brazil), Marcelo almeida (Brazil)

Purpose: To investigate the patients with EEPF that were attendedat the Department of Orthopedics of Santa Casa of Sao Paulo anddetermine which were at risk for slip of the contralateral hip.

Methods: From November 71 to January 98 the clinical charts of736 patients with the diagnosis of Slipped Capital FemoralEpiphysis (S.C.F.E.) were analyzed. Due to the lack of clinicaldata 177 charts were excluded, leaving us with 559 charts, dividedinto four groups: Group A: 253 patients with unilateral disease,not presenting any signs or symptoms of the disease on the con-tralateral hip until the onset of skeletal maturity; Group B: 43patients with unilateral disease that presented contralateral hipinvolvement during follow-up; Group C: 136 patients with bilat-eral disease at the time of diagnosis; Group D: 127 patients whosehealthy proximal femurs were prophylactic pinned. A compara-tive analysis was performed between groups A (unilateral slip) andB (contralateral slip during follow up), in which various factorswere analyzed: gender, side of disease, race, back ground, age atthe time of diagnosis, age of contralateral slip, classification of slip(acute, chronic and acute-on-chronic) and concomitant diseases.

Results: We observed that factors such as age and gender weredirectly related to the development of bilateral disease. The otherfactors studied were not related to the late slip on the contralateralhip.

Conclusions: The study suggests that younger patients (age bellow14 for boys and 12 for girls) at the time of diagnosis are at higherrisk, and could be benefited from bilateral pinning.

Significance: level III.

96

New Trans-trochanteric corrective osteotomy for SCFE based

on 3DCT

Author: Toshio Kitano (Japan)

Co-Authors: Keisuke Nakagawa (Japan), Yuuki Imai (Japan),Kosuke Sasaki (Japan), Takaaki Kuroda (Japan), Mitsuaki Mo-rita (Japan), Kunio Takaoka (Japan)

Purpose: To perform the precise and safe correction of the de-formed femoral head after Slipped Capital Femoral Epiphysis(SCFE), we introduced new osteotomy based on three-dimen-sional (3-D) computerized tomography (CT). Our new osteotomyis the trans-trochanteric oblique rotational osteotomy (TORO) onthe axis of capital slip.

Methods: The procedure of TORO consists of 3 steps. First of themis pre-operative planning. We introduced 3-D imaging software(Mimics�9.11, Materialise, Leuven, Belgium) to find the true axisof capital slip. Using the software, the axis of capital slip could bedrawn on the 3-D proximal femoral images constructed from theCTdata.We describe the circle which center is the axis of capital slipon the lateral image using the software. Second step is the trans-trochanteric oblique rotational osteotomy on the axis of correction.Osteotomy was performed at the site of trochanter through thecircumferential line which center is the axis of capital slip previouslydrawn on the lateral 3-D image using the apparatus specially made.Final step is fixation using a plate specially made for this osteotomyor external fixator. Slip angle (posterior slip angle) wasmeasured on


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the roentgenograph before and after the osteotomy. Post-operativecomplications were checked out on medical records.

Results: Ten children with 11 affected hips were treated using ournew osteotomy. The average age at surgery was 13.4 years (range,11.0 to 16.5). The average slip angle before the osteotomy was58.3°, and the average slip angle after the osteotomy was26.1°. There were no complications after this operation.

Conclusions: TORO could make the precise and safe correction forthe deformed head after SCFE.

Significance: Our new femoral osteotomy on the axis of capitalslip based on 3-D image could make the precise and safe correc-tion for SCFE.

97

Avascular necrosis in acute and acute-on-chronic slipped capital

femoral epiphysis.

Author: Aamer Nisar (United Kingdom)

Co-Authors: Amir Salama (United Kingdom), A G Davies(United Kingdom)

Purpose: This study was carried out to assess various factorsresponsible for the development of avascular necrosis and theeffect of treatment on clinical outcome.

Methods: We studied the clinical notes and radiographs of patientspresenting with SCFE during the period between 1994 and 2003.

Results: Seventy three patients (n = 73) with ninety two (n = 92)hips were included in the study. There were 16 acute, 43 acute-on-chronic, 29 chronic and 4 preslips. Seventy Seven (n = 77) slipswere classified as stable and 15 as unstable slips. Fifty three slips(57.6%) were mild, 34 (37%) were moderate and five (5.4%) weresevere slips. Despite no deliberate attempts to reduce the slip atthe time of surgery eighteen hips (n = 18) showed a median de-crease in slip angle of 8 degrees (range 2—36) in acute and acute-on-chronic slips. The mean preoperative slip angle was 32 degrees(range 9–76) compared to postoperative slip angle of 29.9 degrees(range 10–75) (p = 0.004). Four patients developed avascularnecrosis (AVN). Intraoperative reduction of the slip was signifi-cantly related to development of AVN (p < 0.001). According tothe criteria of Heyman and Herndon eight patients had functionaldeficit at the time of final follow up and clinical outcome was fair,poor or failure. All of these patients had a reduction in the angleof slip at the postoperative radiographs compared to their pre-operative radiographs.

Conclusions: Reduction of slipped capital femoral epiphysis isresponsible for poor outcome and also related to the developmentof avascular necrosis. We recommend single in situ pinning forthese cases regardless of severity of slip.

Significance: Avascular necrosis is one of the most devastatingconsequences of slipped capital femoral epiphysis. In situ pinningof these patients prevents development of avascular necrosis andpoor clinical outcome.

98

Preliminary Results of Cementless Total Hip Arthroplasty

in Adolescents

Author: Renata Suda (Austria)

Co-Authors: Martin Pospischill (Austria), Christof Radler(Austria), Karl Knahr (Austria), Franz Grill (Austria)

Purpose: Joint replacement for treatment of sequelae of pediatrichip disorders is a controversial subject due to the reported survivalrates of total hip arthroplasty (THA) sytems and the expected

revisions. The purpose of this study was to assess clinical andradiographic results of young patients who had undergonecementless THA.

Methods: Between 1998 and 2005 28 primary cementless total hiparthroplasties in 26 patients with osteoarthritis secondary tochildhood hip disorders were performed at our clinic. In all casescementless THA systems (Alloclassic�, Variall�, Bicon�) wereused. Mean age of patients at operation was 19.7 (range 13–27).A retrospective review of the preoperative radiographs and therecords was performed. Mean follow-up was 3.2 years (range0.5–6.5). Clinical outcomes were evaluated using the Harris HipScore (HHS) and the SF-36 questionnaire. Postoperative radio-graphs were analysed according to DeLee and Charnley for thecup. On the femoral side the zones described by Gruen et al.were used.

Results: Mean HHS at last follow-up was 95.7 (100). Pain scorewas 43.1(46), function score was 52.6 (56). No early loosening andno implant fracture were found in these series. In one case (3.6 %)the reason for revision was progressive polyethylene wear. Cupexchange due to post-traumatic aseptic loosening was carried outin one hip (3.6 %). One patient (3.6 %) needed revision surgerybecause of a late deep infection. All of the 28 cups were consideredstable, radiolucent lines around the cup were observed in 5 pa-tients (17.9%).

Conclusions: Cementless fixation in THA is a reasonable technique intotal hip replacement in adolescents. Especially in this group of activeyoung patients progressive polyethylene wear is still amajor problem.Improvement of quality of life can be achieved in most patients.

Significance: These early results may expect good long-term out-comes and suggest that cementless THA is a sufficient solutionin the treatment of osteoarthritis secondary to pediatric hipdisorders.

99

Patient-reported outcomes ten years after hip arthrodesis

Author: Andreas Roposch (United Kingdom)

Co-Authors: John Wedge (Canada)

Purpose: To determine the health-related quality of life of youngadults who underwent hip arthrodesis in their teenage years.Specifically, we were interested in physical function and ipsilateralknee status.

Methods: 10 patients (8 female) who underwent a hip arthrodesis(1987–2001) at a median age of 15 years (SD 2.98) were studiedafter a median follow-up of 10 years (SD 4.71). The SF-36 wasused to determine health-related quality of life (higher scoresrepresent better status). Scores were compared to normativepopulation data (signed rank test). The WOMAC is a disease-specific measure and was used to assess ipsilateral knee function.Its 3 subscales (possible scores) are: pain (0–20), stiffness (0–8),physical function (0–68), whereas lower scores represent betterstatus. One-on-one interviews were performed using a standard-ized questionnaire to explore patient satisfaction.

Results: Patient scored lower in all SF-36 subscales compared tonormative data. Significant differences were found in physicalfunction (P = .001) and vitality (P = .0493) subscales withmean differences (95% CI) of –35.9 (–50.53, –21.26) and –12.9(–24.55, –1.24), respectively. Mean differences (95% CI) in rolefunctioning (P = .175) and pain (P = .132) subscales were–14.6 (–34.76, 5.6) and –13.2 (–29.51, 3.11), respectively. MeanWOMAC scores were 7.44 (pain); 2.11 (stiffness); 24.11 (phys-ical function). For all patients, the most dissatisfying aspect ofthe procedure was physical limitation but 8 rated the limited


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function as acceptable and would have the same proceduredone again. 7 felt their quality of life improved since theoperation.

Conclusions: The results suggest that arthrodesis affects physicalfunction but not role functioning. For patients who are willingto accept improvement of pain at the expanse of their dailyphysical activities, arthrodesis seems to be a good andpredictable treatment option in end stage hip disease. Patientsfor whom physical functioning beyond role activities is impor-tant should not consider arthrodesis but explore alternativeoptions.

Significance: Patients are coping well ten years after hip arthrod-esis but at the expense of their activities.

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Quadruple and periacetabular pelvic osteotomy using single

approach. Technique and results in hip dysplasia and Perthes

disease.

Author: Roger Jawish (Lebanon)

Co-Authors: Jacques Ghorayeb (Lebanon), Rami Khalife(Lebanon), Antoine Kahwaji (Lebanon)

Purpose: We performed with a single anterior approach the periar-ticular pelvic osteotomy which is traditionally achieved with twodifferent approaches. Our population included a group of youngchildren with severe dysplasia, necessitating a high degree of reori-entation where Salter’s osteotomy is classically indicated. In elderchildren a quadruple osteotomy of the ischium, pubis, ilium and is-chial spine was performed to release the sacrospinal ligament andimportant displacement of the acetabulum was achieved.

Methods: 30 osteotomies have been carried out on 26 patients. Themean age was 6.7 years, 10 patients were younger than five, with6 years of follow up [range 2 to 13 years].The indications includedacetabular dysplasia (15 cases) those aged under 5 years had impor-tant acetabular deficiencywith lateral subluxation or dislocation aftertreated DDH, Perthes disease (14 cases) and one caput valgum.

Results: Compared to preoperative clinical exam, the postopera-tive flexion was decreased by 14�, extension increased by 7�,external rotation increased by 5�, internal rotation decreased by5�. Radiographic assessment demonstrated an average angle ofcorrection 20� for the acetabular angle of Sharp, 32� for the CEA,and 18� for the slope of sourcil.

Conclusions: We concluded that lateral coverage must beachieved in a frontal plan, avoiding the figure-of-four maneuversand displacement in a transverse plan. Despite the significantreorientation of the acetabulum, we didn’t observe excessiveexternal rotation. The quadruple osteotomy allowed importantacetabular displacement in elder patients. The single approachavoided prone position and permitted a simpler postoperativemanagement.

Significance: We performed the triple osteotomy in children under5 years old, with severe dysplasia and important acetabular defi-ciency. We described a new technique of periacetabular osteotomywhich has been performed in elder children necessitating impor-tant displacement of the acetabulum.

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Pelvic osteotomy techniques and comparative effects on

biomechanics of the hip

Author: Rajan Maheshwari (United Kingdom)

Co-Authors: Sanjeev Madan (United Kingdom)

Purpose: Dysplasia of the hip in children, characterised by ashallow acetabulum and a deficient coverage of the femoralhead, generally causes altered biomechanics of the hip joint. Akinematic analysis on the individual and comparative spatialmovement of the acetabulum with some of the pelvic osteotomytechniques is performed. The osteotomy providing greater cor-rection in most of the parameters potentially leading to greaterreduction in loading is the choice of the surgeon.

Methods: Adult saw bone hip models have been used. Points ofreference have been carefully chosen and data has been obtainedusing the Polhemus Electromagnetic measuring system beforeand after the osteotomy. Five techniques (Chiari, Salter, Steel,Tonnis and Ganz) have been performed, parameters like theCentre-edge angle, Sharp’s angle, Acetabular Head index(Femoral head cover), translation and rotation in 3 planes havebeen analysed.

Results: Results show an improvement in most of the parame-ters when the above pelvic osteotomies are performed. Centre-Edge angle improved by a mean (in degrees) of 7.4(Chiari),9.6(Salter), 16.9(steel), 28.4(Tonnis) and 31.0(Ganz). There hasbeen marked increase in Femoral head cover with mean 24%with Tonnis and Ganz. Significant changes in rotationalparameters in all 3 planes were achieved, particularly with Ganzand Tonnis techniques.

Conclusions: Traditionally acetabular dysplasia correction hasbeen assessed in one or two dimensions by plain radiographs andtrue three dimensional movement of the acetabulum is difficult toassess with simple techniques. This study describes a simple andreproducible method to compare the various pelvic osteotomiesand comparative effects these can produce on the kinematics ofthe hip joint.

Significance: It is intended to extend this study to include kineticsto compare the forces and stress distribution changes caused byperforming the above techniques and a larger study is recom-mended, based on this technique and the initial trend of resultsshown.

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Minimally invasive, iliac crest-sparing approach (ICSA) for

pelvic osteotomies in children.

Author: Ismat Ghanem (Lebanon)

Co-Authors: Fernand Dagher (Lebanon), Khalil Kharrat(Lebanon)

Purpose: to describe a new surgical approach to the sciatic notch,which allows enough exposure to perform common iliac osteot-omies in children, while fulfilling the criteria of MI surgery.

Methods: The ICSA was used for 65 hips in 54 patients whounderwent a pelvic osteotomy (with or without open reduction ofthe femoral head) for various reasons. Age at surgery ranged from1,7 to 8 years. Surgical technique: The distal part of a modified SPincision is used. The inter-spinal notch (between the anteriorsuperior iliac spine and the anterior inferior iliac spine) is exposedsubperiosteally, between tensor fascia lata and sartorius. Thepsoas tendon is divided. The sciatic notch is approached mediallyand laterally using a periosteal elevator, without splitting the iliaccrest cartilage. Length of skin incision, difficulties encounteredduring exposure, bleeding, easiness and amount of distal fragmentdisplacement following pelvic osteotomy, hazards of internal fix-ation, duration of surgery, and severity of postoperative pain,were recorded for each patient. Acetabular index was measuredpreoperatively, immediately after surgery, and at a follow-upranging from 6 to 40 months.


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Results: Skin incision ranged from 3 to 5,5 cm. The two maindifficulties encountered during surgery were: 1/ Limited viewduring exposure of the medial aspect of the sciatic notch, thesurgical field being obliterated by the surgeon’s hand. 2/ Passageof the Gigli saw from one side of the sciatic notch to the other.Exposure was easier in younger children. Bleeding did not exceed50 ml except for one case (the second case of the series) ofpersistent bleeding from a perforating artery in the sciatic notch,which required shifting to a conventional SP approach. In allcases, displacement of distal fragment was easy and withouttension. Duration of surgery varied from 50 minutes in thebeginning of our experience to 20 to 25 minutes for the last casesof the series (in cases not including open reduction). Pain wasdifficult to assess. Acetabular index improved from an average41� preoperatively to 15� postoperatively and 16� at last follow-up.

Conclusions: The ICS approach fulfills the criteria of MI surgery.When compared to conventional SP, it includes smaller skinincisions, uses anatomical bloodless pathways, avoids injury tothe iliac crest growth plate, and decreases surgical duration andmorbidity, while insuring an optimal coverage of the femoralhead. Some hints at every step of the procedure have beengained with experience. New instruments intended to furtherfacilitate the procedure are designed and currently under fabri-cation.

Significance: It is possible to optimally perform common iliacosteotomies without splitting the iliac crest growth cartilage.

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The spectrum of intra-articular findings of the symptomatic hip

with MED/SED

Author: Dennis Robert Roy (United States)

Co-Authors:

Purpose: The purpose of this study is to review the intra-articularfindings of patients with either multiple epiphyseal (MED) orspondyloepiphyseal dysplasia (SED) who presented with a changein their baseline hip pain.

Methods: The medical records, radiographic studies and opera-tive reports were retrospectively reviewed of patients withMED/SED who presented with either a sudden onset of hippain or a change in their baseline symptoms. The patients hadimpingement signs on physical exam. The intra-articular find-ings were identified at either open arthrotomy or by hiparthroscopy.

Results: Five patients presented for evaluation of their pain. Threepresented with sudden onset during daily activities, while twopresented with progressive pain. One patient, age 4, underwentarthrotomy, while the remaining patients were treated arthro-scopically. Two patients were found to have large chondral frac-tures and rupture of the ligamentum teres; one patient had achondral flap with a loose body, one patient had overly ballotablecartilage, and the final patient had considerable thinning of femoralhead and acetabulum cartilage associated with a large labral tear.

Conclusions: Significant intra-articular pathology can occur inpatients with MED/SED during normal daily activities. Suddenonset of pain or a change in pain status should prompt rapidevaluation and treatment.

Significance: The pathological development of the chondral-osseous junction of the hip in patients with skeletal dysplasias maylead to significant intra-articular events which will contribute tothe early deterioration of the joint.

Session 11b: Hip/Lower extremity II

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Eight-Plate for Temporary Hemiepiphysiodesis to Correct

Angular Deformities

Author: John Eric Herzenberg (United States)

Co-Authors: Rolf Burghardt (Germany), Dror Paley (UnitedStates), Shawn Standard (United States)

Purpose: The eight-Plate Guided Growth System allows surgeonsto perform temporary hemiepiphysiodesis to correct malalign-ment. It is an alternative to the Blount staple and has potentialimprovements: less compression of the growth plate, decreasedrisk of breakage and extrusion, and a more precise implantationtechnique. The senior authors have implanted 50 eight-Plates tocorrect angular deformities of the lower extremities in 40 childrenfrom August 2004 to December 2005. We are reporting our resultsin the first group of patients who have completed treatment.

Methods: Eleven patients (17 eight-Plates) underwent treatmentfor angular deformities that were caused by a variety of condi-tions. Average age at hemiepiphysiodesis was 10 years 2 months(age range, 4 years 11 months–13 years 8 months). The devicewas inserted in the lateral distal femur (two cases), the medialdistal femur (eight cases), the lateral proximal tibia (two cases),the medial proximal tibia (four cases), and the medial distal tibia(one case). Average time between insertion and removal of theeight-Plate was 10.2 months (range, 5–13 months).

Results: Joint orientation angles and the mechanical axis satis-factorily improved in all patients except one who had a resectedosteosarcoma and little potential growth remaining after resec-tion. Mechanical lateral distal femoral angle changed an averageof 9.1 degrees (range, 5–11 degrees), medial proximal tibial anglechanged an average of 6 degrees (range, 0–10 degrees), and lateraldistal tibial angle changed an average of 10 degrees. Mechanicalaxis improved an average of 29.8 mm (range, 0–55 mm). Nohardware failures or other complications were observed.

Conclusions: Performing hemiepiphysiodesis by using the eight-Plate is a safe and effective treatment for improving angulardeformities, even in children as young as 5 years.

Significance: The eight-Plate has the potential to extend the indi-cation for hemiepiphyseal stapling to a younger age group.

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Ceformity around the knee joint using hemiepiphyseal stapling

in children with multiple epiphyseal dysplasia

Author: Tae-Joon Cho (Korea, Republic of)

Co-Authors: In Ho Choi (Korea, Republic of), Chin Youb Chung(Korea, Republic of), Won Joon Yoo (Korea, Republic of), KeeJung Bae (Korea, Republic of)

Purpose: Multiple epiphyseal dysplasia (MED) is a genetic diseasecaused by mutations in cartilage matrix proteins such as type IXcollagen, cartilage oligomeric matrix protein, and matrilin-3. Genuvalgum or genu varum deformities are not uncommon in MEDpatients, and may contribute to development of precocious osteoar-thritis as well as cause cosmetic and functional disturbance. Hemi-epiphyseal stapling has been well established as a safe and effectivemethod for angular deformity correction in growing children. Theauthors present clinical outcome of this method in MED patients.

Methods: Nine children with multiple epiphyseal dysplasia, whounderwent hemiepiphyseal stapling for angular deformity


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correction around the knee joint from January 2000 to May 2006and had staples removed after completion of angular deformitycorrection, were included in this study. They were five boys and 4girls. Among the sixteen knee joints operated upon, thirteen kneejoints had valgus deformity and three varus deformity. Hemiepi-physeal stapling was applied to twenty two physes - fifteen distalfemoral physes and seven proximal tibial physes. The mean age atthe time of stapling was 11.5 years (range, 8 to 14). Two stapleswere inserted in 13 of 15 distal femoral physes and 4 of 7 proximaltibial physes. One staple was inserted in the rest of the physes. Thepatients were regularly followed after operation with standingteleradiograph of the lower limb. Angular deformity correctionwas monitored by measuring the anatomical lateral distal femoralangle (aLDFA), medial proximal tibial angle (MPTA), and themechanical axis deviation (MAD). MAD was determined by thedeviation of the mechanical axis from the center of the knee jointdivided by half of the knee joint width, and described as %.

Results: We didn’t encounter any staple-related complications.The mean duration up to removal of staples was 15.9 months andthe mean follow-up after removal was 15.0 months. Mean aLD-FA improved by 14.7 degrees, and mean MPTA by 8.4 degrees.The mean correction rate was 0.85 degree/ month at the distalfemur, and was 0.67 degree/month at the proximal tibia. TheMAD improved from preoperative 105.5% to 40.2% at the timeof removal, and to 26.2% at the time of the latest follow-up.Thirteen of sixteen knee joints had mechanical axis deviation lessthan 50% at the time of last follow-up.

Conclusions: Hemiepiphyseal stapling efficiently corrected theangular deformity at the knee joint in children with MED withminimal morbidity. Long term consequence until skeletal maturityneeds to be investigated.

Significance: Hemiepiphyseal stapling is safe & effective for cor-rection of the angular deformity at the knee joint in children withmultiple epiphyseal dysplasia.

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Lower Extremity Deformities in Morquio Syndrome: Natural

History and Results of Surgical Correction

Author: Mihir Thacker (United States)

Co-Authors: Mohan Belthur (United States), Aaron Littleton(United States), Freeman Miller (United States), William Mac-kenzie (United States)

Purpose: We undertook this study to define lower extremitydeformities in Morquio syndrome and evaluate the their naturalhistory as well as results of surgical treatment.

Methods: This was a retrospective clinical and radiographic reviewof 16 patients with Morquio syndrome. Patient demographicswere recorded. Lower extremity deformities were analyzed usingstandard radiographs and deformity parameters. Gait analysiswas available for 8/16 patients. The details of surgical procedureswere recorded and the clinical and radiographic outcomes deter-mined.

Results: There were 8 male and 8 female patients. The averageage at presentation was 5 years and 9 months and at last followup was 14 years and 4 months. Gait analysis demonstrated hipflexion deformities as well as increased femoral anteversion withexternal tibial torsion. Natural History: All patients had valgusalignment of the lower extremities. There was progressiveproximal and lateral migration of the hips with flattening andeventual disappearance of the capital femoral epiphysis. Pro-gressive genu valgum was seen with predominant proximaltibial valgus and joint laxity. Ankle valgus and forefootadduction were common.

Results of Surgery: There were a total of 41 surgical procedures in16 patients. The average age at first surgery was 8 + 10 for the hipand 10 years for the knee. Six patients underwent VDRO’s, 4 had ashelf acetabuloplasty and 1 had a Dega osteotomy. Recurrent hipsubluxation was seen in all patients treated with proximal femoralrealignment alone. The mean CE angle improved from –14.1 to 6.5degrees at final follow-up. The mean MPTA and tibio-femoralangles improved from 97 to 92 and 22 to 12 degrees respectivelyfollowing realignment osteotomies or hemi-epiphyseal stapling in12 patients. Ankle valgus correction was performed in 6 patientswith 2 recurrences. One patient with a symptomatic planovalgusfoot did well with a lateral column lenghtening.

Conclusions: Lower extremity valgus in patients with MorquioSyndrome is multifocal. Pre-operative gait analysis was helpful inassessing the sagittal plane and rotational deformities. Earlyprogressive hip subluxation needs to be addressed with bothfemoral as well as acetabular procedures. Recurrent hip and kneedeformities were common and needed revision surgery. Footdeformities though common, are rarely symptomatic.

Significance: Early progressive hip subluxation was common.Genu valgum primarily resulted from proximal tibial valgus andjoint laxity. Recurrent hip and knee deformities were common andneeded revision surgery.

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The ‘‘Four-in-One’’ Procedure for Habitual Patellar

Dislocation in Children with Aplasia of the Femoral Trochlea

and Generalized Ligamentous Laxity

Author: Hyun Woo Kim (Korea, Republic of)

Co-Authors: Sun Young Joo (Korea, Republic of), Hui Wan Park(Korea, Republic of)

Purpose: To examine the clinical results of the ‘‘Four-in-One’’procedure for habitual dislocation of the patella in children withgeneralized ligamentous laxity and aplasia of the femoral trochlea.

Methods: 6 knees in five patients were included in the study. Downsyndrome and William’s syndrome were the underlying disease inthree patients, and all the patients had generalized ligamentouslaxity(Beighton score greater than 7) and aplasia of the femoraltrochlea. All the patients had the following procedure; lateralretinacular release, medial placation, semitendinosus tenodesis,and patellar tendon transfer. The average age of the patients at thetime of operation was 5.5 years and the subjects were followed upto the average of 40 months postoperatively. Clinical results wereevaluated using the criteria of Kujala’s scoring system as well asthe physical examination and radiological findings.

Results: During the follow-up period, there were no recurrent dis-locations, knee joint pain, limitation of motion or gait disturbancesin all cases. The mean Kujala score was 93.8. Two cases had com-plications related to wound healing, but they healed eventually.

Conclusions: The ‘‘Four-in-One’’ procedure was effective in theprevention of recurrent patellar dislocation in patients with gen-eralized ligamentous laxity and aplasia of th femoral trochlea.

Significance: The ‘‘Four-in-One’’ procedure is useful for habitualdislocation of the patella in children with generalized ligamentlaxity and formation failure of femoral trochlea.

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Immediate treatment of congenital knee dislocation

in neonates: personal experience in 32 cases

Author: Nikolay Jurievich Rumyantsev (Russian Federation)

Co-Authors:


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Purpose: The purpose of the study is to show a different types oftreatment programmes for neonates with congenital knee dislo-cation.

Methods: Prenatal sonographic video-evaluation and X-rays atthe birth were used. Treatment methods included permanentgentle manual manipulations (traction & flexion), von Rosensplinting and cast correction.

Results: The mean follow-up is 6 years (range from 1 to 17 years)We use five clinical and radiological criteria to evaluate the results.All results were good or excellent, and no surgical rocedures werenecessary.

Conclusions: The treatment of congenital knee dislocation shouldbe started in the first hours of life.We believe, that this conditioncould be a primarily reversible, but the possibility of correctiondiminishes drastically with every day of patient’s life.

Significance: The analysis of prenatal sonographic data shows,that this condition is formed between 12-th and 24-th weeks ofgestation.

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Correlation of gait analysis with computed tomography

in rotational gait abnormality

Author: Christof Radler (Austria)

Co-Authors: Andreas Kranzl (Austria), Hans Manner (Switzer-land), Michaela Hoeglinger (Austria), Rudolf Ganger (Austria),Franz Grill (Austria)

Purpose: It has been proposed that rotational gait abnormalities inthe normal child are usually reflections of the anatomic deformity.However, compensatory factors may influence the resulting dy-namic rotational profile during gait. We compared rotationalcomputed tomography (CT) data with gait analysis data to eval-uate their correlation and to elucidate the influence of possiblecompensatory mechanisms.

Methods: Between 2001 and 2005 rotational computed tomog-raphy (CT) and gait analysis for assessment of rotational mal-alignment have been performed in 79 patients. CT scans wereavailable for review in 23 patients (46 lower limb segments).Three dimensional gait analysis (Motion Analysis Corporation,Santa Rosa, USA) was performed using the Cleveland clinicalmarker set. Lower limb segments showing more than 15 degreesof frontal plane varus-valgus movement in the knee joint wereexcluded to increase quality of data. The femoral and tibialtorsion as found in the rotational CT was statistically correlatedwith the data from gait analysis for hip rotation and kneerotation at several events during the gait cycle. The relationshipbetween parameters was evaluated by determination of Pearson’scorrelation coefficient.

Results: The study included 6 female and 15 male patients witha mean age at the time of gait analysis of 17 years (9–61 years).All patients presented for correction of rotational malalignmentdue to idiopathic, posttraumatic or congenital rotationaldeformity. Forty lower limb segments (20 left and 20 rightsegments) in 21 patients were analyzed. The mean antetorsionin the femur was 29 degrees (range: 2 degrees of retrotorsion to56 degrees of antetorsion) and the mean external torsion of thetibia was 29 degrees (range: 1–57 degrees). Evaluations ofPearson’s correlation coefficient revealed correlation betweenfemoral torsion and mean hip rotation during the stance phase(r = 0,408, p < 0,05) and at the end of the first double sup-port phase (r = 0,344, p < 0,05). A strong linear correlationwas found between the tibial torsion and the mean knee rota-tion over the whole stance phase (r = 0,764, p < 0,001), theknee rotation at initial contact (r = 0,753, p < 0,001) and

knee rotation at the end of the first double support phase(r = 0,753, p < 0,001).

Conclusions: The rotation of the hip as found in the gaitanalysis showed only weak correlation with rotational CT data.This is not surprising as the hip segment offers many possi-bilities for compensation and muscular influences. The torsionof the tibia was found to correlate very strongly with the gaitanalysis.

Significance: When assessing femoral torsion an effort should bemade to integrate data from rotational CT, gait analysis andclinical evaluation. The evaluation of tibial tosional deformitiescan accurately be performed with rotational CT.

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Dynamic femoral anteversion in an abled-body paediatric

population.

Author: Samuel Jacopin (France)

Co-Authors: Elke Viehweger (France), Michel Jacquemier(France), Vincent Pomero (France), Sandrine Scorsone-Pagny(France), Franck Launay (France), Jean-Luc Jouve (France),Gerard Bollini (France)

Purpose: Clinical consequences of excessive femoral anteversionduring walking motivates numerous consultations in paediatricorthopaedics during childhood. To explain variable rotational gaitbehaviour of the lower limb it’s necessary to investigate the ‘‘dy-namic’’ femoral neck orientation. Existing literature data arebased on virtual mathematical modelling and not on data acqui-sition in children. Our purpose was to measure the so-called‘‘Relative Femoral Anteversion’’ (RFA), the position of thefemoral neck relative to a reference transversal axis, perpendicularto walking direction, along the gait cycle in a healthy pediatricpopulation.

Methods: 27 volunteer healthy children were included (20 boys, 7girls, mean age 9,3 ± 3 years). Anatomic femoral anteversion(AFA), tibial torsion, and hip range of motion was assessedclinically. Instrumented 3D-gait analysis was performed for eachchild. Gillette Gait Index (GGI) was used to select reference gaittrials. Joint centre coordinates and anatomical segments orienta-tion were calculated and we developed a specific computationmodel to calculate the rotation of the femur in relation to thefrontal plane. Therefore RFA was calculated along the whole gaitcycle.

Results: RFA expressed a low amplitude (12,2�) during gait cycle.Its mean value (29�) was very close to the mean AFA value(27,8�). The curve aspect of the RFA during the gait cycle washomogeneous for stance phase and for terminal swing phase.During the loading response phase, the RFA decreased, then theRFA increased during the single limb support. Curve aspect alongswing phase was heterogeneous.

Conclusions: Our results demonstrate low RFA amplitudeduring the gait cycle. We described a typical curve patternwhich varies with gait velocity. Our results based on realtime dynamic analysis in children differ widely from themathematical based literature results. Further prospective RFAstudies may lead to ‘‘RFA’’ patterns correlated to hip pathol-ogies.

Significance: Different RFA patterns due to variable AFA relatedto acetabular torsion may help to explain physiopathology of apart of paediatric orthopaedic pathologies including slipped cap-ital epiphysis, Legg-Perthes-Calve disease or progressive neuro-logical hip dysplasia or consequently development of hip arthritisin adult.


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111

3D Time-resolved Magnetic Resonance Angiography

of the abnormal limbs in children

Author: Pierre Journeau (France)

Co-Authors: Laurence Mainard (France), Damien Mandry(France), Thierry Haumont (France), Pierre Lascombes (France),Michel Claudon (France)

Purpose: To evaluate the interest of magnetic resonance angiog-raphy with Time-Resolved Imaging of the Contrast Kinetics(TRICKS) in children limbs diseases.

Methods: TRICKS is a contrast-enhanced MR angiographictechnique allowing the acquisition of multiple 3D dynamicvolumes (temporal resolution 10 sec). 113 children (mean age10.3 years) were evaluated, including osteochondritis (17), bonyor joint infections (9), epiphysiodesis (8), juvenile chronicarthritis (20), arterio-venous malformations (AVM)(14), benign(32) and malignant tumors (n = 3, with post-chemotherapyfollow-up in 10). TRICKS data were correlated with T2 and T1weighted images, 99Tc bone scintigraphy, surgery and pathol-ogy findings.

Results: In osteochondritis and osteomyelitis, enhancementdelineated sequestrae. In epiphysiodesis, 3D acquisitions alloweda precise localization and size of bony bridges within the enhancedgrowth plate. Early and massive enhancement was observed inactive hypertrophic pannus. AVM kinetics depended on thepresence of shunts. In benign tumors, enhancement correlatedwith scintigraphy uptake. In malignant tumors, decreasedenhancement under chemotherapy correlated with the degree ofnecrosis at pathology.

Conclusions: TRICKS provides high-quality images and kineticsdata on abnormal growth plate vascularization, inflammatorychanges and tumor viability in children limbs diseases.

Significance: The TRICKS imaging is non invasive imagingtechnic allowing to evaluate the quality, and also the quantity ofbone or growth plate vascularization. It is possible to compare theabnormal quantity of vascularization with the adjacent normalbone, needed special software.

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Fibrous hamartoma at atrophic congenital pseudoarthrosis

of the tibia is not osteogenic but osteoclastogenic


Co-Authors: Joong Bae Seo (Korea, Republic of), Dong YeonLee (Korea, Republic of), Won Joon Yoo (Korea, Republic of),Chin Youb Chung (Korea, Republic of), Jin A Kim (Korea,Republic of), In Ho Choi (Korea, Republic of)

Purpose: CPT remains as one of the most challenging orthopaedicproblems. Main pathology of the pseudarthrosis is fibrous ha-martoma (FH) that is continuous with abnormally thickenedperiosteum in the adjacent bone segments. Understanding thebiologic behavior of this pathologic tissue should be a key todevelopment of optimal treatment method. In this study, the au-thors compared the FH cells with normal periosteal cells withreference to mRNA expression of cytokines involved in osteocl-astogenesis and osteogenesis, and responses to exogenous bonemorphogenetic protein (BMP) treatment.

Methods: After approval from the IRB, fibrous hamartoma (FH)surgically excised during osteosynthesis for atrophic type CPT anddistal tibial periosteum (TP) obtained as a normal control duringtibial derotational osteotomy in cerebral palsy patients were used.

Fibroblast-like cells were enzymatically dissociated, and grown inDMEM with 10% FBS. FH cell from 5 patients and TP cells from2 patients were used in this study. Total RNA was extracted, andBMP-2, BMP-4, and NF1 mRNA expression was tested usingRT-PCR. RANKL and OPG mRNA expression level wasquantified using real time RT-PCR and standardized by that ofGAPDH. Both FH cells and TP cell were treated with rhBMP-2(R&D System, Mineapolis, MN)(0 or 100 ng/ml) for 2 weeks.Cellular alkaline phosphatase (ALP) activity was determined andmRNA expressions of the transcription factors involved inosteoblastic differentiation, such as Dlx5, Msx2 and Runx2, weremeasured using real-time RT-PCR.

Results: Both FH and TP cells were spindle-shaped and indis-cernible morphologically. They expressed BMP-2, BMP-4, andGRD1 and GRD2 types of NF1 mRNAs. RANKL mRNAexpressions in the FH cells were higher than in the TP cells,whereas OPG mRNA expression were lower. BMP treatment in-creased ALP staining and activity in TP cells, while decreased inFH cells. The mRNA expression of Dlx5 was up-regulated andthat of Msx-2 was down-regulated by BMP treatment in both FHcells and TP cell. Runx2 mRNA expression increased in TP cells,but resulted in divergent changes in FH cells.

Conclusions: FH cells seem to maintain some of osteogenic phe-notype, but suppressed osteogenic phenotype by BMP treatmentcontrary to TP cells. This suggests that main defect of the fibroushamartoma lies in the response to BMP signals. This study alsoshowed that the FH cells are more osteoclastogenic than TP cells.

Significance: These findings suggest that meticulous excision of thefibrous hamartoma tissue is mandatory in the treatment of CPT asit would not respond to either endogenous or exogenous BMP’s.Enhanced osteoclastogenicity of this tissue seems to contribute todevelopment of CPT.

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The performance of an Extensible Intramedulary Nail anchorad

by hooks (HIMEX) in Osteogenesis Imperfecta

Author: William Dias Belangero (Brasil)

Children with osteogenesis imperfecta often need surgical treat-ment for correction of deformities and for avoiding new fractures.The use of extensible nails, is accepted, but the great number ofpos-surgical complications requires many reoperations.

The objective of the study was to evaluate the performance of anextensible intramedulary nail named HIMEX, anchored inepiphysis by hoocks, for children with osteogenesis imperfecta.The performance was measured by the effect of the nail forreducing the number of fractures, improving the motor develop-ment, decreasing the migration of the nail and for increasing thenail survival.

A retrospective transversal study was done, with all patients treatedfrom 1990 to 2004 with the HIMEX. The casuistic included 14 pa-tients aged from two to eighteen years old; eight females; sevenpatients type III, six type IV and one type I, according SILLENCE(1981). The average age at the first fracture was nearly five months(148,21 days), with average fractures/patient of 42,6.

Forty six bones in the lower limb were treated (28 femur, 18 tibia),with 39 primary insertion (25 femur, 14 tibia) and seven revisionprocedures (3 femur, 4 tibia). The average follow-up was50,35 months, statistically longer for femoral procedures(60,14 months) than for tibia procedures (35,11 months). Theaverage age at the insertion of the first rod in femur was signifi-cantly higher than in tibia (7,64 years X 11,56). After of surgicaltreatment there was a statistically significant decrease of thenumber of fractures from 42,6 to 0,78 fractures/patient. Although


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there has been improvement in the motor development, the resultswere not statistically significant (HOFFER e BULLOCK, 1981).The percentage of reoperations was 18%. The migration of the nailoccurred in 5/39 surgeries (12%). By survivorship analysis patientshad a higher risk of requiring reoperation when the procedure wasmade in tibia. The type of osteogenesis imperfecta, the age of thepatients at the surgery and the period when the surgery was madewere not statistically significant for requiring reoperation.

It was concluded that the use of HIMEX significantly reduced thenumber of fractures and the incidence of migration besides toincrease the nail survival, regarding literature basis.

Session 12b: Cerebral Palsy

114

Rates of utilization of gait analysis for surgical decision making

for ambulatory cerebral palsy in North America

Author: Unni G Narayanan (Canada)

Co-Authors: Shannon Weir (Canada), Alan Morris (Canada), SueRedekop (Canada)

Purpose:

1. Measure the rates (and determinants) of utilization of gait anal-ysis for surgical decision-making in ambulatory CP;

2. Estimate surgeons’ beliefs about the clinical value of gaitanalysis for decision making & their confidence/certainty oftheir beliefs;

3. Gauge the support for a multicentre randomized trial toaddress whether the addition of gait analysis to surgical decision-making improves the functional outcomes of orthopaedicsurgery;

4. Identify the primary outcome/s of choice for such a trial.

Methods: A survey of 732 members of POSNA was conductedover 6 months. After pilot testing, members were invited tocomplete a self-administered web-based online questionnaire, alsoavailable in paper form for return by fax/mail.

Results: Responses were received from 413/732(56.4% totalresponse rate), of which 354(48.4%) were fully completed sur-veys: 323/680(47.5%) for US & 31/52(60%) for Canadian sur-geons, from140 different cities in 43/50 US States and 11 citiesin 7/10 Canadian provinces. 90% reported CP managementincluding multilevel surgery was part of their practice. 59%(209/354) reported some training in gait analysis. 38% of respon-dents did not have access to a gait laboratory. 8% had accessfor research only. For those with access, 44% relied on privatehealth insurance but 20% did not have any funding for clinicalgait analysis. 59% of respondents believe that gait analysis isindicated at least sometimes for decision making prior to mul-tilevel surgery. Only 41% of the respondents actually use gaitanalysis for this purpose. The main reasons for this differenceincluded lack of access to a gait lab, lack of funding, or poorexperience with interpretation. The overall rates of actual uti-lization of gait analysis for clinical decision making amongsurgeons who treat children with CP was 42.6%(US) and25.8%(Canada). There was wide variation in surgeons’ beliefsabout the value of clinical gait analysis and the indications fordecision making prior to multilevel surgery. 47% of therespondents were certain/very certain about their beliefs, 36%somewhat certain & only 7% uncertain. 69.8% indicated theirwillingness to participate in a multi-centre trial to resolve thecontroversy. The outcome measures of choice for such a trialwere the Pediatric Outcomes Data Collection Instru-

ment(PODCI) and the Gross Motor Function Mea-sure(GMFM-66).

Conclusions: There is wide area variation in the rates of utiliza-tion of clinical gait analysis in Canada and the US. Despite widevariation in their beliefs about the clinical value of gait analysis,surgeons have little uncertainty about their beliefs.

Significance: Ambulatory children with CP are either being de-prived of a valuable assessment in many centres or being subjectedto an unnecessary & expensive evaluation in others. The surveyresults should provide the impetus for a much needed multi-centreRCT to address this controversy.

115

Power generation in children with spastic hemiplegic cerebral

palsy

Author: Jacques Riad (Sweden)

Co-Authors: Freeman Miller (United States)

Purpose: Spastic hemiplegic cerebral palsy is a challenging disor-der where often relatively high functional and cognitive levelmakes the children good candidates for physiotherapy programswith coordination and muscle strengthening exercises. The goal ofthis study was to investigate the power generation on both thehemiplegic and non-involved side, from the hips and ankles inchildren with spastic hemiplegic cerebral palsy, who had no pre-vious surgery.

Methods: Ninty-nine patients with spastic hemiplegic CP with amean age of 8.4 years (range 4.0–19.8) were included. Medicalrecords and three dimensional gait analysis data were reviewed.Patients were classified using Winter’s criteria and classified intoeither group 1,2,3 or 4. Twenty-two patients (22%) of the total99 could not be classified in any group and we call this group0, since they had the smallest deviations from normal. Theground reaction force vectors were collected and together withkinematic data moments and power generation/absorptioncould be calculated. The power generation was calculated as thearea under the curve on the hip and ankle graphs. The A1power generation in the hip represents mainly the extensormuscles of the hip, the gluteus muscles. The A2, the powerabsorption and the A3 the iliopsoas muscle power generation.In the ankle the A1 curve represents power absorption, the A2ankle power generation in the early part of stance phase that isnot present in the normal population. The A3 in the ankle inlate stance phase represents the normally existing gastro-soleusmuscle power generation.

Results: The hip extensor power generation, A1, was higher onboth the hemiplegic and the non-involved side in all classifica-tion groups compared to age matched normals. The powergeneration from the iliopsoas, A3, was very close to normal inall groups on both sides. The normally not existing powergeneration in the early part of stance phase was present in allgroups on both the hemiplegic and non-involved side. Thepower generation from the ankle regarding the gastro-soleusmuscle A3 in all groups, had less ankle power generationon both the hemiplegic and non-involved side compared tonormals.

Conclusions: We found a major power generation shift from theankle to the hips in children with spastic hemiplegic cerebral palsyboth on the hemiplegic and the non-involved side. This could beinterpreted as if symmetry in power generation is a way of com-pensating for decreased ankle power generation on the hemiplegicside. This may also mean that power loss, such as after tendonachilles lengthening, at the ankle may be of less importance in thehemiplegic cerebral palsy child.


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Significance: The results could support that muscles strengtheningphysiotherapy should be directed toward the hip power generatorsmainly and coordination exercises should be focused distally tothe knee and ankle. Consideration of the power shift might alsoinfluence surgical treatment plans.

116

Morphometric Changes Of The Acetabulum After Dega

Osteotomy In Cerebral Palsy

Author: Chin Youb Chung (Korea, Republic of)

Co-Authors: In Ho Choi (Korea, Republic of), Tae-Joon Cho(Korea, Republic of), Won Joon Yoo (Korea, Republic of), MoonSeok Park (Korea, Republic of)

Purpose: To analyze the effect of Dega osteotomy on acetab-ulum in cerebral palsy using 3 dimensional computed tomogra-phy.

Methods: Fourteen hips of 9 cerebral palsied patients with hipinstability were evaluated, and the contralateral hips of 10 uni-lateral LCP patients were used as a control. There were 7 malesand 2 females with the mean age of 7.8 years. Dega osteotomy andfemoral varization derotation osteotomy was performed in allaffected hips, and 3D CT was taken pre- and postoperatively. Forthe assessments, 3 directional acetabular indices (anterosuperior,superolateral and posterosuperior) were designed and measuredusing multiplanar reformation. Acetabular volume was also cal-culated.

Results: All hips were concentrically reduced without complica-tions. Anterosuperior and superolateral indices were significantlyimproved toward the value of control group (p = 0.001), andposterosuperior index was even smaller than that of control grouppostoperatively (p = 0.007). The volume of acetablum increasedby 67% and showed a statistical significance (p = 0.001).

Conclusion: We conclude that not only posterosuperior but alsoanterosuperior coverage is improved after Dega osteotomy. Fur-thermore, Dega osteotomy actually increases acetabular volume.

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Ten-year follow -up of bilateral hip reconstruction in severe

whole body cerebral palsy.

Author: Fergal Monsell (United Kingdom)

Co-Authors: Mohannad Barakat (United Kingdom), Tom While(United Kingdom), Martin Gargan (United Kingdom), JanePyman (United Kingdom)

Purpose: The results of a functional, clinical and radiologicalstudy of 30 children (60 hips) with whole body cerebral palsy arepresented with a mean follow-up of ten years.

Methods: Bilateral simultaneous combined soft-tissue and bonysurgery was performed at a mean age of 7.7 years (3.1–12.2).Evaluation at ten years involved interviews with patient/carersand clinical examination. Plain radiographs of the pelvis assessedmigration percentage and centre-edge angle.

Results: Twenty two patients were recalled. Five had died ofunrelated causes and three were lost to follow-up. Pain wasuncommon, present in 1 patient (4.5%). Improved handling wasreported in 18 of 22 patients (82%). Carer handling problems wereattributed to growth of the patients. All patients/carers consideredthe procedure worthwhile. The range of hip movements improved,with a mean windsweep index of 36 (50 pre-operatively) Radio-logical containment improved, with mean migration percentage of

20 degrees (50 preoperatively) and mean centre-edge angle of 29degrees (–5 preoperatively) No statistical difference was notedbetween the three year and ten year follow-up results demon-strating sustained improvement in clinical and radiological out-come.

Conclusions: Bilateral simultaneous combined hip reconstructionin whole body cerebral palsy provides painless, mobile and ana-tomically competent hips in the longer term.

Significance: The majority of the available literature considers theshort term outcome of surgical reconstruction of the hips in thiscondition. This paper demonstrates that the initial improvementsin structure and function are maintained in the longer term.

118

Proximal femoral resection arthroplasty for patients

with Cerebral Palsy and dislocated hips

Author: Andreas Knaus (Norway)

Co-Authors: Terje Terjesen (Norway)

Purpose: Hip dislocation of several years duration in cerebralpalsy(CP), especially in the most severe mentally retarded andnon-ambulatory individuals with quadriplegia, can lead to manyproblems including pain as the most annoying. During the lastyears we have performed proximal femoral resection in thesecases. The aim of the current study was to evaluate the clinicaloutcome of this operation, especially to what degree pain wasreduced and whether sitting balance and perineal care improved.

Methods: During the period 1998 to 2005 we operated 22 patientswith chronic hip dislocation. Theywere 20 non-ambulatory patientswith quadriplegic CP, 1 patient with Down syndrome and 1 patientwith Arthrogryposis(13 with unilateral dislocation and 9 withbilateral). The average age at operation was 15(3–27) years. Thecriteriae to select patients for operation were hip dislocation whichhad lasted for 2 years plus severe clinical problems like pain(13patients), problems with perineal care(13), and difficulties withseating(3 patients), or a combination of these symptoms(10 pa-tients). The operative technique used was the proximal femoralresection-interposition arthroplasty as described by Mc Carthyet al. in 1988. 16 patients underwent bilateral resection(9 withbilateral dislocation and 7 with unilateral), 6 patients unilateralresection (5 with dislocation and 1 with subluxation). Postoperativetreatment was skin traction for 2–5 weeks for most of the patients.After 35(3–72) months follow-up time a telephone questionnairewas designed to ask patients or caretakers about pain, mobility,function and about their rate of overall satisfactionwith the surgery.Radiographs taken immediately after surgery were compared tothose taken at the most recent clinic visit to assess proximal femoralmigration and the presence of heterotopic ossification. Clinicalcharts were reviewed for details of the surgical procedure, postop-erative care and complications after surgery.

Results: 15 patients were satisfied(9 very satisfied) with the sur-gery, 4 were unsatisfied and 2 were unsure. 5 patients were dead.Complications after surgery included prolonged pain up to6 months, 1 deep vein thrombosis and 1 patient developed oede-ma, lost appetite and needed gastrostomia. 1 patient was reoper-ated because of heterotopic ossification. Pain rated on a scalefrom 1–10 was in average 7(1–10) before surgery and reduced to2(1–7) at follow-up. All operated hips had an improved range ofmotion. All 10 patients without sitting ability before surgery wereable to sit afterwards.

Conclusions: Pain and function, especially sitting ability, improvedpostoperatively and the majority of patients and caretakers weresatisfied with the surgery.


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Significance: Patients with CP and severe pain or other majorproblems because of long-standing hip dislocations seem to ben-efit from proximal femoral resection.

119

The triceps surae muscle flexes and internally rotates

the hip under load

Author: Reinald Brunner (Switzerland)

Co-Authors: Carlo Frigo (Italy), Thomas Dreher (Germany)

Purpose: Internal rotation gait in patients with spastic cerebralpalsy is a common problem. Correction by bony or soft tissuesurgery at the hip level is often disappointing. Other factors henceneed to be responsible for internal rotation as well.

Methods: A biomechanical model of the body is created andanimated. Soleus and gastrocnemii activity is simulated withoutand with floor resistance (influence of gravity). The results fromthe model study are verified in a review of 47 consecutive patientswith spastic hemiplegia and 49 with diplegia respectively (meanage 12 y, no Botulinum toxin therapy for at least 6 month or anysurgery before). All these patients underwent full instrumentedgait analysis (VICON 360 6 cameras, 2 Kistler force plates, dy-namic EMG). 3D hip and pelvic kinematics was correlated withankle kinematics. A paired t-test was used to compare the 2groups (significance set at p = <0.05).

Results: Simulation of soleus activation without gravity showsplantarflexion as expected. With floor resistance the hip is inter-nally rotated and flexed with extension of the knee, together withretrotorsion and elevation of the ipsilateral pelvis. Similar hap-pens with gastrocnemii but the knee is flexed. Knee flexion beforeactivation of the tested muscles erases the effect on hip and pelvisat least partially. For hemiplegia correlation of ankle flexion andhip rotation was r = 0.5, p = 0.001, for pelvic rotation r = o.4,p = 0.007. For diplegia, r = o.1, p = 0.262 and r = 0.1,p = 0.366 respectively. Diplegic patients showed significantlymore knee and hip flexion than hemiplegic patients in stance phasewhile ankle flexion did not differ.

Conclusions: Plantarflexion under load produces hip internalrotation and pelvic retroversion as a direct effect which is ofimportance in patients walking with little or no knee flexion suchas hemiplegic patients. This effect, however, is not proven in di-plegic patients who walk with bent knees.

Significance: Triceps overactivity and shortening need to be cor-rected as well in patients with hip inernal rotation deformities.

120

The functional outcome of soft tissue procedures

for the treatment of spastic pronation in children

and adolescents.

Author: Konstantinos Malizos (Greece)

Co-Authors: Nikolaos Rigopoulos (Greece), Athanasios Liantsis(Greece)

Purpose: The spastic pronation (SP) is considered as the mostprevailing segment of spastic upper extremity pattern. We arepresenting the overall outcome in upper extremity function of softtissue procedures for the treatment of SP.

Methods: In a 5-yrs period: (2000–2005), 18 children/adolescents:(11 boys, 7 girls), mean age: 7.6, suffering from hemiplegia (13) orquadriplegia (5) were treated surgically for SP. IQ was normal andfamily support adequate in all cases. At least one of the followingsoft tissue procedures were performed in each patient: flexor

tendon lengthening (8), pronator teres rerouting (13), bicepsbranch lengthening (5), transfer of flexor carpi ulnaris to theextensor radialis brevis (13). Patients were classified (Gerschwind& Tonkin) as type I-IV according to pre- and post-operative rangeof pronation/supination. Final ranges of motion of wrist/elbow/shoulder were recorded and gross/fine motor skills as well.

Results: Follow-up period ranged from 1–5.5 yrs. The majority ofpatients were 6–8 yrs. Although all of them had undergone lowerextremity procedures, no one had been operated in upperextremity before. Tendon transfers represented almost 54% ofsoft tissue procedures and pronator teres rerouting was 43% ofthem. The best improvement in final ROM was in type III patientsand represented 34% of favourable results.

Conclusions: A significant improvement was recorded not only ingross/fine hand function but also in elbow and shoulder finalactive range of motion, indicating the biomechanical importanceof spastic pronation treatment (especially soft tissue procedures)in the overall upper extremity function.

Significance: A significant improvement was recorded not only ingross/fine hand function but also in elbow and shoulder final ac-tive range of motion, indicating the biomechanical importance ofspastic pronation treatment (especially soft tissue procedures) inthe overall upper extremity function.

121

Utility of Bone Scan in Non-Communicative Children

with Pain

Author: Gela Bajelidze (United States)

Co-Authors: Mohan Belthur (United States), Freeman Miller(United States), Kirk Dabney (United States)

Purpose: Pain in non-communicative children is difficult tolocalize and diagnose. The purpose of this study is to reportour experience using a three-phase whole body Technetiumbone scan as a screening tool in identifying the source of per-sistent pain in profoundly handicapped children who can notcommunicate.

Methods: We reviewed the medical and imaging records of 45patients who met the inclusion criteria of the study, which in-cluded a diagnosis of spastic quadriplegic cerebral palsy with se-vere motor and cognitive impairment, persistent pain of morethan one week in duration with no recognizable source, and athree-phase bone scan as part of the pain workup.

Results: The study group included 26 females and 19 males withan average age at presentation of 13.5 years (range 3–20 years).A positive bone scan (tracer uptake) was seen in 24 patients(53.3%). A diagnosis and the source of pain was identified in all24 patients with a positive bone scan, with the bone scan beinginstrumental in establishing a diagnosis or localization in 22patients. A diagnosis was never established in the 21 patientswith a negative bone scan. Based on the bone scan resultsadditional imaging was obtained at the position indicated. Bonescan was used to establish a diagnosis of fracture in 10 of 24patients and a variety of other diagnoses. Other diagnoses in-cluded three patients with painful internal hardware, two withsinusitis, two with infections, and one with obstructed kidneys,among others.

Conclusions: Based on the results of this study we feel that thebone scan can be a useful tool in identifying the source of per-sistent pain in the profoundly handicapped, non-communicativechild.

Significance: Bone scan is a viable imaging option to identify thesource of persistent pain in the profoundly handicapped non-


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communicative child. Bone scan can assist in localizing the sourceof pain and direct the location for further imaging as needed.

122

Scoliosis in Quadriplegic Cerebral Palsy: Risk factors

for progression

Author: Hakan Senaran (United States)

Co-Authors: Suken Shah (United States), Kirk Dabney (UnitedStates), Joseph Glutting (United States), Freeman Miller (UnitedStates)

Purpose: The natural history of scoliosis and risk factors forprogressive scoliosis in children with spastic quadriplegic cerebralpalsy (CP) await clarification. The effect of adolescent growthspurt on the progression of scoliosis in CP has not been clearlydefined. To define the natural history of scoliosis, risk factors forprogressive scoliosis, and the effect of adolescent growth spurt onthe progression of scoliosis in children with spastic quadriplegiccerebral palsy.

Methods: A retrospective review of the medical records andradiographs of 135 cerebral palsy patients followed at the sameinstitution who had adequate radiographs of the spine at initialand follow up presentation and who had at least 25 degrees ofscoliosis at follow up was performed. The effects of curve type,adolescent growth spurt, functional capacity of the patient andsurgically treated previous hip subluxation were evaluated on therate of curve progression and pelvic obliquity.

Results: The mean rate of curve progression was found to be 13.9degrees/year in spastic quadriplegic children. Scoliosis was diag-nosed and treated at an earlier age in wheelchair bound patientscompared to ambulatory patients. The rate of curve progressionincreased proportionately to the worsening functional capacity ofthe patient. Using analysis of covariance, juvenile pa-tients(<10 years at last follow up) had significantly higher rate ofcurve progression than the adolescent patients(>10 years old atinitial presentation). Surgically treated previous hip subluxationsignificantly increased the magnitude of pelvic obliquity. Curvetype and gender have no effect on rate of curve progression.Lumbar curves were the most common.

Conclusions: The adolescent growth spurt has no effect on the rateof curve progression, but most curves increased with growth. Thespasitic quadriplegic patients who had previous hip subluxationshould be followed closely for pelvic obliquity, to protect them fromthe potential complications of pelvic obliquity such as sitting in-balance, pressure ulcers and hip pain. Gender and curve type has nosignificant effect on rate of curve progression. Spastic quadriplegiccerebral palsy patientswho developed curves at less than 10 years ofage andwhoare nonambulatorywith previous or co-existing spastichip disease should be monitored at frequent intervals and theircaretakers counseled on the natural history of progressive scoliosissince they have highest risk of curve progression.

Significance: Spastic quadriplegic cerebral palsy patients whodeveloped curves at less than 10 years of age and who are non-ambulatory with previous or co-existing spastic hip disease shouldbe monitored at frequent intervals and their caretakers counseledon the natural history of progressive scoliosis since they havehighest risk of curve progression.

123

Femoral derotation osteotomy as part of single-stage

multi-level surgery in diplegic cerebral palsy children using

Intramedullary Stable Elastic Nail fixation (ISEN)

Author: Tim Theologis (United Kingdom)

Co-Authors: Julie Stebbins (United Kingdom), Andrew Wain-wright (United Kingdom), Nicky Thompson (United Kingdom)

Purpose: Femoral derotation osteotomy (FDRO) is often part ofsingle-stage multi-level (SSML) surgery in children with spasticdiplegic cerebral palsy (CP). Failure of the fixation followingearly weight bearing, non-union, infection and incomplete cor-rection are potential problems. Periosteal stripping is undesirablewhile muscle dissection to gain adequate bone exposure mayfurther compromise pre-existing problems of weakness.Muscleweakness is now a recognised problem in CP. We have shownthat lower limb muscles remain weaker than pre-operatively at1 year after SSML, although gait parameters are significantlyimproved. We are therefore in the process of combining new‘‘strength preserving’’ surgical techniques, allowing earlier mo-bilisation, with resistance strength training. As part of this pro-gramme, we perform the FDRO using closed corticotomy andfixation with ISEN. The aim of this study was to compare theearly results of strength preserving surgery to conventionalSSML, with particular focus on the results of the femoral oste-otomy.

Methods: Seven patients who underwent 13 FDROs as part ofSSML were compared with an equal number of patients matchedfor age and function (GMFCS) who underwent conventionalSSML. Clinical examination and gait analysis were performed pre-operatively and at 6 months post-op. Routine radiographs weretaken at 6–8 weeks post-op. The surgical technique included distalinsertion of both nails, advancement to the isthmus of the femur,closed corticotomy at this level, derotation and final advancement.A k-wire centrally placed in the femoral neck was used to assess thecorrection of anteversion. The clinical and gait parameters in thetwo groups were compared using t-test (p < 0.05).

Results: All osteotomies healed without complications within6–8 weeks post-operatively. The ISEN group showed significantlyless blood loss (average 109 ml vs 255 ml, p < 0.0002) and timeto mobilise (average 8.5 days vs 45 days p < 0.00004). Operativetime was shorter in the ISEN group (191 min vs 245 min butp = 0.22). Comparison of the groups at 6 months showed nosignificant difference in the correction of femoral anteversion,the Gillette Gait Index and the gait parameters relating todynamic hip rotation. Hip rotation during gait corrected to nor-mal limits at 6 months post-operatively in 11/13 legs in bothgroups.

Conclusions: Performing FDRO in the context of multi-levelsurgery in CP can safely and effectively be achieved with cortic-otomy and fixation with ISEN. The correction achieved, asmeasured clinically and with gait analysis at 6 months post sur-gery, is similar to conventional techniques. Moreover, our tech-nique led to significantly less blood loss, faster mobilisation as wellas shorter surgical time.

Significance: Our technique carries significant advantages overconventional techniques.


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Poster Presentations

Basic Science

124

WITHDRAWN

125

Zink in Non-mature Bone.

Author: Bjarne Møller-Madsen (Denmark)

Co-Authors: J Ovesen (Denmark), JS Thomsen (Denmark)

Purpose: The aim of the present study was to visualize Zn ions incartilage tissue and synovial membrane.

Methods: Fortyfive male Wistar rats, aged four weeks wererandomly divided into three groups. They received diet withdifferent amounts of zink added. Group A received zink-free diet.Group B received normal diet. GroupC received diet supplementedto 60 mg zink/kg. Rats were sacrificed 4 weeks later. Hind limbswere dissected from the body and fixed in glutaraldehyde. Longi-tudinal sections were prepared according to the zink specificNeo-Timm method and examined microscopically. Controls wereincluded.

Results: Alimentary zink supply resulted in an increase in theheight of the total growth plate in a dose-dependent manner. Zinkwere localised in chondrocytes of epiphyseal and articular carti-lage and in the inner layer of the synovial membrane.

Conclusions: Previously publiced data have suggested zink to be aregulator of the calcification. Nobody has previously visualised Znions in the chondrocytes of the articular cartilage.

Significance: The localisation may indicate a role in the calcifica-tion of cartilage and/or a role in the regulation of the formation ofcartilage and thereby the longitudinal growth of long bones.

Neuromuscular disorders

126

Strategy to treat bilateral hip dislocations in arthrogryposis

multiplex congenita -open reduction including circumferential

capsulotomy and iliopsoas transfer using extensive anterolateral

approach-

Author: Kiyoshi Aoki (Japan)

Co-Authors: Hirofumi Akazawa (Japan), Takumi Nasu (Japan),Sachiko Goto (Japan), Hirosuke Endo (Japan), Shigeru Mitani(Japan), Ko Oda (Japan)

Purpose: Arthrogryposis multiplex congenita (AMC) is a raredisease with multiple joint contractures. It was widely believedthat bilaterally dislocated hips should not have been reducedsince movement was satisfactory and results of open reductionwere poor. Akazawa reported middle-term follow-up (the meanwas 11.8 years) of the new open reduction method (J.B.J.S.(Br)80 636–640 1998). The purpose of this presentation is to reportlong-term follow-up (the mean was 20.2 years) and thinkabout the role of our method for bilaterally dislocated hips inAMC.

Methods: From 1954 to 1995, we have examined 48 arthro-grypotic children. Of these, there were 11 patients with 21 hipdislocations; 10 had bilateral and one unilateral dislocation.Since 1977 we have performed a new method of open reductionincluding circumferential capsulotomy and iliopsoas anterolat-eral transfer on ten bilaterally dislocated hips in five childrenwith AMC. The mean age at surgery was 31.5 months (17 to64) and the mean follow-up 20.2 years (15.4 to 29.6). Follow-up examination included assessment of the range of movementand walking and radiography. Motion in the joint was evalu-ated on the criteria of Gruel et al. Anteroposterior radiographsof each hip were graded according to the classification ofSeverin.

Results: At the final follow-up, all patients walked without crut-ches or canes. Two managed independently, one required a longleg brace and two had short leg braces because of knee and/or footproblems. Walking ability was maintained in all patients. Theclinical results were good in six hips, fair in two and poor intwo. On the Severin classification eight hips were rated as good(group I or II).

Conclusions: We believe that our open reduction method includingcircumferential capsulotomy and iliopsoas transfer using extensiveanterolateral approach could be one of the useful strategies totreat bilateral hip dislocations in AMC.

Significance: Long-term follow-up (the mean was 20.2 years) ofthe open reduction method including circumferential capsulotomyand iliopsoas transfer using extensive anterolateral approach forbilaterally dislocated hips in AMC is reported.

127

‘Keep them walking!’: Functional results of tendon transfers

in MMC

Author: Arnold T. Besselaar (Netherlands)

Co-Authors: Alexander Haverkamp (Netherlands), RalphSakkers (Netherlands), Rene Castelein (Netherlands), Hans Pruijs(Netherlands)

Purpose: Many patients with myelomeningocele (MMC) haveprogressive deformities of the feet causing a decrease in ambu-lance level. These deformities can either be caused by structuralabnormalities in the foot or can be secondary to muscle imbal-ance. A number of reports describe favourable results of tendontransfers in this last group but reports on long-term functionaloutcome after these procedures are scarce. In this retrospectivestudy, children with MMC are followed after tendon transfers inthe feet until after puberty.

Methods: Seventy-one children with MMC with a motor levelbeneath L2 had tendon transfers in the feet in the WilhelminaChildren’s Hospital between 1985 en 2006. Because ambulanceoften decreases in puberty, follow-up was done until after puberty(minimal age of follow-up 13 years in girls and 14 years in boys).After the usage of this inclusion criterium 32 of the 71childrenwere selected. The ambulance level according to Hoffer wasscored pre-operatively and at last follow-up. (Hoffer 1: commu-nity walker, 2: household walker, 3: therapeutic walker and 4:wheelchair bound). The level of MMC and the presence or ab-sence of hydrocephalus was recorded.

Results: Mean age at operation was 8.4 years and mean age atfollow-up was 19.3 years. Decrease of ambulance level was notstopped in the upper lumbar MMC’s, mean Hoffer increased from2.8 to 3.2 for L2–L3 levels and from 1.6 to 1.9 in L3–L4 levels allwith hydrocephalus. Ambulance was improved in the L5–S1 lev-els, Hoffer score decreased from 1.2 to 1.0 For S1 and lowerlevelsHoffer score remained stable at 1.The group L5–S1 levels with

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S58 Poster presentations: Abstracts 124–322/J Child Orthop

hydrocephalus showed also a decrease in Hofferscore, from 1.6 to1.1. MMC’s ambulance levels seem to improve after tendontransfers of functional muscles. Children without hydrocephalusseem to have a better outcome.

Conclusions: Many reports are written about joint mobility resultsrelated to tendon transfer operations in MMC. However effectson ambulation, for example by using the Hoffer score, have notbeen published. This study shows the level of MMC and thepresence/absence of hydrocephalus as main factors that influencethe final outcome. Tendon tranfers can preserve or improveambulation levels in the long-term in children with lower lumbarand lumbar-sacral MMC.

Significance: level II, cohort study.

128

The Effect of Hamstrings Stretching on Hip Displacement

in Cerebral Palsy

Author: Chia Hsieh Chang (Taiwan)

Co-Authors: Yu Chen (Taiwan), Zhon Lee (Taiwan)

Purpose: Hamstring, a hip extensor, is seldom regarded as a factorfor hip displacement in cerebral palsy. A common method tostretch hamstrings is passive knee extension when hip 90� flexion.This study is to explore the changes of hip when hamstrings arestretched at 90-90 position.

Methods: Twenty children with spastic cerebral palsy had pelviscomputer tomography (CT) before operation for hip displacement.Patients were supine on a special flame with one hip flexion (studyside) and one hip extension. Two sets of CT studies were done whenresting in 90-90 position and when hamstrings stretching. Thepower holding the legs in stretching position was 7.0–8.5 lb mea-sured by a hand-held dynamometer. Distance from triradiate car-tilage to the lateral margin of femoral epiphysis was measured andcompared between resting and stretching using paired-t test.

Results: Twenty children had CT study at age of 5.8 (4.0–8.5)years. The migration percentage of the 40 hips was 47% (28–81) inaverage. Distance from triradiate cartilage to the lateral margin offemoral epiphysis was 42.1 mm at resting and 44.8 mm at ham-strings stretching, and the difference is statistically significant. Thelateral displacement (2.7 mm) was equal to 13% migration per-centage when divided by the epiphysis diameter. This phenome-non was not noted in normal children.

Conclusions: Spasticity induces muscle contraction and applies aposteriorly displacing force on the femur, when hamstrings arestretched at hip flexion. We recommend stretching hamstrings forchildren with cerebral palsy by passive hip abduction at hipextension position instead of 90-90 position.

Significance: Further deterioration of hip displacement was dem-onstrated by stretching hamstrings at 90-90 position in the chil-dren with established hip displacement.

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Botulinum toxin before orthopaedic surgery in cerebral palsy

children, what are the benefits?

Author: Bruno Dohin (France)

Co-Authors: Remi Kohler (France), Christophe Garin (France)

Purpose: Spasticity could be aetiology of pain in cerebral palsy(CP) children. Orthopaedic surgery is often needed in such patientand post surgical pain could be increased by spasticity. Moreover,symptoms could be worse by abnormal movements, cast immo-bilization and patient’s anxiety. Treatment of spasticity is needed

after orthopaedic surgery in CP children (Nolan J 2000). It hasbeen previously reported in a randomized study (Barwood S 2000)a benefit as regard of pain in using botulinum toxin (BT) beforesurgical tenotomy in CP children. The aim of this work was toassess the benefits, as regards of pain and comfort, obtain by theuse of BT before bone surgery in total body involved CP children.

Methods: Two successive groups of 9 total body involved CPpatients were compared in a retrospective study. All the patientsunderwent an orthopaedic surgery procedure for bone surgery ormultilevel surgery. The second group was treated before surgerywith multilevel injection of BT. The main studied criteria were:efficiency and adverse effects of BT, duration of hospitalizationand pain symptoms, length of level III analgesic treatment(morphine), sleep quality and skin lesions under cast immobili-zation.

Results: No significant difference was noted in the characteris-tics of the both groups except the treatment with BT. Efficiencyof BT was clinically confirmed using Aschworth scale and noadverse effect was noted. The mean ages of the both groupswere 8.7 y (ET 2.04) versus 10.9 y old (ET 4.37). The meanbody weights were 20 Kg (ET 5.6) and 26 Kg (ET 7.7). Dose ofBT in the BT group was a mean of 11.6 U BOTOX�/kg (9.7 to14.8). The mean delay for BT injection before surgery was27 days (23 to 31). All the patients had cast immobilizationafter surgical procedure, except 2 (BT group, orthopaedictraction). The mean duration was 6 weeks in both groups. Nosignificant variation was noted in duration of hospitalization:7.33 days (ET1.5) versus 7.88 d (ET1.7) and duration of levelIII analgesic treatment: 4.33 days (ET 1.9) versus 4.16 d (ET2.5). However, the duration of pain symptoms decrease signif-icantly from 6.87 d (ET2.9) to 2.22 d (ET 1.7) and sleep qualitywas improve from 7/9 patients to 1/9 patients with disturbsleep. Four under cast skin lesions were noted in the first groupbut none in the BT group.

Conclusions: We can not confirm that BT used in bone surgeryinduces lesser consumption of analgesic. However, ourresults support the hypothesis that treatment of spasticity usingBT before bone surgery decrease duration of postoperativepain and improve comfort of children. Moreover, the studysuggest that postoperative under cast skin lesions could beprevent.

Significance: This work suggest that benefits as regard of pain andcomfort could be obtain when using BT as multilevel injectionbefore orthopaedic surgery in spastic total body involved CPchildren.

130

Ambulatory activity, health and quality of life in youth

with arthrogryposis


Co-Authors: Erin Dillon (United States), Ken Jaffe (UnitedStates), Kristie Bjornson (United States)

Purpose: To compare physical activity between youth withamyoplasia or distal arthrogryposis and typically developingyouth (TDY) and to explore the correlation between the ambu-latory activity achieved by youth with arthrogryposis and self-reported health and quality of life.

Methods: This is a cross-sectional comparision study. The dailyfrequency, duration and intensity of ambulatory activity weremeasured using the StepWatch? Activity Monitor (SAM).Twelve youth with amyoplasia or distal arthrogryposis and 11age and gender matched TDY wore the monitor on their ankles

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Poster presentations: Abstracts 124–322/J Child Orthop S59

for 7 days. Subjects completed the Activities Scale for Kids,Performance (ASKp) and Capabilities (ASKc) questionnaires tocompare self-reported activity levels with SAM measurements.The Child Health Questionnaire, Child Version (CHQ-CF 87)and Parent Version (CHQ-PF50) measured self-reported healthstatus. Quality of life was measured with the Youth Quality ofLife Research version (YQOL-R) completed by both parent andchild.

Results: The mean age of the arthrogryposis group was 10.9while the mean age of the TDY group was 9.5. There were 8males and 4 females in the arthrogryposis group and 6 malesand 5 females in the TDY group. Youth with arthrogryposistook an average of 5425.25 +’- 1100.65 steps each day andspent 8.50 +/– 2.86 percent of their active minutes in high steprates. The age and gender matched TDY took an average of7420.91 +/– 1557.97 steps each day and spent 11.91 +’- 5.07percent of their active minutes in high step rates. The youthwith arthrogryposis scored an average of 73.6108 +/– 10.8012on the ASKp self-report follow up while the TDY scored anaverage of 91.4009 +/– 3.6042. There was a trend for childrenwith amyoplasia to have more limitation than children withdistal arthrogryposis.

Conclusions: Youth with arthrogryposis took fewer total stepseach day than TDY and spend a lower percentage of each day inhigh activity levels. The youth with arthrogryposis also scoredlower on the ASKp activity scale than TDY.

Significance: This is the first study to quantify functional differ-ences for children with amyoplasia and distal arthrogryposis fromtypically developing children. Information regarding baselinefunctional disability is important to assess the impact of inter-vention.

Cerebral Palsy

131

Quantifying nerve traction injury during correction of knee

flexion deformities in children with cerebral palsy

Author: Claudia Auner (United Kingdom)

Co-Authors: Haur Tho (United Kingdom), Ramesh Nadarajah(United Kingdom), David Ingram (United Kingdom), MarkPaterson (United Kingdom)

Purpose: Bilateral hamstring lengthening is used to correct flexiondeformity at the knee in children with cerebral palsy. To ourknowledge, there has been no publication which reports the fre-quency of post-operative peripheral nerve complication in thesepatients. Damage to the nerve may occur at the time of operationafter passive stretching or post-operatively when the limb issplinted in its new position.

Methods: Seven children with cerebral palsy were treated withhamstring lengthening by the senior author. The amount ofcorrection of the deformity was determined by the pre-andpostoperative measurement of popliteal angles in each case.We used neurophysiological studies to evaluate the effects ofhamstring lengthening on nerve function in these patientsboth pre-operatively and at pre-determined periods post-operatively.

Results: Post-operative peripheral nerve complication is frequentin these patients and sub-clinical nerve damage does occur.

Conclusions: A relationship exists between amount ofcorrective lengthening and the degree of neurophysiologicalabnormality.

Significance: Our results, combined with clinical judgement, helpprovide guidelines for safe corrective surgery.

132

Ambulatory Activity in Youth with Cerebral Palsy.

Author: Kristie Fay Bjornson (United States)

Co-Authors: Basia Belza (United States), Deborah Kartin (UnitedStates), Rebecca Logsdon (United States), John McLaughlin(United States)

Purpose: To describe the day-to-day ambulatory activity of youthwith Cerebral Palsy (CP) compared to typically developing youth(TDY).

Methods: Within a cross-sectional comparison study design, theStepWatchTM, was calibrated to each youths walking pattern,was worn for 7 consecutive days during the school year. Five(24 hour) days of data (four school days and one weekend day)were analyzed. Average total steps per day, percentage of alltime active, ratio of medium to low activity level and percentageof time at high activity levels were calculated. Low activity wasdefined as < 14 step/min, medium 14–42 step/min and highactivity. A convenience sample of 81 youth with CP, GMFCSLevels I-III, and 30 TDY recruited from three tertiary carechildren’s hospitals and a regional military hospital. Participantage averaged 11.8 (SD+ 1.2) years, half were male (52%),majority were Caucasian (79%), and one third of guardians(36%) attended some vocational school or college.

Results: Average steps per day were 4,244 (CI 3739–4749) and6,740 (CI 6123–7355) for youth with CP and TDY respectively(p < .001). Youth at GMFCS Level I averaged significantlymore steps per day than Levels II and III (p < .001). Per-centage of total active time walking ranged from 10 to 67% foryouth with CP with only the Level III youth significantly dif-ferent (p < .01) from TDY. Ratio of medium to low activitywas ordered by functional level (TDY > CP) and ranged from.14 to .47. Percent of time in high activity level ranged fromzero to 20%, and increased with higher functional level. Youthat Levels II & III differed from TDY for both variables(p < .003). Youth in Level 1 demonstrate variability ofwalking (% medium to low) and a level of high step activity(> 42 steps/minute) consistent with the TDY sample.

Conclusions: Daily ambulatory activity (performance) increases asGMFCS level (capacity) increases . Youth with CP in level I ap-pear as active as the TDY. Youth requiring assistive devices towalk have the greatest limitation in number of steps taken per day,overall active time, ability to use a variety of activity levels and/orattain and use high activity levels.

Significance: Treatments aimed at improving daily ambulatoryactivity have the most potential for change in youth at Levels IIand III. These results provide preliminary normative data ofwalking activity in youth with CP using an objective measure-ment.

133

Long term outcome in cerebral palsy patients

with unilateral hip dysplasia managed by proximal femoral

osteotomy

Author: Khaled Emara (United States)

Co-Authors: khaled Emara (Egypt), Johnathan Sembrano(Philippines), Vector Bialik (Israel), Michael Aiona (UnitedStates), Michael Sussman (United States)

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Purpose: review the long term outcome of intertrochnteric oste-otomy for hip subluxation in GMFCS level 5 children, and thelong term effect on the contralateral hip.

Methods: This study presents a long term follow-up of 28 spasticcerebral palsy patients (GMFCS level V) who presented withunilateral hip subluxation. All patients were managed initially byunilateral soft tissue release and proximal femoral inter-trochan-teric osteotomy with internal fixation. All patients included in thestudy were followed until skeletal maturity. We reviewed clinicaland operative notes, and radiographs from the time of presenta-tion until age of 21. The data collected included the GMFCS level,demographic data, type of surgery, method of fixation, type ofimplant, any other surgical procedures before, associated or fol-lowed the index procedure, migration percentage, acetabularinclination, and associated scoliosis.

Results: There were 14 male & 13 female patients identified.Average age at the time of intertrochanteric osteotomy was7 years and 2 months old. Out of the 28 patients 13 osteotomyfor the contralateral hip during the follow up period. The aver-age interval between the initial surgery & the contra lateral hipsurgery was 6 years and 3 months. During follow-up 15 patientsneeded re-operation due to recurrent deformity for the operatedhip. These revisions included revision of the inter-trochantericvarus osteotomy +/– soft tissue release, and pelvic osteotomy.

Conclusions: Unilateral inter-trochanteric osteotomy in cerebralpalsy patients with GMFCS level 5 is associated with high chanceof resubluxation and the need for further intervention during thelong term follow-up. There is also a high chance for the contra-lateral hip subluxation in this group of patients (46.4%). There-fore patients undergoing surgical treatment for unilateral hipsubluxation must continue to be monitored for repeat or contra-lateral subluxation until skeletal maturity.

Significance: this study show the long term effect of intertro-chanteric varus osteotomy for hip containment on the treated hip& the contralateral hip.

134

The use of Botulinum toxin A in the treatment

of hip subluxation in spastic cerebral palsy

Author: Kristof Fabry (Belgium)

Co-Authors: Kaat Desloovere (Belgium), Anja Vancampenhout(Belgium), Guy Molenaers (Belgium)

Purpose: The purpose of this study is to evaluate the effect ofBotulinum toxin A (BTX-A) on the subluxation of the hips inpatients with spastic CP.

Methods: We report on 12 cerebral palsy patients with 15 treatedhips. Ten patients were quadriplegic and two were diplegic. Theinitial radiographic evaluation was taken at an age between5 years and 7 years and 3 months (median: 5 y and 6 months).Reimer’s migration percentage was determinded on a standarda.p. X-ray one to fourteen (median 2.63) months before and twoto nine months (median 5,68) after botox infiltration. The dose oftherapeutic Botox per muscle was selected based on muscle sizeand the desired treatment effect Post botox abduction was givenby an abduction brace or long leg casts with an abduction bar.Intensive stretchings of adductor and psoas musculature wasstarted. The orthosis was worn during 23 hours a day during6 weeks. After this period continuous abduction was built inwheelchair and nightorthosis. To exclude the effect of outliners ina limited test group, non-parametric statistical analyses wereperformed. The data analysis of the study were split up into threeparts: 1. analysis of the total group (N = 15), 2. analysis of thesubgroup with two follow-up times (N = 11), 3. analysis of the

subgroup receiving two BTX-A treatments (N = 6). For eachgroup, the median and interquartile range (IQR) for the 4parameters were calculated at different evaluation times. A Wil-coxon signed rank test was performed determining statisticalsignificant differences between pre and post BTX-A conditions.The critical P-value was defined as 0.05. All statistical procedureswere performed with the SAS system.

Results: A significant improvement (p < 0,01) of Reimers’ indexwas noticed after the first botox infiltration. The index decreasedfrom 42% to 35% and also the interquartile range narrowed. Postbotox X ray’s were taken at a median of 5,68 months. From elevenof our patients a secondX-raywas available taken at amedian of 11,2 months after the botox infiltration. The Reimers’ index againincreased to a median of 40% wich meant a significant worseningcompared to the first post botox value (p < 0,05). Six patientsreceived a second botox infiltration, between 9 and 34 months aftertheir first treatment (at a median age of 6 years and 11 months).This group is too small to draw statistical conclusions. But a de-crease with a narrow interquartile range could be achieved. ThemedianReimers’ indexdecreased from42%to36%after the secondinfiltration without any excessive value above 40% . So these pa-tients could have been stabilized conservatively during 2 years.

Conclusions: The use of BTX-A decreases the subluxation per-centage of the hips in CP patients. A repeat treatment should beconsidered.

Significance: This study showed us how an early varisation-dero-tation osteotomy can be delayed in CP patients with subluxatinghips.

135

Medial column arthrodesis in spastic plano-valgus foot.

Author: Patrıcia Moraes de Barros Fucs (Brazil)

Co-Authors: Celso Svartman (Brazil), Rodrigo Assumpcao(Brazil), Simone Simis (Brazil)

Purpose: The treatment of spastic plano-valgus feet is challengingespecially in adolescents and young adults, due to severe and rigiddeformities. The purpose of this study is to present the preliminaryresults of the surgical treatment of this deformity by arthrodesis ofthe foot medial column and internal fixation with a small frag-ment DCP plate.

Methods : Between March 2003 and September 2006, 13 patients(22 feet) with spastic Cerebral Palsy and plano-valgus feet weretreated with arthrodesis of the foot medial column and internalfixation with a small fragment DCP plate. The mean age was17 + 2 (min. 13 + 2, max. 29 + 9), 7 male and 6 femalepatients. 5 patients non-walkers, 5 household-walkers and 3 com-munity walker. 5 diplegic and 8 tetraplegic. The right side wasoperated in 9 feet and 13 on the left side. The surgical indications :severe deformity, gait dysfunction and pain. The arthrodesis onthe medial column addressed the talonavicular, navicular-medialcuneiform and medial cuneiform-1st metatarsal joints, being allcases internally fixed with a molded small fragment DCP plate, torestore the medial longitudinal arch. In 3 feet was associated thearthrodesis of the calcaneo-cuboid joint and in 3 feet tendonAchilles lengthening. All patients were in short leg cast for a meantime of 8 weeks. After this period physiotherapy was initiated. Allradiographic measurements were done on the lateral view of thefoot : - angle of the inclination of the calcaneus: min. –26�, max.16�, mean –2,3�.- talocalcaneal angle : min. 22�, max. 55�, mean38,6�. The mean follow-up period was 1 year and 6 months(ranging from 0 + 6 to 3 + 6).

Results: All patients are being followed and presenting withimprovement of the foot deformity, no pain or shoe wear dif-

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ficulties. No change in function status of the patients occurred.Radiographically post-operatively: angle of the inclination ofthe calcaneus improved to a mean of 10�, min. 5�, max. 18�;talocalcaneal angle with mean 35,4�, min. 23�, max. 48�. Therewere two hardware failures due to pseudoarthrosis at thenavicular-medial cuneiform joint. This complications weremanaged by changing the hardware and bone grafting, healinguneventfully.

Conclusions: In conclusion the stabilization of the foot medialcolumn could be an option in the treatment of the severeand rigid spastic plano-valgus feet in adolescent and youngadults.

Significance : Case series study, Level 4.

136

External fixation of hip osteotomies in patients

with neuromuscular conditions

Author: Anastasios D. Kanellopoulos (Greece)

Co-Authors: Leonidas Badras (Greece), Dimitrios Lamprou(Greece)

Purpose: To assess the efficacy of external fixation in securingupper femoral osteotomies in patients with cerebral palsy.

Methods: 12 patients,5 females and 7 males with mean age 9 yrs(range 5–16) with hip dislocation secondary to cerebral palsyunderwent varus derotational osteotomies that were fixed withexternal fixation. One patient had bilateral dislocations.

Results: Mean follow up was 25 mo(range 14–37 mo). Neck shaftangle correction was at an average of 43 degrees (range 35–54). Allosteotomies healed with no loss of the initially achieved correc-tion. No patient required blood transfusion. All devices were re-moved at the office.

Conclusions: External fixation is efficassious in stabilizing upperfemoral osteotomies in patients with cerebral palsy.

Significance: External fixation can be an alternative to plateand screw fixation of upper femoral osteotomies, since it can beperformed through a smaller surgical approach, it is adjustableeven after surgery and does not require a second operation forremoval.

137

Change of functional status in children with

cerebral palsy after percutaneous myofascial

lengthenings

Author: Anastasios Kanellopoulos (Greece)

Co-Authors: Stamatios Vrettos (Afghanistan), Hristos Giannak-opoulos (Afghanistan), Leonidas Badras (Afghanistan)

Purpose: To assess the effect of a minimally invasive techniquethat requires no hospitalization and no post-operative immo-bilization on the functional status of children with cerebralpalsy.

Methods: The study includes 74 patients that were preoperativelyclassified to the 5 stages slassification according to their gmfcs thatwas also assessed. The score and the stage was re-determined at6 months,12 and 24 months post-operatively. All such measure-ments were performed by a certified pediatric physiotherapistspecialized in cerebral palsy,blinded to the method. Mean age ofthe patients were 8 years (3.5–16).

Results: No patient lost pre-operative functional status. Nonerequired hospitalization. All demonstrated at final follow up at 24

mo one stage improvement at least and a mean 16% inrease oftheir gmfm score at 6 months and 24% increase at 24 monthsaccordingly.

Conclusions: According to this study function improvement can beanticipated in children with cerebral palsy through a minimallyinvasive technique where muscle length is achieved through per-cutaneously performed myofascial cuts.

Significance: Soft tissue surgery in cerebral palsy patients hastraditionally been open with a period of hospitalization and postoperative immobilization. The method discussed offers favourableresults having the merits of requiring no hospitalization and noimmobilization with profound benefits to patient’s emotional andfunctional status.

138

Neurogenic foot deformities – Optimal treatment

for individual foot deformities

Author: Alexander Krebs (Austria)

Co-Authors: Walter Strobl (Austria), Robert Csepan (Austria)

Purpose: Patients with cerebral palsy and neurogenic diseases of-ten suffer from foot deformities limiting mobility and quality oflife. We analysed the results of surgical correction and determinedthe optimal treatment for the main deformities.

Methods: We analysed retrospectively the results of surgical cor-rection of foot deformities. 87 Patients were treated between 1995and 2003. We have actual data from 51 Patients (59%) with 68feet treated. Mean follow up time is 4,25 years. We had 23 Pa-tients with neurogenic clubfoot, 16 with flatfood, 25 with pesequinus, 2 pes cavus and 2 hallux valgus. Of these patients 73%were able to walk before surgery.

Results: Measuring quality of life we evaluated pain, walkingdisorders and problems by skin lesions with a Visual AnalogueScale (0–10). Pain decreased from 4,01 to 1,58 (p < 0.001),walking problems improved from 6,87 to 3,31 (p < 0.001),problems by skin lesions improved from 3,79 to 1,35(p < 0.001). Maximum walking time increased from a mean of17 minutes to 52 minutes (p < 0.001). The level of mobilitywas increased in 34%. These results were the basis for theanalysis of the best treatment for each deformity. For eachgroup (neurogenic clubfoot, flatfoot and equinus) the best andpoorest outcomes were selected and analysed. We evaluateddiagnosis, indication for surgery, mobility and expectations ofthe patient before surgery in comparison to the outcome,postoperative physiotherapy and the use of orthoses.

Conclusions: Surgical reconstruction of neurogenic foot deformi-ties showed excellent results. Essential is a muscular balancing toachieve long lasting results. Regular physiotherapy and nightorthoses can improve the outcome. In conclusion we like topresent our algorithm for the surgical and conservative treatmentof neurogenic foot deformities.

Significance: Therapeutic Study, Level III.

139

Intrathecal Baclofen Therapy for Children with spastic cerebral

palsy and total body involvement.

Author: Alexander Krebs (Austria)

Co-Authors: Walter Strobl (Austria), Radomir Cumlivski (Austria)

Purpose: Management of functional disturbing or painful spasticityin patients with spastic cerebral palsy and total body involvement is

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crucial. Oral medication with anti spastic medicaments is oftenlimited by the side effects and local treatment with botulinumtoxine type A would exceed the maximum dose in certain patientswith total body involvement. In these special cases we use intra-thecal baclofen since 1999. Our aim of this study is to evaluatequality of life after implantation of a baclofen pump.

Methods: An intrathecal baclofen pump was implanted in 15patients since 1999. 10 patients had spastic cerebral palsy, 5 pa-tients head injuries. We analysed spasticity according to themodified Ashworth scale and maximum sitting time. Sittingcomfort, pain, nursing and positioning were analysed using a vi-sual analogue scale.

Results: The mean Ashworth scale decreased highly significantfrom 4.38 to 3 (p < 0.001). Other parameters also showed sig-nificant (p < 0.1) improvement. Patients and care takers werevery satisfied with the results. Quality of life increased byimproving the sitting abilities and reducing pain.

Conclusions: Intrathecal baclofen therapy is an efficient and safetherapy for patients with severe total body involvement. Qualityof life may be increased. Excellent cooperation and compliance bypatients and/or their care takers are essential because regularchecks and refillings are necessary every 3 to 6 month. To achievegood postoperative results an individual test period with anexternal pump is necessary for these patients.

Significance: Therapeutic Study, Level IV.

140

Management of spasmodic torticollis and abnormal

trunk posture with botulinum toxin type A in children

with spastic type cerebral palsy

Author: Hideaki Kubota (Japan)

Co-Authors: Suyun Ryu (Japan), Yutaka Oketani (Japan), AijiMatsuura (Japan), Yumi Ito (Japan), Hiromichi Hara (Japan)

Purpose: The porpose of this study was to examine the effects ofbotulinum toxin type A (BTx-A) injection for improving spas-modic torticollis and reducing trunk spasticity in children withspastic type cerebral palsy.

Methods: 14 children with cerebral palsy (median age when firstreceving medicaiton was 7.1 years) were injected with BTx-A. Theevaluation was carried out before and each month after an in-jeciton. The assessment included the modified Tsui scale, theAshworth scale, the aid difficulty scale and Cobb’s ange.

Results: All children had spastic quadriplegia classified at theGMFCS level V. No major side effects appeared during treatmentand the follow-up period. We found a significant improvement inthe Ashworth scale and the aid difficulty scale.

Conclusions: BTx-A is a safely and useful medication forimproving spastic muscles imbalance nad secondary dynamicdeformity in the neck and trunk muscles as well as extremitiesspasticity of children with cerebral palsy.

Significance: There are a few papers with regard to examining theeffects of BTx-A injection for improving spasmodic torticollis andreducing trunk spasticity.

141

Analysis of scoliosis progression in patients with cerebral palsy

treated by Baclofen pump implant

Author: Guido La Rosa (Italy)

Co-Authors: Francesco Costici (Italy), Osvaldo Mazza (Italy)

Purpose: The Authors analyze a group of 15 patients with cerebralpalsy, treated by Baclofen pump implant, to verify if the treatmentwith muscular relaxing drugs could benefit the progression of apre-existing scoliosis or the development of a new scoliosis.

Methods: Literature review shows a general worsening inpre-existing implant scoliosis, even if different authors havecontrasting opinions.15 patients was analyzed for scoliosis pro-gression,monitorized via x-rays pre and post-treatment.Followupranged from two to twentyfour months.

Results: This work analyzes scoliosis evolution curves consid-ering follow-up and scoliosis severity classification at the timeof implant. In patients with developing scoliosis, we haveconsidered the relationship between King type of curve andthe drug dose released by the pump, in order to make thepossible connection between critical curve angle, drug doseand King type of deformity.A significant curve progressionwas recorded at followup,irrespective of Baclofen administra-tion,mainly depending on curve severity at the moment ofimplant.

Conclusions: Neurological scoliosis natural evolution is soremarkable that it’s difficult to evaluate if the real influence of theBaclofen pump implant on a scoliosis development is effectivelyworse than a deformity natural progression.

Significance: Evidence of scoliosis progression in patientswho have scoliosis exceding 60� prior to implant must bekept in mind,in order to treat spinal deformity simultaneouslywith a Baclofen Pump implant,or in a sequential way ofprocedure.

142

Reliability of Popliteal Angle Measurement: A study

in Cerebral Palsy Patients and Healthy Controls

Author: Patrick Maathuis (Netherlands)

Co-Authors: Sabine ten Berge (Netherlands), Jan Halbertsma(Netherlands), Nienke Verheij (Netherlands), Karel Maathuis(Netherlands)

Purpose: The popliteal angle is a widely used clinical measure forhamstring contracture in cerebral palsy (CP) patients, as well as inhealthy individuals. Reliability of popliteal angle measurement isbeing questioned. The aim of this study is to determine the reli-ability of popliteal angle measurement by means of visual andgoniometric assessment.

Methods: Three different observers, measured the popliteal anglein 15 CP patients and 15 healthy volunteers. In each subjectpopliteal angles were visually estimated and measured with ablinded goniometer twice by all observers with approximately onehour between measurements.

Results: The intra-class correlation coefficient (ICC) was lower inthe CP group compared to healthy controls. The ICC for intra-observer differences was higher than 0.75 for both groups. TheICC for inter-observer reliability of visual estimates and gonio-metric measurements was low for both groups. Intermethod ICCwas higher than 0.75 for both groups.

Conclusions: Measurements in the CP group appeared to be lessreliable than measurements in the control group. Intra-observerreliability is reasonable for both groups, but lower in CP pa-tients than in controls. Inter-observer reliability of both visualestimates and inter-observer reliability of goniometrical mea-surements is low. No significant differences in reliability havebeen found between visual estimation or goniometric measure-ment.

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Significance: Because of low inter observer reliability of poplitealangle measurement his should not be the only parameter in clin-ical decision making in CP patients.

143

Changes in dynamic pedobarography and 3-dimensional gait

analysis after subtalar arthrodesis for pes planovalgus

in patients with cerebral palsy

Author: KyungSoo Oh (Korea, Republic of)

Co-Authors: HuiWan Park (Korea, Republic of), HyunWoo Kim(Korea, Republic of), KunBo Park (Korea, Republic of)

Purpose: To analyze the results of subtalar arthrodesis for pesplanovalgus deformity in children with cerebral palsy using dy-namic pedobarography and gait analysis.

Methods: 28 patients(48 feet) who recieved subtalar arthrodesisbetween 2003 and 2004 were included in this study. 21 patients areboys and 7 patients are girls. The mean age at the time of oper-ation was 9 years 2 months and the mean follow up duration was12 months. Three-dimensional gait analysis and dynamic foot-pressure measurement were performed to analyze the results ofindex operation.

Results: The pressure of medial midfoot was decreased and thepressure distribution of forefoot was improved. But, the pressure of1st metatarsal head was decreased below normal range. The sagittalangle of pelvic anterior tilt was increased. Themoment andpower ofplantarflexion of ankle were not improved. But, peak knee exten-sion was increased because of increased ankle dorsiflexion. So, kneeextension-ankle plantar flexion coupling was improved.

Conclusions: The proper lengthening of plantar flexor for con-cerning about ankle dorsiflexion and power of ankle plantarflexoris an important factor for the gait improvement after subtalararthrodesis.

Significance: This study is the analysis the result of extraarticularsubtalar arthrodesis by 3-D gait analysis and dynamic pedoba-rography.

144

Dynamic pedobarographic analysis of calcaneal lengthening

osteotomy and extraarticular subtalar arthrodesis

in patients with cerebral palsy

Author: KunBo Park (Korea, Republic of)

Co-Authors: HuiWan Park (Korea, Republic of), KyungSoo Oh(Korea, Republic of), HyunWoo Kim (Korea, Republic of)

Purpose: The purpose of this study is to analyze the diffferencesbetween extraarticular subtalar arthrodesis and clacaneal necklengthening osteotomy using dynamic pedobarogrdphy.

Methods: The patients with other foot deformity, recurred defor-mity during follow up period and overcorrection of foot deformitywere excluded. 26 patients(40 feet) were selected. Group I (20 feet)were received calcaneal neck lengthening osteotomy and group II(20 feet) were received extraarticular subtalar arthrodesis. Thefollow up periods are not different between two groups.

Results: The relative impulses of hallux, 1st metatarsal head,medial midfoot were decreased and the relative impulses of lateralmidfoot, medial and lateral calcaneus were increased in all gropus.The relative impulses of 1,2,3,4th metatarsal heads were moredecreased in group II and those were below normal range. But, ingroup I, there are no differences to normal value in the relativeimpulses of 1,2,3,4th metatarsal heads.

Conclusions: The normalization of the relative impulses of1,2,3,4th metatarsal heads of group I means that the plantarflex-ion is more improved in group I. The increase of lateral columnlength in group I is the cause of improvement of plantarflexionand we think this may be the results of the increase of workinglength of peroneus longus.

Significance: The increase of lateral column length after calcanealneck lengthening osteotomy is the cause of better improvement offoot-pressure distribution and we think this may be the results ofthe increase of working length of peroneus longus.

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Results of triple arthrodesis for equinovarus foot deformity

in cerebral palsy children and adolescents

Author: Szymon Pietrzak (Poland)

Co-Authors: Bartlomiej Grabowski (Poland), Jaroslaw Czubak(Poland)

Purpose: The aim of the study was to assess the results of triplearthrodesis performed in cerebral palsy (CP) patients withequinovarus feet treated in our department between 1995 and2004.

Methods: The material consists of 109 CP children with footdeformities. Among numerous operative techniques triplearthrodesis was performed in 23 equinovarus feet and data ofthese 20 patients were assessed in further analysis. The age atsurgery was from 6 to 18 years (mean 12 years). The follow-upwas from 1 to 10 years (mean 5.3 years). Clinical assessment in-cluded data about pain, function and orthoses if they were ap-plied, as well as information about other surgical procedures. Thepositioning of hind- and forefoot was assessed, as well as range ofmotion and presence of other deformities. The radiographicevaluation was based on X-rays taken in a-p and lateral views.The GMFCS was applied for the functional assessment.

Results: None of the patients reported pain before the surgery,3 of them reported pain after long walking in the follow-up.Overcorrection was observed in 3 feet, arthrosis – in 11 feet afterthe surgery. The patients did not improve functionally after dur-ing the follow-up, (the mean pre-op GMFCS score was 2.7 vs 2.6post-op).

Conclusions: Surgery did not significantly improve patients’functional status. There was no correlation between the functionalstatus and the presence of arthrosis, although all these patientswho reported about pain in the follow-up had evident arthrosis onthe X-rays.

Significance: Equinovarus deformity of the feet in CP children,caused by the primary muscular imbalance, significantly impairstheir motor function. The triple arthrodesis of the foot enablescorrection of more severe and rigid deformities.

146

Intraoperative Measurement Of Muscle Properties Reveal

A Relationship Between Muscle Remodeling And Contracture

Formation

Author: Eva Magdalena Ponten (Sweden)

Co-Authors: Richard Lieber (United States), Stefan Gantelius(Sweden)

Purpose: The development of muscle contractures represents aserious surgical and therapeutic challenge. Unfortunately, struc-tural and functional changes that occur in muscles that cause the

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contracture are poorly understood. We developed a tool to mea-sure muscle sarcomere length (Ls) in children with cerebral palsyand then measured flexor carpi ulnaris (FCU) sarcomere lengthprior to tendon transfer surgery (n = 17 children). Measurementsfrom the FCUs of radial nerve injury patients were used as‘‘control’’ values to represent normally-innervated muscle.

Methods: Prior to surgery, the degree of contracture was assessedby measuring the extent of passive wrist motion. Then, duringsurgery, the FCU muscle belly was exposed and small fiber bun-dles isolated by blunt dissection. Laser diffraction was performedand sarcomere length was measured by using the ±1st orderspacing distance.

Results: Intraoperative Ls were extremely long in spastic FCUmuscles compared to normal FCUs from radial nerve injury pa-tients (4.6 ± 0.3 lm vs. 2.9 ± 0.2 lm). Importantly, there was ahighly significant correlation between the degree of contractureand the intraoperative sarcomere length (r = 0.70, p < 0.005).Specifically, the greater the contracture, the longer the measuredLs. The relationship between degree of contracture (in degrees)and intraoperative Ls was: y (�) = 15.5¢ Ls (�/lm) + 130�.Conclusions: There is a progressive remodeling of the muscle-ten-don unit during contracture formation. These data suggest that theincrease in sarcomere length may be due to progressive loss ofserial sarcomeres during contracture formation. This would havethe functional effect of pulling the wrist into flexion as sarcomeresare lost. The underlying mechanism for the muscular changes thatoccur secondary to upper motorneuron lesion is not known.

Significance: These results on the relation between sarcomerelength and contracture in the upper limb in cerebral palsy givenew information on the molecular changes during contractureformation.

147

Mini-invasive subtalar stabilisation of pronated feet

in CP patients.

Author: Jan Poul (Czech Republic)

Co-Authors:

Purpose: To introduce mini-invasive subtalar stabilisation ofpronated feet in CP patients,the method which can replace opensurgery.

Methods: Totally 13 feet in 7 patients were operated. Principles ofoperation: Harvesting the cancellous bone graft from iliac wing byusing the set for mosaic plasty. Denudation of sinus tarsi fromlateral mini-incision was done by using an arthroscopic shaver(blades and burrs).Then after the foot was manipulated into thecorrection a guiding wire was introduced from mini-incision overthe talar neck slightly caudally and dorsally through the neck oftalus and both cortices of calcaneus under the control of x-rayimage intesifier. Insertion of cannulated screw followed. Har-vested bone grafts were transferred into denudated sinus tarsi bydelivery tamp. All three mini-incisions were closed each with onesingle suture. POP cast for 6 weeks, then AFO orthosis for3 months. All operated feet were severely everted. Age 6–8 years.Male-4, female-3. Operation time 1 hour per one foot.

Results: Short follow-up 6–12 months. In all but 3 feet full cor-rection of the deformity was achieved. In all only discrete scarswere apparent.

Complications: Breakage of the shaft of the cannulated screw in 3out from 13 feet. In two retrograde-migration of the screwdeveloped needing refixation. On x-ray apparent talocalcanealfusion was achived in 8 out from 13 feet.

Conclusions: Results are preliminary, patients are uder follow-up.It seems, it could be a good method of subtalar stabilisation fornear future.

Significance: Comparison of presented results (partial failure in 3out from 13 cases, 23%)with classical open surgery (Dennyson-Fulford) does not show substantial difference.

148

Classification of spastic hemiplegic cerebral palsy

in children

Author: Jacques Riad (Sweden)

Co-Authors: Freeman Miller (United States)

Purpose: The Winter classification of spastic hemiplegic cerebralpalsy (CP) is based on sagittal kinematic data from three-dimen-sional gait analysis used in preoperative decision making andpostoperative evaluation. Our goal was to investigate how wellchildren with spastic hemiplegic CP can be classified usingWinter’s criteria. Secondly, we assessed if patients move betweengroups over time and/or with surgical intervention.

Methods: One hundred and twelve patients with spastic hemiplegicCP with a mean age of 8.1 years (range 3.6–19.8 years) and nosurgery before the first gait analysis were included. Medical re-cords and gait analysis data were reviewed and patients wereclassified using Winter’s criteria. Forty-six patients had two gaitanalysis and were reclassified.

Results: Thirty-one patients (28%) with no ankle dorsiflexionabove neutral during swing phase were classified as group 1.Twenty-two patients (20%) who had no ankle dorsiflexion aboveneutral during the whole gait cycle were classified as group 2.Nineteen patients (17%) had total knee range of motion less than45 degrees and were considered group 3. Fourteen patients(12%) with less than 35 degrees range of motion at the hip wereclassified as group 4. We found 26 patients (23%) that could notbe classified according to Winter’s criteria. We defined thesepatients as group 0, since they showed the least deviation fromnormal values. Each of the five groups in our study showed ahigher mean velocity of gait and the patients were younger thanin any of the groups from the Winter study. In regards torotational alignment, kinetic variables, and to a certain extentmuscle tone, group 0 showed the least deviations. When re-classifying patients after a mean of 3 years, 8 of 15 had deteri-orated in the non-surgical group, moving to a higher numberedgroup. No patient in the non-surgical group had improvedmeaning moved to a lower numbered group and 7 remained inthe same group. In the surgical group 19 of 31 treated patientshad improved and moved to a lower numbered group. Fourpatients had deteriorated and moved to a higher group while 8remained in the same group.

Conclusions: The Winter classification failed to classify 23 % (26/112) of our spastic hemiplegic cerebral palsy children. We suggestthat the classification be complemented with the less involvedgroup 0. In this way all patients can be classified and thus treat-ment plans can be established for all patients. The classificationcan be divided into ankle, knee and hip joint involvement. Theankle-involvement can be further divided into three separategroups. Treating physicians should be aware of the possibility thatpatients may move into another classification group over time.

Significance: This complement of the Winter classification,including all patients makes the system a useful tool in making notonly treatment plans but can also help in follow-up studies and inresearch.

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149

Cartilage defects associated with knee pain in adolescents

with cerebral palsy

Author: Karin Petra Schara (Slovenia)

Co-Authors: Arabella Leet (United States)

Purpose: The aim of our retrospective reiew study was to reporta case series of four young adults with cerebral palsy andcartilage defects in the knee joint as the etiology of knee pain.Most children and adolescents with knee pain are thought tohave knee pain secondary to contractures, patella alta, ormalalignment syndrome (femoral anteversion with compensa-tory external tibial torsion). Although early degenerative chan-ges have been reported in the hip joint, no description of loss ofarticular cartilage in the knee as the etiology for knee pain hasbeen previously described.

Methods: We report four cases from two centers one in Ljubljana,Slovenia and the other Baltimore, USA treated in our institutionsduring last three years. Three male patients were ambulatoryspastic diplegic and one female non-ambulatory spastic quadri-plegic, age 14 to 16 years. They all presented with severe knee painand effusion. Knee flexion contractures were present in all casesand progressed over time. In three patients moderate traumapreceded the onset of clinical signs. Plain radiographs showedpatella alta and knee flexion but did not have evidence of sub-chondral bone changes. MRI or diagnostic arthroscopy wereperformed in two patients; the remaining patients had an ar-throtomy for patellar stabilization.

Results: Cartilage loss in the distal femoral condyle of the kneewas seen during arthroscopy or patella stabilization in the studypopulation. The range of denuded area varied from a minimumof 1 cm2 to a maximum of 4 cm2. One patient had a medialmeniscal tear and partial meniscetomy was performed. Anotherpatient underwent chondroplasty in order to fill in a 4 cm2 le-sion on the medial femoral condyle in combination with ham-stringlenghtening. In two patients, a patella stabilizationprocedure was performed and the cartilage deformity weredrilled with a small caliber drill into the subchondral bone,followed by hamstring lengthening. All four patients improvedclinically following surgery.

Conclusions: Loss of the cartilage surface in the knee can causesevere knee pain with loss of ambulatory function in patients withcerebral palsy, but the pain may be attributed to other etiologiesinstead. The prevalence and the cause of cartilage defects in theknee in adolescents and young adults with cerebral palsy is un-known, but should be considered in the differential diagnosis ofknee pain in patients with cerebral palsy.

Significance: Adolescents may have cartilage defects in the kneecausing pain and loss of function. Surgical intervention is ofbenefit to return patients to a better functional level. We are notsure if this is a rare pathology, or is simply missed with knee painbeing contributed to other etiologies.

150

Subtalar Fusion in Cerebral Palsy Patients. Results

of a new technique using corticocancellous allograft

Author: Hakan Senaran (Turkey)

Co-Authors: Mary Nagai (Canada), Kirk Dabney (United States),freeman miller (United States)

Purpose: Valgus deformity of the hindfoot in cerebral palsypatients is common and causes functional deterioration and

shoe fitting problems together with skin ulcerations. The aimsof this study are to present an intraarticular technique of sub-talar fusion using allograft and internal fixation to achievestabilization and to report the results and clinical outcome of aseries of intraarticular subtalar arthrodesis performed in chil-dren with cerebral palsy.

Methods: We performed a retrospective review of radiographs andmedical records of 145 children with cerebral palsy who underwentintraarticular subtalar fusion from January of 1994 to December of2004. The subtalar joint was fixed through the anterior facet with acannulated screw while the anterior aspect of the calcaneus wasparallel to the anterior aspect of the head of the talus. Tricorticaliliac crest allograft was placed into the sinus tarsi and the denudedposterior facet area. Results are grouped as good, satisfactory andpoor according to the radiographic and clinical outcome.

Results: Good results were obtained in 242 feet (96%). Satisfactoryresults were obtained in 6 feet (2%) which were painless pseudo-arthrosis of subtalar joint in 2 feet and screw removal was requiredin 4 feet because of pain. Non union of the subtalar joint togetherwith recurrence of deformity was observed in 5 feet (2%) which isaccepted as poor result and required revision surgery. No deepinfections, implant failure, or allograft failure were observed after amean of 4.8 years follow up.

Conclusions: In conclusion, our described technique of intraar-ticular subtalar joint fusion is safe and effective in children withCP, and produces a high rate of satisfactory results.

Significance: Pes planovalgus deformity in children with cerebralpalsy can be corrected effectively with the described subtalar fu-sion technique using corticocancelleus allograft.

151

Intramedullary fixation following diaphyseal derotational

osteotomy in children – A preliminary report

Author: Deepak G Shivarathre (United Kingdom)

Co-Authors: Raheel Shariff (United Kingdom), Jay Sampath(United Kingdom), Alfie Bass (United Kingdom)

Purpose: Various methods of fixation following femoralderotational osteotomy for correction of excessive femoral ante-version in children have been reported with no one procedureproven to be superior. The key to the success of the surgery lies inachieving correction and early mobilisation. There are definitebenefits to early mobilisation and rehabilitaion of childrenundergoing multi-level surgery. We report the clinical and radio-logical outcome of intramedullary fixation following correctivefemoral diaphyseal derotation in children. The study also reviewsthe safety and benefits of the procedure in multilevel lower limbsurgery in children with spastic diplegia.

Methods: We conducted a retrospective study of all femoral dia-physeal derotational osteotomies with Trigen antegrade intrame-dullary fixation (TAN system, Smith & Nephew) from April 2005to June 2006 in 9 consecutive patients with 14 affected limbs. 8 outof the 9 children had spastic diplegia and 5 children underwent theosteotomy as part of multilevel surgery. Difficulty in walking withfrequent tripping and falls was the most common complaint inmost of the children.

Results: The mean age at surgery was 13.7 years (Range 11.2 –17.3 years). The mean preoperative femoral anteversion was 43.6degrees (Range 30 – 50 degrees) with the mean internal & externalrotation being 61.6 (Range 50 – 70) & 8.3 (Range 0 – 20) degreesrespectively. The average follow-up period was 9.5 months(Range 1.5 – 15 months). All patients mobilised with crutches inan average of 5 days (Range 3–12 days) and full weight bearingwas achieved by 65 days (Range 45 – 150 days). Marked

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improvement in gait was noted in all children with postoperativemean internal & external rotation being 42.9 & 52.6 degreesrespectively. There were no post-operative complications and wehave not encountered any instances of avascular necrosis to date.Correction was maintained at the final follow up in all childrenwith good bony union by 8 – 12 weeks.

Conclusions: Intramedullary fixation following diaphyseal dero-tational osteotomy in children is a safe, effective, cosmetic andreliable procedure with rapid bony union attributable to biologi-cal fixation and early mobilisation.

Significance: Good early results have been obtained in childrenwith cerebral palsy undergoing this procedure as a part of themultilevel corrective surgery.

152

Comparison of Hinged and Rigid Ankle-Foot-Orthoses

on CP Diplegic Ambulation Using Gait Analysis

Author: Sheldon Simon (United States)

Co-Authors: Deborah Wilson (United States), Thomas Santner(United States)

Purpose: Ankle-foot orthosis (AFO) are prescribed for childrenwith CP diplegia to prevent dynamic equinous. It is also hoped thatthe use of such orthosis - rigid or hinged – will improve theirwalking ability. But as walking ability varies widely, we sought todetermine whether any barefoot gait parameter can help to pre-scribe which brace type optimizes walking improvement.

Methods: We examined 43 consecutive CP diplegia children withspastic equinous who were referred for clinical gait evaluationwithin 3 months after being prescribed a new AFO by theirtreating physician and made by the child’s orthotist. Those in thetwo brace groups were compared with respect to age; leg length;velocity, stride length, cadence; sagittal hip, knee, and ankle joint-angles; and ambulatory function (household, limited, full com-munity).

Results: There were no differences between groups with respectto demographics. With either brace, age-related stride-lengthand velocity increased, whereas age-related cadence remainedunchanged or decreased slightly. For rigid AFO users, thedifference in age-related velocity between barefoot and bracedwalks increased independent of barefoot velocity. For hingedAFO users, the difference depended on barefoot velocity andthe gait-cycle time when maximum knee extension and maxi-mum dorsiflexion occurred. As age-related barefoot velocityincreased, the difference in velocity decreased, exceeding thatfound for those with rigid braces only at low speeds. In only afew children did wearing either brace alter their functionalambulation status.

Conclusions: Barefoot gait parameters can predict the improve-ment in walking speed when a hinged brace, while the changemade by a rigid brace seems independent of such parameters.

Significance: Prescribing brace type based on barefoot walkingfunction may be important only at speeds that change the child’sfunctional ambulatory level. At other speeds, the cost of eachbrace type and the braces effect on other functions, seem asimportant.

153

Characterizing Muscle Strength Deficits in Patients with

Spastic Diplegia: The Impact of Selective Dorsal Rhizotomy

(SDR)

Author: Michael D. Sussman (United States)

Co-Authors: Cathleen Buckon (United States), Susan SienkoThomas (United States), Michael Aiona (United States), BarryRussman (United States)

Purpose: To determine if muscle strength differs based on loca-tion, joint position and type of muscle activity in patients withspastic diplegia with and without dorsal rhizotomy.

Methods: Study Design: Prospective cohort: Sixteen patients withspastic diplegia (GMFCS Level 1&2), eight patients >5 yearsfollowing SDR and eight age-matched patients with spasticdiplegia and eight peers were studied. Muscle strength at the el-bow, knee and ankle were assessed using a Biodex System 3 Proisokinetic dynamometer.

Results: Elbow: No significant differences were found in upperextremity strength.

Knee: Isometric extensor strength was decreased in both patientgroups compared to peers at 30� and 60�, but not 90�. Iso-metric flexor strength was decreased in only the SD groupcompared to peers in all testing positions Concentric extensorand flexor strength were decreased in the SD group comparedto peers at all speeds and compared to the SDR group at thefaster speeds during flexion. Concentric extensor strength in theSDR group was decreased at only the slowest speed whileconcentric flexor strength was decreased at all speeds comparedto peers. Eccentric extensor strength was decreased in the SDRgroup compared to peers while no differences were seen ineccentric flexor strength. Ankle: Isometric and concentricplantarflexor and dorsiflexor strength were decreased in bothpatient groups compared to peers for all testing positions andspeeds, with concentric dorsiflexion more impaired in the SDgroup than SDR group at the faster speed Eccentric plantarfl-exor strength was decreased in the SDR group compared to theSD and peer groups, while no differences were seen in eccentricdorsiflexor strength.

Conclusions: Muscle strength deficits are greater distally thanproximally in patients with spastic diplegia. Isometric musclestrength was affected by joint position in both patient groupswith greater impairment when muscles were in a shortenedposition. The difference between patients with and without ahistory of SDR suggests that decreased spasticity improvesconcentric strength at faster speeds of movement; however, thereduction in eccentric extension strength in patients with ahistory of SDR indicates the need for further investigation.

Significance: Children with spastic diplegia have muscle weaknesswhich may be improved by a muscle strengthening program.Those children who underwent dorsal rhizotomy may have greaterconcentric strength at faster speeds due to elimination of antag-onist spasticity. Muscle strengthening may provide functionalimprovement.

154

Orthopaedic Treatment of the Neglected Child

and Adolescent with CP

Author: Selim Yalcin (Turkey)

Co-Authors: Cengiz Cabukoglu (Turkey), Nadire Berker(Turkey)

Purpose: Some children with CP cannot receive proper medicalcare because of reasons related to the family, the society and tothe health care system they live in. Neglected children are un-able to reach their full potential and become a burden for theircaregivers in the long run. Most neglected children needorthopaedic surgery for better function. The decision to per-

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form surgery is risky because the prognosis may be poorer thanexpected. This is a descriptive study of the consequences oforthopaedic treatment of neglected children and adolescentswith CP.

Methods: A total of 23 children and adolescents with CP whohad major orthopaedic deformities limiting function due toneglect were included. The age range was from 12 to 22 yearsand the minimum follow-up period was 2 years. All thepatients were either mild total body involved (9 cases) or severediplegics (14 cases) who had ambulation potential but wereunable to due to major deformities of the lower extremities.The deformities consisted of severe knee flexion, ankle plan-tar flexion, ankle dorsiflexion and valgus, and femoral ante-version.

Results: All patients underwent surgical release of the kneeflexion contracture, 9 required distal femur knee extension os-teotomy, 1 required talectomy and 4 had derotational osteoto-mies. Main problems encountered in the postoperative periodwere pain in all cases, fractures of the distal femur in 2 cases,and poor compliance with the exercise program in 9 cases. Skinproblems occurred in 19 cases even though casts were not usedin any of the patients and all used plastic KAFOs. The reha-bilitation program lasted for an average of 15 days as an in-patient in the hospital, average of 30 days as an outpatient inthe rehabilitation unit and a home program with communitybased physical therapy for a year. All patients were standing inplastic KAFOs in parallel bars at the time of discharge fromthe hospital and all were able to walk in paralel bars at thetime of discharge from the outpatient rehabilitation unit. Fol-low-up at a year post-op showed that 60% were ambulatory athome, 20 % had only therapeutic ambulation and 20% werewheelchair-bound.

Conclusions: The neglected patients needed bone surgery as well asmuscle tendon lengthenings to correct the deformities to stand inan erect posture. Muscle weakness, pain and skin problems weremuch more pronounced compared to the young child who re-ceived adequate therapy. Patients who had not had primarymobility before surgery, had little motivation and no social liferemained at the therapeutic ambulation level after surgery in spiteof aggressive rehabilitation.

Significance: It is difficult to gain ambulation in a child who hasbeen in a wheelchair for a couple of years. In spite of all, childrenwho have good intelligence and strong motivation should be giventhe chance of ambulation through orthopaedic surgery andaggressive rehabilitation.

12 - Tumors and metabolic disorders

155

Continuous decompression of unicameral bone cyst

with percutaneous application of cannulated screws:

new treatment option

Author: Janez Brecelj (Slovenia)

Co-Authors: Lovro Sohodolcan (Slovenia)

Purpose: We present decompression treatment of the solitary bonecyst with special canulated screws and determine its role in theresolution of unicameral bone cyst by comparison to surgical andsteroid treatment.

Methods: Titanium cannulated screw was designed and first usedby the first author in 1995. Its shape permits the use of aspecial targeting system for screw insertion (Heli Pro �) and itsremoval once the goal of decompression therapy has been

achieved. Surgical technique. Under fluoroscopic guidance a 2-mm K-wire was drilled through a 5-mm skin incision, advancedthrough the centre of the cyst cavity and fixed to the oppositecortex. It was left in place throughout the procedure to serve asa guiding device. Using cannulated instrumentation the proxi-mal cortex was perforated with a 3.5 / 2.2-mm cannulated drill,and a 4.5 / 2.6-mm screw was inserted over the K-wire. Inorder to achieve optimal fluid drainage, the appropriate lengthof the screw was determined by positioning its tip in the centreof the cavity. The cyst was aspirated through the screw, and acystogram was performed using 50% Iohexol (Omnipaque)solution to determine if there were separate cavities. If separatecavities were present, a new screw was placed in each cavity,following the same procedure. Once the cyst had healed, thescrews were removed percutaneously.

Results: To evaluate new treatment we studied 69 children withunicameral bone cysts treated either by 1) open curettage andbone grafting, 2) steroid injection, or 3) cannulated screw inser-tion. During a mean follow-up of 69 months (range, 12–58), thecysts were evaluated by radiological criteria. The treatment wasconsidered to be a failure if a subsequent procedure was under-taken or indicated (grade 3 or 4). Cysts rated as radiologicallyhealed or healed with defect (grade 1 or 2) were regarded as havingbeen successfully treated. The healing rate after the first treatmentin group 1) was 25% in group 2) 12% and in group 3) 29%. Afterthe second treatment the healing rate was 50% in group 1), 19%in group 2) and 65% in group 3).

Conclusions: The study has demonstrated the advantages of thedecompression technique for unicameral bone cysts over opensurgery and steroid injections treatment. This result also stresses thedefinite role of mechanical disruption of the cyst in its resolution.

Significance: We propose a new, simple and successful method forthe treatment of unicameral bone cyst which is also safe and couldbe performed as a day case.

156

WITHDRAWN

157

Nancy Nail Fixation of Femoral Fractures in Children

With Osteogenesis Imperfecta.

Author: Riad Dakwar (Israel)

Co-Authors: Gershon Volpin (Israel), Haim Shtarker (Israel)

Purpose: Stable minimal invasive fixation of femoral fractures inpatients with Osteogenesis Imperfecta. We report our experienceduring the past 3 years with fixation of femoral fractures usingNancy Nails, in 9 children with Osteogenesis Imperfecta.

Methods: The average age of patients was 5.2 (2–9) years. Eightwere diagnosed as Osteogenesis Imperfecta Type I, and one asType III. All patients had an anamnesis of at least 6 previouspathologic fractures of limbs; in two of them pathologic vertebralfractures were also found. In two patients who had normalalignment of the femur before the fracture and without narrowingof the medullar canal, closed reduction and percutaneous nailingwere performed through short incisions above the distal femoralphysis on both sides. In the remaining seven patients, who hadsevere malalignment or obstruction of the canal by a former cal-lus, open reduction of fracture with re-canalization of the med-ullary canal was performed. In two patients multiple osteotomies

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of femur were performed in order to correct severe deformity. Intwo cases spica cast was applied after the surgery, in all other casesknee immobilizer (Johns bandage or Zimmer Splint) was applied.Weight bearing was allowed after appearance of callus on controlX-Ray (6–9 weeks after surgery, depending on age and weight ofthe child).

Results: Fracture healing was achieved in all cases. All patientswere free of pain. No cases of infection were observed, and nocases of postoperative contracture of knee joint were observed.No growth arrest of femoral bone was observed after surgery.Normal alignment was restored in all cases with previous mal-alignment of femur. In three of the patients an exchange with alonger nail was performed one and half years after the firstsurgery, through a short incision in the distal femur. Fourpatients had prophylactic nailing of contra lateral side. 8 patientswith OI Type-I were able to walk without pain and limping. Thepatient with OI Type III had never walked before surgery. He is2.5 years old and does not yet walk. One patient with OI typeI developed severe bilateral genu varum. Two patients hadadditional fractures of femur after Nancy nail fixation, butfractures were undisplaced. The nail prevented displacement andno additional surgery was performed.

Conclusions: This method has been proven useful for fixation ofpathologic fractures in Osteogenesis Imperfecta. There were nocomplications in our series.

Significance: Easy and stable method of fixation of brittle bone.

158

Skeletal features of primary hyperoxaluria type 1

Author: Samer El Hage (Lebanon)

Co-Authors: Ismat Ghanem (Lebanon), Andre Baradhi(Lebanon), Chebl Mourani (Lebanon), Samir Mallat (Lebanon),Fernand Dagher (Lebanon), Khalil Kharrat (Lebanon)

Purpose: Hyperoxalurias are rare metabolic disorders, which canbe lethal if not adequately treated. The purpose of this study is todescribe the skeletal manifestations of primary hyperoxaluria type1 (PH1), the most common of the primary hyperoxalurias.

Methods: We clinically and radiographically reviewed 12 consec-utive patients diagnosed with PH1 aged between 2 and 17 years.Current and past medical histories were taken and each patient wassubjected to a complete skeletal survey including spine, pelvis, upperlimb, lower limb, and kidney-ureter-bladder X-rays. X-rays wereinterpreted by two independent pediatric osteo-articular radiologists.

Results: All patients had evidence of some degree of renal involve-ment, 4 of whomwere at the end stage renal disease (ESRD) andwereunder dialysis. The main symptomwas skeletal pain and was presentonly in the 4 severely involved patients and appeared during the firsttwo years after initiation of dialysis. The two most severely involvedpatients had evidence of pathologic fractures two of which necessi-tated internal fixation. Patients with less severe renal impairment didnot have any musculoskeletal symptoms. Radiological signs werepresent in patientswith or without symptoms and consistedmainly ofcharacteristic dense and radiolucent metaphyseal bands and distinc-tive vertebral osteocondensations, which were found mainly inthe severely involved individuals, and other less specific such as os-teopenia, subperiosteal erosions, distal phalangeal osteolysis andperiosteal appositions which were also found in less severely involvedpatients. Interestingly, our study revealed the presence of spondylol-ysis in 25% of cases, one of which was associated with a grade 1spondylolisthesis.

Conclusions: Skeletal involvement in PH1 is only seen in the ad-vanced renal failure stages and may or not be symptomatic. It

comprises radiographic signs which are almost specific of oxalosissuch as dense and lucent metaphyseal bands, as well as the ver-tebral osteocondensations, and other less specific signs probablyrelated to the secondary hyperparathyroidism and renal osteo-dystrophy. Pathologic fractures occur in severely involved indi-viduals and should be aggressively managed. To our knowledge,this is the first study describing cases of spondylolysis in con-junction with hyperoxaluria.

Significance: Primary hyperoxaluria has typical skeletal featuresindependently from any associated renal failure. This is the largestseries reporting on such manifestations and the first to ourknowledge to report on spondylolysis as a possible and notexceptional manifestation of primary hyperoxaluria.

159

Autogenic fibula bone graft in treatment humeral cyst lesion.

Long term follow-up.

Author: Andrzej Grzegorzewski (Poland)

Co-Authors: Marek Synder (Poland), Ewa Pogonowicz (Poland)

Purpose: Benign bone tumors usually do not give problems duringtreatment course. Simply surgical excision is the best option. Somebenign bone cyst (aneurismal bone cyst, bone cyst, fibrous dys-plasia) could lead to bone destruction, pathologic bone fractureand become clinically malignant tumors. The aim of the study islong term follow-up of the autogenic fibula bone graft in treat-ment of humeral cyst lesion.

Methods: The study population consisted of 20 patients, mean ageat the time of surgery was 11.8 years (range, 3 – 28 years) andmean follow-up was 19 years (range, 2 – 24 years). All patientsunderwent the same surgical procedure. Local destruction (bothlayers: trabecular and spongy bone) of the humeral bone causedthe need of bone graft. The bone graft from fibula (length range:8–18 cm) was taken the first, than the humeral tumor was wholeexcised with trabecular layer and the fibula bone graft was in-serted intramedullary between ends of the humeral bone withoutany fixation. Cast immobilization was applied immediately afteroperation for 6 – 12 weeks and than patients underwent physicaltherapy for 1 – 4 months. We did not observe any bone graftfracture, bone graft loosening or nerve paresis. Histologicalexamination revealed bone cyst (10 cases), aneurismal bone cyst(4), fibrous dysplasia (2) and ossifying fibroma (2).

Results: Final clinical examination after growth end revealed fullrange of motion of the humeroscapular joint in all cases and thehumeral bone shortening in 3 patients (range, 3 – 7 cm, mean4.5 cm). The reason of the humeral shortening was bone tumorlocalization directly to proximal humeral epiphyseal growth plate,which was destroyed either by tumor or during operation. Weobserved full restoration of the fibula in 6 patients. We did not seeany cyst recurrence during follow-up. Patients did not complainfor tibia or foot pain.

Conclusions: Autogenic fibula bone graft in treatment humeralcyst lesion gives clinically and radiologically very good results andit is a save procedure.

Significance: Recommended method of treatment humeral cystlesion with bone destruction.

160

Management Of Deformities in Thalassemia Patients

Author: Gamal Ahmed Hosny (Egypt)

Co-Authors: Mohamed Fadel (Egypt)

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Purpose: Beta-thalassemia is a common cause of chronic hemo-lytic anaemia and it represents a major genetic disease and apublic health problem. It contributes to marked osteopenia,frequent fractures and skeletal deformities. Hypertransfusiontherapy in the last 20 years has prolonged life expectancy[Vinchinsky, 1998]. High incidence of deformities in thalassemiahad been reported before[Exarchou, 1984] which would increasethe morbidity in these cases. However, the risk of infection,osteoporosis and immune problems may preclude operative cor-rection. We report our experience in operative correction ofdeformities in thalassemics using external fixator.

Methods: From 1999 till 2004, 5 cases with thalassemia major withskeletal deformities were referred to our institution. Age of pa-tients ranged from 11 y to 21y with an average of 14.5y. Therewere 3 female and 2 males. The right side was affected in 2 cases.The site of the deformity was tibial in 2 cases, femoral in 2 casesand humeral in one case.Shortening ranged from 5.5 to7 cm.Evaluation parameters included: pain,limb length discrep-ancy, mechanical axis deviation, ROM, functional activities andsatisfaction of the patients.

Results: Follow up period ranged from 1y to 4y. There were 2excellent and 3 good results. The average healing index was48 days/cm. The time in the fixator ranged from 5 to 9.5 m.Complications included: pin tract infetion in all cases and fractureafter fixator removal in 2 cases.

Conclusions: Up to the best of our knowledge management ofskeletal deformities in thalassemia patients using external fixationhas not been previously reported. Bone lengthening and correc-tion of deformities has been successful using external fixator withlonger time for regenerate formation.

Significance: Recently,the prognosis of thalassemia has muchimproved, with many people surviving to the fifth decade of life.Therefore, it is feasible to reduce the morbidity due to skeletaldeformities with the application of external fixators.

161

Percutaneous injection of bone marrow

and demineralizing bone matrix of bone cysts stabilized

with intamedullary fixation

Author: Anastasios Kanellopoulos (Greece)

Co-Authors: Hristos Giannakopoulos (Greece), Leonidas Badras(Greece)

Purpose: Bone cysts in children are of ambigous aetiology.bothmechanical (as medullary canal occlussion) and biological (in-creased bone resorption) causes are considered. This study as-sess the efficacy of a combined approach that addresses bothfactors.

Methods: 17 skeletally immature patients with active bone cystswere studied. All had MRI, CT, and biopsies performed.Closed elastic flexible nailing was performed in all but onepatients, that a cortical strut was used. After stabilization of thebony segment and at the same surgical session a mixture ofautologous bone marrow and demineralized bone matrix wasinjected percutaneously into the cyst. All cysts had length morethan 2.5 times the normal bone diameter. 4 were located in thefemur and 13 at the humerus. Mean age was 8 yrs(6–13). 6patients were females and 11 males.

Results: All cysts went into involution according to the Neerclassification. No refracrure occurred. All patients returned tosports with no restrictions.

Conclusions: The combination of mechanical stabilization ofactive bone cysts in children with biological stimulation with

demineralized bone matrix and bone marrow mixture was provensuccessful in the management of these lesion.

Significance: This study reinforces the recently represented in theliterature trend that mechanical stabilization of active bone cystsin children leads to their involution especially if it is combinedwith biological stimulation.

162

Direct percutaneous Ethibloc injection in the treatment

of Aneurysmal Bone Cysts: long term follow-up

Author: Guido La Rosa (Italy)

Co-Authors: Piergiorgio Falappa (Italy), Fausto Fassari (Italy),Antonio Di Lazzaro (Italy), Rita Devito (Italy), ElisabettaGenovese (Italy)

Purpose: Objective: To evaluate long term efficacy of AneurysmalBone Cysts (ABC) treatment with Ethibloc percutaneous injec-tion.

Study Design: Prospective observational non-randomized study

Methods: Matherials and Methods: Fortyone patients affectedby ABC were treated by means of percutaneous Ethiblocinjection, delivered under fluoroscopic imaging or CT. Filling ofthe cysts was incomplete, to avoid retrograde leakage andintracystic overpressure. The whole treatment was monitorizedby magnetic resonance imaging to detect relapse or monitorossification of the cavitary lesion. Follow-up lasted from 2 to98 months.

Results: Thirty nine patients showed remarkable shrinkage of thecystic lesions with cortex thickening. The reduction of the lesionwas not satisfactory for only two patients who has been succes-sively operated on by means of courettage and grafting of the cyst.Pain disappeared in35 patients, persisted in two and occurredoccasionally in four. No severe complications were observed: threepatients had a local leakage of Ethibloc through the injection site,self resolving without complications. One had a mild allergicreaction.

Conclusions: In our experience direct percutaneous Ethiblocinjection is effective in the treatment, after a mandatory histologicdiagnosis; furthermore scleroembolization does not preclude anysubsequent surgical approach. MRI must be considered in all thephases of therapeutic treatment,including follow-up.

Significance: Usefulness of a percutaneous,mininvasive terapeu-thic method to treat pediatric ABC.

163

Percutaneous radiofrequency ablation of the osteoid osteoma:

our experience.

Author: Maria Gabriella Lettera (Italy)

Co-Authors: Fabrizio Cigala (Italy), Venanzio Iacono (Italy),Francesco Sadile (Italy), Antonio Lambiase (Italy), LucaMaddaluno (Italy), Vittorio Iaccarino (Italy), F Fiore (Italy),Flavio Fazioli (Italy)

Purpose: The purpose of this paper is to evaluate CT-guided ra-diofrequency (RF) ablation as a minimally invasive therapy forosteoid osteoma with regard to our clinical success and immediateand delayed complications.

Methods: From November 2004 to June 2006, in the Departementof Orthopaedic Surgery of University ‘‘FedericoII’’ and in the

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Departement of Orthopaedic Surgery of National Institute ofTumours ‘‘G.Pascale’’, we observed 30 patients with osteoidosteoma; all patients clinically suspected of having an osteoidosteoma (they complained nocturnal pain that was not related tophysical activity and that was typically allieviated by ingestionof salicylates) were screened according to a protocol that in-cluded the performance of radiography in two orthogonaldirections, CT scanning with reconstructed section thickness of1–3 mm and triple-phase bone scintigraphy. 30 patients under-went percutaneous radiofrequency ablation for an osteoidosteoma: 22 male and 8 female (male-female ratio = 2,75), withan average age of 17 years (age range min 3, max 47). Two ofthese patients underwent surgery before they were treated withthermocoagulation. The procedure of thermocoagulation wasperformed in regional or general anesthesia; after localization ofthe nidus with 1 mm CT sections, osseous access was estabi-lished with an 11-gauge Jamshidi needle. RF ablation wasperformed at 90�C for a period of 4–5 minutes with use of arigid RF electrode with a diameter of 1 mm.The mean durationof the entire procedure was 60 minutes. In all cases, the pro-cedure was effected in Day-surgery: discharge was scheduled forthe next morning to control the pain and the occurrence ofimmediate complications.

Results: Clinical success was achived in 96% of patients; in all ofthem the nocturnal pain caused by osteoma disappeared withinone day. 1 of 30 patients (3%) had residual pain, without impairedfunction, after first thermocoagulation session. Complicationswere observed in two patients: one patient had neurophaty ofsciatic nerve, another one had myalgia after the treatment, bothresolved in around six months.

Conclusions: CT-guided percutaneus RF ablation is a simple,minimally invasive, safe and highly effective tecnique for treat-ment of osteoid osteoma in alternative to the traditional opensurgical treatment. This procedure is particularly indicated inosteoid osteoma deeply located, requiring an aggressive and riskysurgical approach.

Significance:

164

The Natural History of Lower Limb Deformities Seen

in Hurler’s Syndrome Following Bone Marrow Transplantation

Author: Randeep Mohil (United Kingdom)

Co-Authors: Philip Hopgood (United Kingdom), John Grainger(United Kingdom), Robert Wynn (United Kingdom), Ed Wraith(United Kingdom), Tim Meadows (United Kingdom)

Purpose: To determine the natural history of lower limb defor-mities in Hurler’s after bone marrow transplantation.

Methods: Between 1990 and 2005, 24 patients have been success-fully engrafted and have been followed up for a mean of 6.8 years(range 18 months to 15 years) at Royal Manchester Children’sHospital. We describe the lower limb problems and their man-agement in these patients. We report on their skeletal developmentfollowing successful transplant. Radiographic analysis was doneusing the following measurements where possible – acetabularindex, centre-edge angle, migration percentage, femoral neck-shaftangle and tibio-femoral shaft angle.

Results: Of the 24 patients, one has had bilateral staged shelf acetab-uloplasty and bilateral staged medial epiphyseal stapling (MES). oftheuppertibia.ThesecondpatienthashadbilateraluppertibialMES.

Conclusions: There is very little in the literature on the long-termnatural history of the orthopaedic manifestations of Hurler’sSyndrome after bone marrow transplantation. Presently there is

no consensus as to the best management of the lower limbproblems in this disorder.

Significance: Well conducted long-term follow up is essential.

165

The Histopathological Features of Proteus Syndrome


Co-Authors: Deborah Eastwood (United Kingdom), SusannahHoey (United Kingdom), Loshan Kangesu (United Kingdom),John Harper (United Kingdom), Neil Sebire (United Kingdom)

Purpose: To describe the histopathological features encountered ina series of patients with Proteus syndrome from a single centre.

Methods: Patients with Proteus syndrome who had undergonetherapeutic surgical resection or biopsy were identified from adatabase and the histopathological findings were reviewed, withparticular reference to descriptive features of the underlying tissueabnormality.

Results: There were 18 surgical specimens fromnine patients, medianage 4 (range 1–9) years, including four main categories; soft tissueswellings (lipomatous lesions), vascular anomalies (vascular mal-formation and haemangioma), macrodactyly (hamartomatousovergrowth) andothers (sebaceousnaevusandnon-specific features).In all cases the clinical features of overgrowth were due to increasedamounts of disorganised tissue, indicating a hamartomatous-typedefect in which normal tissue constituents were present but with anabnormal distribution and architecture. Vascular malformationsrepresented a prominent category of lesions, accounting for 50% ofthe specimens, predominantly comprising lymphatic and lympho-vascular malformations. No malignancy or cytological atypia wasidentified in any case.

Conclusions: The histopathological features of lesions resected fromchildren with Proteus syndrome predominantly include hamarto-matous mixed connective tissue lesions, benign neoplasms such aslipomata and lymphatic-rich vascular malformations.

Significance: Proteus Syndrome is a rare, sporadic overgrowthdisorder for which the underlying genetic defect remains un-known. Although the clinical course is well-described, this is thefirst systematic histopathological description of the lesionalpathology.

166

Minimally Invasive Treatment Of Aggressive Unicameral Cyst:

Intramedullary Fixation With Metaizeau Elastical Rods

And Arthroscopic Curettage.

Author: Antonio Pascarella (Italy)

Co-Authors: Pasquale Guida (Italy), Nando de Sanctis (Italy),Narco Rizzo (Afghanistan), Pier Luigi Di Giacomo (Italy), RoccoCavallo (Italy), Mariano Di Salvatore (Italy)

Purpose: Many surgical techniques have been described for thetreatment of pathological fractures due to aggressive unicameralbone cysts in order to varying rates of success and incompletehealing or recurrence. Many Authors suggested curettage andbone grafting as effective treatment in case of active lesion inchildren 8 – 12 years old, adjacent to the physis with width of thelesion exceeds that of the adjacent physis and recurrence or per-sistence. Due to invasive nature of operation this method non ispreferred by several Authors :we preferred minimally invasivetreatment consisting closed reduction and flexible with titaniumrod (Nancy)intramedullary fixation for low operative morbiditywhether for the fracture or for the cyst; in case of recurrence of the

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cyst the closed curettage of the cyst with arthroscopic techniquecan be applied successful.

Methods: Between 2002–2004 40 aggressive unicameral cysts wereobserved as pathologic fractures in patients between 5–15 yearsold in these cases there was a significant loss of bone stock. The siteof involvement was in 33 patients the metadiaphysis of humerus, in7 the femur; radiograms reveal expanding lesion in metaphyseal-diaphyseal site with cortex tinned from its inner surface and ero-sion with infraction with displacement. The parents were informedabout contextual presence of two lesions: the fracture and cyst. Theproposed internal fixation with Nancy titanium rods heals the firstand might heal the second lesion ; in case of failure this method donot exclude another possibility of treatment as arthroscopiccurettage. The Nancy flexible intramedullary fixation was per-formed with retrograde access 3 0 4 mm. diameter. Two nails with‘‘ Eiffel Tower’’ construction were inserted by two miniportals1 centimetres far from the physis. Follow up of treated lesion wasmade with periodic x rays performed every 45 days.

Results: In 36 patients after a 2-year period of observation the cysthas completely or incompletely healed but with a sufficient bonestock in the remainder four cases the arthroscopic procedure wasperformed. Curettage of cystic wall by trimmer blade and multipleminiportals 4,5 millimetres is the best way to treat all the cyst. Inall the cases we used the standard optical cannula 30�.Conclusions: In conclusion minimally invasive treatment by Nancyrods and artrhoscopy can be effective because assure high inci-dence of favourable results by decompression-scaffolding of thelesions.

Significance: the patient quickly recover natural life and schoolattendance.

167

Elastic Stable Intramedullary Nailing for the Treatment

of Fractures of the Femur and Humerus in Osteogenesis

Imperfecta

Author: David Rowland (United Kingdom)

Co-Authors: Andrew Morgan (United Kingdom), JamesFernandes (United Kingdom), Michael Bell (United Kingdom)

Purpose: Treatment of acute fractures in Osteogenesis Imperfectapresents a significant challenge. Plaster immobilisation and non-weightbearing cause loss of bone density. Plates are undesirablebecause of the risks of stress shielding, osteopaenia and peri-prosthetic fracture. Straight rods rods provide adquate stabilisa-tion of the length of a bone but are technically difficult to insert,particularly in the presence of deformities from previous fractures.Spica treatment for femoral fractures may be uncomfortable andcarries a risk of malunion, which may predispose to furtherfractures. Traction requires long inpatient stays. Non operativetreatment of humeral fractures is difficult and has a significant riskof non-union or malunion, often related to the shape of the chestagainst which the arm rests. We present the results of treatment offemoral and humeral fractures with elastic intramedullary nails.

Methods: A retrospective review of notes and patients provided 8cases (3 female and 5 male). The mean age was 12 years. Wetreated 6 femoral fractures and 2 humeral fractures. The femoralfractures were acute. The humeral fractures had been treated non-operatively with no success. Standard techniques for the insertionof elastic nails were used. Care was taken to ensure that the nailsdid not breach the cortex of the bone as they were advanced.

Results: All fractures progressed to union. Two of the patients re-quired further surgery to adjust the position of the nails after theimplants backed out, causing discomfort. There were no infections.

Conclusions: Elastic stable intramedullary nailing in osteogenesisimperfecta is a satisfactory method for treating fractures of thelong bones, even in the presence of preexisting deformity whereother methods may be difficult. There is a small risk of minorcomplications, namely backing out of the implants but this can beavoided if the nails are buried or if soft tissues are formally closedover the ends of the implants.

Significance: We demonstrate that a recognised technique for themanagement of fractures may be applied to patients with osteo-genesis imperfecta, a group in whom such treatment has notpreviously been described.

168

Fifteen years survival and extensive, unexpected functional

regeneration of the knee joint following the resection

of the medial femoral condyle.

Author: Kalman Szepesi (Hungary)

Co-Authors: Gabor Kovacs (Hungary), Istvan Morocz(Hungary), Gabriella Szucs (Hungary)

Purpose: To present a case in which the medial condyle of thefemur was resected due to osteosarcoma at the age of 8. Thepatient is currently alive after 15 postoperative years. Tumorrecurrence or metastasis was never observed. Without furtherreconstructive surgery, the knee joint of the patient showedextensive functional regeneration to such an extent, that at the ageof 23, the joint is fully stable in extension, and the patient is able towalk without any aiding device.

Methods: The patient was admitted to our department in 1991due to uncertain left knee symptoms that have been persistingfor the two previous months. In addition, one week preceedinghis admission, the knee swell and pain was experienced also atnight. The X-ray, CT and angiographic examinations showed alytic tumor in the medial condyle of the femur, that elevated butdid not penetrate the periosteum and partially destroyed thephysis. During surgery, it was possible to resect the tumor withinthe normal tissues, thus the medial condyle was removed to-gether with the medial collateral and the cruciate ligaments andthe medial part of the joint capsule. The histological diagnosiswas osteosarcoma. Subsequently the patient received postoper-ative chemotherapy according to the COSS-86 protocol.According to the protocol, at the timepoint of the definitiveoperation, the resection surface of the femur was surgicallyexposed but the area was tumor-free as proved by histology.Following the application of a plaster cast, the child began towalk by using a caliper that stabilized the operated knee. Fifteenmonths after the operation, the child fell and the femur brokeimmediately proximal to the resection site. The dislocation-freefracture heeled in a plaster cast without any complication andthe patient subsequently walked without any problem with thehelp of a caliper. Unexpectedly, four years after the operationthe child was able to use the affected joint securely without anyaiding device and was walking with an only slightly noticeablelimp.

Results: The follow-up X-ray showed the thickening of the femur,and the regular CT and scintigraphy controls did not indicateeither metastasis or tumor recurrence. At present, at the age of 23,the patient lives a normal life, works as a professional driverwithout the use of any aiding device. His affected knee joint isfully stable in extended position, and 80o of flexion is possible. Heis satisfied with his condition and does not request either recon-structive surgery or an orthopaedic shoe to alleviate the 6 cmshortening of the limb.

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Conclusions: Unexpected good result was observed after partialresection of the knee joint due to osteosarcoma, and treatmentaccording to protocol COSS 86.

Significance: In special cases even of highly malignant tumors verygood results can be achieved with adequate treatment.

169

Eosinophilic granuloma in children and adults – the scottish

experience

Author: Kar Teoh (United Kingdom)

Co-Authors: Jim Huntley (United Kingdom), Kishan Sokhi(United Kingdom), Robin Reid (United Kingdom), Daniel Porter(United Kingdom)

Purpose: Langerhans cell histiocytosis (LCH) is a tumour-likecondition that runs a variable clinical course. Recent series havesuggested that skeletally immature patients with a solitary bonyfocus (eosinophilic granuloma) have an especially good prognosis.We aim to compare recurrence/progression rates for Scottishpatients with solitary eosinophilic granulomas, according to skeletalmaturity.

Methods: A retrospective case note review of patients witheosinophilic granuloma were identified from the Scottish BoneTumour Registry.

Results: We identified 70 cases of biopsy-proven non-spinal eosin-ophilic granuloma of bone. Of these, 39 were skeletally immature(<16 years) and 31 were skeletally mature (>16 years). Follow-up (mean 8.25 years) was either continuing or to discharge/death.On the basis of initial screening (skeletal survey/bone scan), 9 cases(13 %; 4 and 5 patients, from the paediatric and adult groupsrespectively) were found to have multi-focal disease. Consideringthose with unifocal disease: (i) in the immature group, 6 patients (ex35; 17%) developed a further manifestation of the condition (2 hadrecurrences at same site; 2 developed a distinct focus in bone; 1developed a distinct soft tissue lesion causing spinal cord com-pression; 1 developed diabetes insipidus), (ii) in the mature group, 3patients (ex 26; 12%) developed a distinct focus in bone but therewas no other recurrence/progression.

Conclusions: For this population, these data show that the prog-nosis for paediatric patients with isolated eosinophilic granulomaof bone must be more guarded than that suggested by other series.

Significance: Based on our study, the clinical course for paediatricpatients with isolated eosinophillic granuloma might not be asgood as stated in other series and would require more aggressivetreatment to prevent recurrence.

Limb reconstruction

170

Metatarsal Bone Lengthening By Callus Distraction

In Childhood Congenital Brachymetatarsia

Author: John Anastasopoulos (Greece)

Co-Authors: Aikaterini Aretaki (Greece), Stylianos Kolovos(Greece), George Matsinos (Greece), Elias Karanikas (Greece)

Purpose: Congenital brachymetatarsia is a rare deformity of thefoot that may lead to functional (irritation, metatarsalgia, cal-luses, stress fractures) and cosmetic problems. The aim of thesurgical correction is the restoring of the normal length of the

metatarsal. The purpose of this study is to present the postoper-ative outcome in six children (eight metacarpals) with congenitalbrachymetatarsia who underwent metatarsal lengthening by callusdistraction.

Methods: Between July 2001 and March 2006 eight congenitalshort metatarsals in six children (five girls and one boy) with agesranging from 10 to 14 years were lengthened by callus distractiontechnique (Callotasis) using the Orthofix M101 Standard Mini-Rail Lengthener. The follow up time ranged from 6 months to48 months. One patient had bilateral congenital short 1st meta-tarsal, and another one had bilateral short 4th metatarsal. Thethird patient had short 3rd metatarsal (right foot), the fourthpatient had short 5th metatarsal (left foot), and the last two pa-tients had short 4th metatarsal (one right and one left foot).Lengthening was initiated on the day 7 after application ofexternal fixator and metatarsal diaphyseal osteotomy at a dis-traction rate of 0,5 mm per day. Weight bearing was allowed1 day post op. The regenerate was monitored with standard x-raysand the fixator was removed after sufficient callus consolidationhad been achieved.

Results: The median lengthening obtained was 15 mm (range 9 –25 mm) which was 35% (range 20–63%) of the original metatarsallength. The median bone healing index (BHI) was 66,1 days/cm(range 38,0–87,8). In all metatarsals the target length wasachieved. All patients tolerated the procedure well and were sat-isfied with the functional and cosmetic results. No bone graftingwas done. No neurovascular compromise, malunion or angulationdeformities were noted. In 4 of the 8 cases joint stiffness andnarrowing of metatarsophalangeal joint space were observedduring distraction but these were gradually resolved after theremoval of the external fixator. Superficial pin tract infections in 5patients were treated with per os administration of antibiotics.

Conclusions: Metatarsal lengthening by callus distraction inchildhood congenital brachymetatarsia it is simple and safeprocedure without serious complications.

Significance: Although requires longer treatment period, callusdistraction gives sufficient lengthening for the treatment ofcongenital brachymetatarsia. It overcomes the disadvantages ofone-stage lengthening which include a small gain in length, nocapability of early weight bearing, and neurovascular damage.This method could be recommended as the procedure of choice.

171

It is possible to propose an early planned series of moderate

lengthenings for complete congenital fibular deficiency

Author: Olivier Francois Badelon (France)

Co-Authors:

Purpose: Fifteen years ago the recommendation was an earlySyme amputation in complete absence of the fibula if the limblength discrepancy was 4 cm or greater at one year of age. In thepractice of the author, parents had refused this indication. Onthe other hand in 1985–86, he had an initial experience with thetechnique of Ilizarov in young children, which showed that it waspossible to expand the indication of lengthening when the hip wasstable with a functional foot.

Methods: Five patients with unilateral involvement have beentreated since 1989. The femorotibial inequality was 54.8 mm(35–80) at one year of age, with a discrepancy of 19.4 % (13–30).The calculated shortening at skeletal maturity was 15.6 cm(10–24), not including the foot. A posterolateral release of the footwas performed before walking age in 3 cases, with an osteotomyof the distal tibia in 2 patients and an arthrodesis of the anklein one patient. The lengthenings were begun at 2 years of age

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(1.6–2.8) for the tibia with a lateral release of the leg, and at4 years of age (3.5–4.4) for the femur. They had 5.6 lengthenings(3–7) per child, 21 of the tibia and 7 of the femur, with an angularcorrection of 10 to 40 degrees without bone resection. The callo-tasis technique was used (1 mm per day) with an external fixatorof Ilizarov in 2 procedures and an Orthofix in 26, without weight-bearing during the lengthening period. Lengthening per bonesegment ranged from 15 to 40 mm (12 to 20 %). The intervalbetween each lengthening was 9 to 23 months.

Results: Complications occurred only in the lengthened bone with7 bowings, 5 fractures and one chronic infection in the hole of apin. No articular disturbances were observed. A genu valgum of20� was treated by a simple osteotomy of the upper tibia in one Atthe last follow-up, all the children had finished their lengtheningprogram with an epiphysiodesis of the contralateral knee by12 years of age (10 to 13). They were 15.7 years of age (15–17.6).The femorotibial inequality was 3 mm (+5/–10) with a limb dis-crepancy of 38 mm (–15/–45) because of the foot. They had a genuvalgum of 9 degrees (5/12). The foot was in a lateral position in 3but functional in all. All of them had normal shoes with a com-pensation of 12 mm (8/20) and a medical sole in only one. Theyhad a normal lifestyle without any effect on schooling.

Conclusions: This step by step lengthening program should beconsidered before 3 years of age if the predicted femorotibialinequality at skeletal maturity is less than 25 cm and if the foot isor will be functional after surgical release.

Significance: This proposition should be considered in youngchildren with other diseases. It is safer and simpler than the at-tempted greater lengthenings in older children and adolescents,with the possibility of prosthesis avoidance during the schoolyears.

172

Factors affecting distraction osteogenesis at the proximal tibial

metaphysis in congenital pseudoarthrosis of the tibia patients


Co-Authors: In Ho Choi (Korea, Republic of), Ki Seok Lee(Korea, Republic of), Won Joon Yoo (Korea, Republic of), ChinYoub Chung (Korea, Republic of), Sang Min Lee (Korea,Republic of)

Purpose: Tibial shortening is the most frequently encounteredproblem remaining after osteosynthesis in congenital pseudoarth-rosis of the tibia (CPT). Ilizarov method enables comprehensiveapproach by concomitant limb lengthening. Previous reports onIlizarov method focused mainly on achievement of bony union atthe pseudarthrosis site. The purposes of the current study were toinvestigate the outcome of distraction osteogenesis at the proximalmetaphysis using Ilizarov method in CPT patients, and to find outthe risk factors for poor or delayed bone formation.

Methods: Twenty-seven cases of distraction osteogenesis (DO) in22 patients with CPT were divided into two groups. Group I wasthose in which the target length was achieved with healing index(HI) of 70 day/cm (median value) or less, and Group II those inwhich HI was over 70 day/cm or additional procedures were re-quired. Clinical and radiological characteristics were comparedbetween these two groups. They included age at the time of sur-gery, type of Ilizarov construct, association with neurofibroma-tosis type I, length gain, overall distraction rate, proximal tibialdysplasia, presence of intramedullary rod, and repeated length-ening. HI was again compared among another subgroups dividedaccording to the significant risk factors. Statistical analysis wasperformed using Mann-Whitney U test, Fisher’s exact test, andKruskal-Wallis test.

Results: Ten cases belonged to Group I, of which HI averaged39.3 day/cm. Seventeen cases belonged to Group II with a meanHI of 117.4 day/cm. In Group II 12 autogenous bone grafts and 4bone marrow injections were performed additionally. Length gainand distraction rate were larger in the Group I reflecting theirfavorable conditions for distraction osteogenesis. All the caseswith proximal tibial dysplasia (11 cases) or repeated lengthening(6cases) belonged to Group II, which were statistically significant.The other parameters were not significantly different between thetwo groups. When the 27 cases were divided into four groupsaccording to the two risk factors, significant difference in HI wasobserved among the four groups. Those who did not have any ofthese two factors showed the largest length gain and distractionrate, and the shortest HI.

Conclusions: Proximal tibial lengthening and repeated lengtheningare two significant risk factors for poor bone formation in dis-traction osteogenesis at the proximal metaphysis of CPT.

Significance: Distraction osteogenesis at the proximal tibial me-taphysis can be safely performed in CPT patients without theserisk factors. Delayed bone formation or nonunion is expected withany of these risk factors. Physeal distraction may be an alternativeoption in these cases.

173

The role of CT-angiography in diagnosis and treatment strategy

of proximal femoral focal deficiency (PFFD) Pappas II and III

Author: J Chomiak (Czech Republic)

Co-Authors: M. Horak (Czech Republic), M. Masek (CzechRepublic), M. Frydrychova (Czech Republic), P. Dungl(Czech Republic), O. Adamec (Czech Republic), M. Ostadal (CzechRepublic)

Purpose: To evaluate the role of CT-angiography and 3D-CTreconstruction of PFFD Pappas II and III for diagnosis andtreatment strategy.

Methods: 7 patients (6 boys, 1 girl, age 2 to 11 years) with PFFDPappas II and III underwent CT examinations with visualisationof vessels between July 2005 and August 2006. Iomeron 400 (dosesacc. to weight) and Siemens Somatom Sensation 16 were used forthe examination. There were 6 patients with Type III and 1 patientwith Type II according to Pappas, respectively. In all but one, theright side was involved. The feet were normal in 6 patients andsevere hypoplasia of tibia and fibula and 2-rays foot were presentin 1 patient.

Results: CT examination revealed proximal femoral epiphysis indysplastic acetabulum in 6 cases, which was connected through thesoft tissue with remnants of diaphysis (Type III), whereas thefemoral epiphysis was not seen in 3 patients on plain radiograph. Inone case (Type II) proximal epiphysis failed in dysplastic acetabu-lum, and remnant of femur was highly proximally dislocated.Angiography reconstruction had shown the normal anatomicalvascular pattern of the extremity in 5 cases, where the extremity andpseudoarthrosis were supplied through the femoral artery as thebranch of the external iliac artery. In 2 cases, both types of PappasIII, the pseudoarthrosis was supplied from the femoral artery(external iliac artery) as the terminal branch, but the remnant of theextremity was supplied from the internal iliac artery, which entersthe thigh dorsally from the hip joint and continues to the poplitealartery. The concomitant veins follow the arteries in 6 cases. Therewere no significant anastomoses between the femoral and poplitealarteries in this vascular pattern. This vascular pattern was notconnected with any external body exceptions. The children weretreated according to the age and type of deficiency. Namely, therewere 2 pseudoarthroses reconstructions and lengthening of the

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femur, 1 knee-for-hip procedure, 1 pelvi-femoral distraction and 3patients younger than 3 years used the ortho-prosthesis.

Conclusions: 3D-CT reconstruction helps to identify the proximalfemoral epiphysis and the spatial configuration of the pseudo-arthrosis. The CT-angiography reconstructions show either anormal or atypical pattern of the vascular supply of pseudoarth-rosis and the extremity. Both methods in combination were usedfor the decision of the type of surgical approach and surgicalmethod in order to save the blood supply of pseudoarthrosis andextremity.

Significance: We have not found literature reports concerning asystemic study of the vascular pattern of the PFFD type PappasII-III. CT reconstructions and angiography help the surgeon de-cide the treatment strategy. These methods can introduce a newconcept of the current classifications and improve the treatmentstrategy of PFFD.

174

Correction of deformities in children using the Taylor spatial

frame

Author: Mark Eidelman (Israel)

Co-Authors: Viktor Bialik (Israel), Alexander Katzman (Israel)

Purpose: Taylor Spatial Frame (TSF) is a unique external fixator.Using computer software, the TSF can correct the most diffi-cult deformities and simultaneously correct six-axis deformities.The purpose of this study was to determine the effectiveness of theTSF for treatment of various conditions in pediatric patients.

Methods: We reviewed treatment of 40 patients (51 frames) whowhere operated on from January 2003 until December 2005. Meanage of patients at the time of surgery was 12.5 years (range 3.5–16 years). Eleven patients had complicated fractures, six Blount’sdisease, five malunions with subsequent growth arrest, two hadcongenital short femurs and tibiae, four knee flexion contractures,four clubfeet, and eight had various deformities of the lower limbs.

Results: All frames were removed after a mean time of12.6 years(range, 8–20 weeks).All but one patient were anatomi-cally corrected, and all contractures were corrected. Complica-tions included superficial tract infection in 20 patients, threechildren had fractures of femora through regenerate, and two hadcomplications related to half-pin insertions (transient peronealnerve palsy and genicular artery bleeding).

Conclusions: We believe that TSF is excellent tool for the cor-rection of multiple plane deformities in children and adolescentsand significantly expands our ability to correct precisely the mostdifficult deformities.

Significance: Combination of a stable external fixator and theaccuracy of computer based technology makes the TSF the treat-ment of choice in the precise correction of limb deformities.

175

Distraction osteogenesis lengthening

with and without deformity correction using Orthofix

and Ilizarov fixators.

Author: German Garcia-Llaver (Argentina)

Co-Authors: Eduardo Stefano (Argentina), Gabriela Martinez(Argentina), Nestor Vallejos-Meana (Argentina)

Purpose: The goal of this study was compare the result andcomplications of distraction osteogenesis lengthenings in 2 dif-ferent Orthopaedic Hospitals.

Methods: Between 1993 and 2003 the authors review the result andcomplications of 248 bone lengthenings. We divided the cases in 2groups:

Group I Axial Bone Lengthening 161 segments (128 in HNRGand 33 in DKCH)

Group II Bone Lengthening + Deformity Correction 87 seg-ments (70 at HNRG and 17 at DKCH)

Results: The average age at the time of frame application was10.8 years old in HNRG and 16.7 years old in DKCH. We per-formed an statistical analysis taking in consideration the time inframe, percentage of the initial bone length lengthened, lengthachieved, angular correction, bone healing index and complica-tions rate to determine the effect of the type of frame andsimultaneous deformity correction on these parameters.

Conclusions: The type of frame used and the simultaneousdeformity correction in addition to the lengthening procedurewere not determinants factors in terms of complications rates andbone healing indices (p < 0.05). Patients who were 14 years oldor more were associated with higher rates of complications. Webelieve that BHI is a controversial parameter to evaluate the finalresult of a bone lengthening because depends on the amount oflength gained and subjective criteria to frame’s removal and couldnot be used to predict an increase in the complications because ofpoor bone formation.

Significance: Distraction osteogenesis is a useful and effectivemethod of bone lengthening but we suggest lengthen no more that20 % of the initial bone length or no more that 6 centimeters inpatients with LLD and no more that 8 to 10 centimeters in thosewith short stature due to skeletal dysplasia, because beyond thislimit the risk of complications and additional anesthesia increasedramatically.

176

Treatment of limb length discrepancy using the Ilizarov method

Author: Vicky Vassiliki Gereis (Greece)

Co-Authors: Nikolaos Papandreou (Greece), Dimitris Pasparakis(Greece), Nikolaos Agorastidis (Greece), Georgios Pistevos(Greece).

Purpose: To study the results and complications of the Ilizarovmethod for the treatment of leg length discrepancy.

Methods: During the period from 1986 to 2002 we treated 142children with leg length discrepancy of various aetiologies. Themean age was 12.7 years (range 4–20). All children were treatedwith the Ilizarov external fixator. Outcome measures used, weretotal length gained, number and severity of complications,correction of residual deformities, leg length equalisation andpatient satisfaction. Alterations in limb function (improvementor deterioration) were also noted. Follow up ranged from 3 to13 years.

Results: The total length gained ranged from 6–13 centimetres,with an average of 9.6 cm. Using limb length equalisation andaxis correction as an outcome measure, the results were rated asvery good. The functional and aesthetic results were also verygood, in relation of course to the severity of the initial disorderthat caused the discrepancy. The majority of complications wereminor; most were observed in children with leg lengthinequality of congenital aetiology and did not alter the finalresult. The complication rate decreases with increasing experi-ence of the medical team, owing to the learning curve of themethod.

Conclusions: The Ilizarov method is a reliable method for thetreatment of large leg length discrepancy. In addition to length-

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ening, residual deformities can also be corrected, resulting inrestoration of the mechanical axis and improvement of function.The complication rate is high, but most are minor and do notaffect the final result.

Significance: This is a long term follow up study of a largeseries that adresses the results and complications of the Ilizarovmethod.

177

Humeral lengthening in achondroplastic

patients using the Ilizarov system and a peripheral

supracondylar osteotomy

Author: Vicky Vassiliki Gereis (Greece)

Co-Authors: Dimitrios Pasparakis (Greece), Nikolaos Papand-reou (Greece), Nikolaos Agorastidis (Greece), Georgios Pistevos(Greece)

Purpose: To evaluate the results of humeral lenthening in achon-droplastic patients, using the Ilizarov method.

Methods: From 1996–2002 52 humeral lengthenings were per-formed in 26 achondroplastic patients using the Ilizarov appara-tus and a peripheral supracondylar osteotomy. There were 16boys and 10 girls with a mean age of 14 years 8 months (range10–18). The total length gained in each segment ranged from6,5–10 cm (mean 7.57 cm). The average treatment time was6.2 months with a mean healing index of 26 days/centimetre oflength. The average follow-up time was 6 years.

Results: Functional and aesthetic results were graded as excel-lent or very good with high patient satisfaction. Most compli-cations were of mild severity and did not alter the final result.There were six superficial pin tract infections that respondedwell to oral antibiotics. There were no cases of deep infectionor osteomyelitis. There was one case of delayed union and onefracture following removal of the apparatus that was treatedwith a plaster cast and healed uneventfully. There were 2neurapraxias of the radial nerve during lengthening that re-solved by slowing down the rate of lengthening for a few days.

Conclusions: Humeral lengthening using the Ilizarov techniqueand a peripheral osteotomy, is safe and reliable with anacceptable complication rate. The length gained aided in greaterautonomy and patient confidence as well as in better bodyproportions.

Significance: This is a large series of humeral lengthening using theIlizarov external fixator and a supracondylar osteotomy. Thestudy demonstrates the results as well as the advantages and dis-advantages of this method.

178

Results After Limb Reconstruction using

the Taylor-Spatial Frame to Treat Congenital

& Acquired Paediatric Problems

Author: Gordon Andrew Higgins (United Kingdom)

Co-Authors: Christopher Bradish (United Kingdom)

Purpose: To assess the use and versitility of the Taylor-SpatialFrame for correction of paediatric deformities. Including Blountsdisease, fibular hemimelia,Olliers disease,Congenital Pseudoarth-rosis of the tibia, growth arrest due to idiopathic growth arrestand growth arrest after meningiococcal septicaemia.

Methods: We identified all consecutive patients, under the age of18, who have had treatment with a Taylor-Spatial frame at the

Royal Orthopaedic Hospital. All frames were applied by the se-nior author. We recorded the diagnosis, initial deformity param-eters, number of days taken for correction to beachieved,satisfaction of correction according to normal values,amount of time frame worn and complications; including jointcontractures, subluxation,dislocation, neuropraxia and deepinfection.

Results: 17 Taylor-Spatial frames were applied. 13 patients weretreated and 4 patients had bilateral treatment.The average age was9.4(2–17) years. The average time taken to achieve correction was29 (12–80) days. The average valgus deformity was 10.2 (5–15)degrees and the average varus deformity was 16.1 (14–23) degrees.Rotational deformity ranged from 10–20 degrees and leg length-ening ranged from 0–50 mm. There were no deep infections,neuropraxias, joint subluxation or contractures noted. 38% ofpatients had staph aureus pin site infections confirmed bymicrobiology. These were all treated with antibiotics and erradi-cated. All patients achieved full correction.

Conclusions: We found the Taylor-Spatial frame to be very ver-satile and effective at treating complex limb deformities andachieving sound bony union in children. Children, with parents,can understand and operate the frames.

Significance: There is little published data with the use of Taylor-Spatial frames in children. Treatment of complex limb deformitieswith the ilizarov frame is complicated and difficult. The Taylor-Spatial frame, and computer generated correction data, is apowerful tool that can be simply adjusted by children and theirparents to correct deformities reliably and successfully.

179

Forces during limb lengthening with different distraction

rhythms in a child with constitutional shortness

Author: Joachim Horn (Norway)

Co-Authors: Harald Steen (Norway), Gudrun Aarnes (Norway),Per Ludvigsen (Norway), Leif Kristiansen (Norway)

Purpose: Tensile forces are believed to be an indicator of softtissue adaptation during limb lengthening, and thereby to playan important role in the pathogenesis of complications associ-ated with distraction osteogenesis. Based on previous results,the purpose of our investigation was to see if a distractionrhythm which includes one day without lengthening every 4thday would reduce tensile forces in the treated limb compared tocontinuous lengthening and to see how tensile forces influencelengthening index and pain.

Methods: An 18 year old female with constitutional shortnessunderwent bilateral bifocal lengthening using an Ilizarov externalfixator. Tensile forces were regularly measured by force trans-ducers mounted in series across the proximal lengthening zone.Lengthening was performed with an average distraction rate of0.75 mm/day and a distraction rhythm of 3 · 0.25 mm/day on theleft tibia and 4 · 0.25 mm/day with one day ‘‘off’’ every 4th dayon the right tibia. Distal lengthening zone was distracted0.75 mm/day on both sides.

Results: The total achieved lengthening for each side was 70 mm,35 mm at each lengthening zone. Force values were lower in thelimb which followed the distraction rhythm with one day withoutlengthening every 4th day. Maximum tensile force in this limb was250 N compared to 300 N in the other limb. These differenceswere significant according to Kleinbaums test of slope and forcedifference (p < 0.001). The side with continuous lengtheningshowed higher force values, but better healing and less pain(Paired t-test: p < 0.001) for the patient.

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Conclusions: Pre-planned regular rest periods in distraction re-sulted in: reduced tensile forces across the callotasis zone, in-creased lengthening index and increased pain.

Significance: Upper and lower limits of tensile forces may exist foroptimal bone healing, and in the present study tensile forces ofabout 300 N were probably closer to the optimal value for stim-ulation of osteogenesis.

180

Distraction Osteogenesis in Lower Limb

Author: Mahzad Javid (Iran, Islamic Republic of)

Co-Authors: Gholam Shahcheraghi (Iran, Islamic Republic of),Fatemeh Hadavi (Iran, Islamic Republic of)

Purpose: Report the variability of Ilizarov leg lengthening resultsin a mixed practice set-up,where the majority of patients comefrom villages far away from the main hospital, and go back,after aweek, to their homes where there is no easy access to healthfacilities.

Methods: 61 lower limb segments in 56 patients with leg lengthdiscrepancy who had undergone lengthening with Ilizarovtechnique and principals were evaluated with an average of6.1 years follow-up. Besides full joint, limb and gait evaluation,detailed functional outcome assessment was performed by sev-eral evaluation tools including Short Musculoskeletal FunctionAssessment, WOMAC, MACTAR, and SF36. The parents’ andpatients’ satisfaction questionnaires were also completed by allthe cases.

Results: Among the 17 cases of congenital bone deficiencies, 11post paralytic,11 post traumatic, 8 post infection,and 9 miscel-laneous cases,like congenital tibial pseudarthrosis and osteo-genesis imperfecta a mean length of 7.6 centimeters from a singlebone was obtained. The healing index was 30.5 days per centi-meter for unifocal and 19.2 for bifocal lengthening. The groupof congenital deficiencies which included 7 bifocals had thelowest and the paralytic ones the highest indices. The goal ofone stage lengthening was achieved in 82% and was not reachedin 8 cases who had an estimated discrepancy of 8–19 centime-ters-either due to parents’ intolerance to the lengthy procedureor due to major complications.Side-effects were observed with arate of 0.4 per femoral and 0.8 per tibial lengthening. The fe-murs-mainly congenital deficiencies-encountered more majorside-effects, often requiring additional surgeries. Bifocal length-ening faced 0.9 per segment side-effect, in comparison with 0.4in unifocals. The younger than 8 year old patients, thoserequiring simultaneous deformity correction and congenital casesundergoing more than 8 centimeters of lengthening were affectedby more side-effects. In terms of function, improved walking,jumping, stair navigation and sporting activities was seen in 80%and remained unchanged in 20%. WOMAC score was excellentor good in71.4% and fair in 28.6%. 52 patients were satisfied,with congenital cases being the happiest. The 4 unsatisfied caseshad not achieved the full expected length and would requireadditional lengthening. The amount of gained length or thecategory of disease had no meaningful relation with encounteredside-effects.

Conclusions: Ilizarov technique can be safely used for major lengthgain. Despite its high rate of side-effects, it is associated with highsatisfaction rate, and significant functional improvement.

Significance: One does not need a sophisticated limb lengthen-ing center for lengthening,and the technique can be easily andsafely used for villagers leaving far away from major treatmentcenters.

181

Comparison of free fibula transfer and Ilizarov method

for reconstruction of Congenital Pseudarthrosis of tibia

Author: Durga N Kowtharapu (India)

Co-Authors: Rajasekaran S (India), Dheenadhayalan J (India),Raja S (India), Hari Venkatramani (India)

Purpose: Congenital pseudarthrosis of the tibia is a rare and dif-ficult condition to treat, and in the past a large number of patientshave undergone amputation. With the advent of Ilizarov tech-nique and microsurgical bone transfer radically changed themanagement of this condition. Comparison of our experience withboth the techniques is presented.

Methods: Nine cases of congenital pseudarthrosis of tibia weretreated in our hospital. Of these Five patients were treated byIlizarov technique. Two patients who went into non-union usingIlizarov technique and an additional four children were treated bymicrosurgical free fibular transfer. Age of the patient’s rangedfrom 1.5 yrs to 5 yrs. The longest followup with Ilizarov groupwas 9 yrs and in free fibula was 5 yrs.

Results: We achieved bone union in all patients of free fibulatransfer group and three patients in Ilizarov group. In Ilizarovgroup average surgical procedures were six (includes framerealignment, bone grafting and change in to free fibular group) Infree fibular graft group, only one surgical procedure was done inall patients, which excluding the removal of ‘K’ wire and externalfixator. In Ilizarov group two patients required bone graftingprocedure at docking site at average of 17 months (14 months and20 months) due persistent nonunion and union achieved in boththe cases at average of 24 weeks (27 weeks and 26 weeks). Twopatients in this group changed to free fibular graft procedure dueto unsatisfactory bone growth and recurrence of deformity afteran average of 8.5 months (8 months and 9 months) duration ofpresence of fixator in the patient was varying from 8 months to10 months (mean 9 months) Six patients were treated in free fib-ular graft procedure, which includes the two patients whomchanged from Ilizarov group. Bone union was achieved from10 weeks to 14 weeks (mean 12 weeks) in all patients.

Conclusions: Microvascular free fibular transfer is now our pre-ferred technique for the management of congenital pseudarthrosis.It provides a reliable bone union compared with Ilizarov technique.Patient compliance is also better. Inability to simultaneously correctleg length and additional deformities of the foot are limitations.

Significance: The sample is too small to calculate the statisticalsignificance.

182

Combination of Transphyseal Elevating Osteotomy,

Epiphyseodesis, Meta-diaphyseal Osteotomy with Axial

Correction and Lengthening in Blounts Disease

Author: Joachim Lauen (Germany)

Co-Authors: Kathrin Hochmuth (Germany), Jens Eckhoff(Germany)

Purpose: Blounts disease (tibia vara) is characterized by a growthdisorder of the medial part of the tibial physis, metaphysis andepiphysis.

Methods: A transphyseal osteotomy with elevation of the medialtibia plateau and simultaneous epiphyseodesis in combinationwith a second closed wedge valgization-derotation corticotomymeta-diaphyseal and lengthening was performed using a mono-

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lateral fixator. With transphyseal opening wedge osteotomyproximal to the MCL insertion the ligamentous laxity was re-tensioned by acute distraction. The permanent growth arrest byepiphyseodesis stopped the deformity progression. The callusdistraction corrected the length deficiency.

Results: Five cases were treated with this method, the follow uptwo to five years. Uncomplicated surgeries could be reported,lengthening progress and consolidation time were within regularhealing indices.

Conclusions: The clinical and radiographic results showed thecomplex options of this combined double osteotomy procedure.Definitively a reconstruction of tibial plateau with a betterrealignment of knee joint, an axial and derotational correctureand a length gain could be achieved in all cases.

Significance: The surgical method reconstructs the multi-leveldeformity, stops the growth disorder, regains length deficiencyand retensiones ligament laxity.

183

Combined correction and lengthening of forearm deformities

with external fixator

Author: Joachim Lauen (Germany)

Co-Authors: Kathrin Hochmuth (Germany), Jens Eckhoff(Germany), Rainer Gradinger (Germany)

Purpose: Congenital forearm deformities are rare, the growthdisorders relatively complex. Surgical reconstructions are difficult,because of severe growth disorders with associated joint anoma-lies. Most methods refer to acute reconstructions using closed oropen wedge osteotomies with limited length gain. Combinedcorrection and lengthening techniques with monolateral fixatorswere less reported.

Methods: 22 patients were included in this study, ages 10 to 25.Indications were Madelungs deformity (5 cases), complex defor-mities by congenital multiple exostosis (14 cases), and post-trau-matic physeal growth disorders with axial deformity and lengthdeficiency (3 cases). The surgical technique included a strictly ra-dial and ulnar pin application from an open approach, acutedeformity correction, lengthening by callusdistraction. The sys-tems used, were standard monolateral fixators, for speciallengthening demands a new long rail module constructed with ahigher axial stability.

Results: Malformations and length deficiencies, stability andfunction were improved in all treated cases. No contractions orvascular complications were seen, a temporary paraesthesia for afew days remitted ad integrum. The infection rate was restricted topin tract infections grade 1, no higher grades occurred. Systemrelated the double ball joint proofed instable for lengthening de-mands.

Conclusions: The surgical technique with mono- or bilateralapplication of fixators without compromising muscles or tendonsreduces the complications of contractures.

Significance: The defined sites of pin application allow a func-tional control of the lengthening extent.

184

The results of the modified Van Nes rotationplasty

for proximal femoral focal deficiency.

Author: Tadeusz Lejman (Poland)

Co-Authors: Bartholomew Kowalczyk (Poland)

Purpose: To present the results of our own modification of thissurgical technique.

Methods: Between 1988–2004, we operated on 6 children withunilateral PFFD type II according to the clinical Gillespie andTorode classification. There were 4 boys and 2 girls in theaverage age at the surgery 7.5 year (range: from 3 to 16 years).Three children had type C and another 3 had type D accordingto the radiological Aitken classification. The mean follow upperiod was 8 years (range: from 3 to 10 years) and the averageage of the patients at follow up was 15.5 years (range: from 6to 26 years). At the surgery, in all except one patient, thefemoral artery and the peroneal nerve were not exposed. Theanterior, medial and lateral aspect of the knee capsule wasexposed by a sharp dissection. The posterior aspect was sepa-rated bluntly from the popliteal fossa and its structures wereprotected with Hohmann elevators. The biceps tendon was nottranssected in all the cases. After the resection of the kneearticular surfaces and external rotation of the calf in all but onechild, an additional rotational osteotomy of the midtibia wasneccesary to achieve 180 degrees of rotation. In all the patients,an intramedullar Rush rod stabilization was used. All the pa-tients were clinically and radiographicaly evaluated at followup. Five teenage or adult patients completed the quality of lifequestionnaire.

Results: There were no neurological or vascular complications.A solid fusion was achieved in all the patients. On follow up,all the patients walked efficiently without crutches using aprosthesis. In four children, the foot derotated and two of themrequired repeated midtibial osteotomy. All children had fullextension of the ‘‘knee’’ and its mean active flexion was 80degrees (range: from 45–120). Three children had an averageflexion contracture of the hip of 13.3 degrees. The mean activemovements of the hip were: flexion – 67.8 degrees, abduction –38 degrees, adduction – 11 degrees, internal rotation – 45.8degrees, external rotation – 11.6 degrees. The appearance of theoperated extremity was fully accepted by all the patients, theirfamilies and the society. All the patients reported an improve-ment in their physical and social abilities. None of them wasbothered with the operated leg; none felt less attractive thanbefore operation. Four of them would definitely choose thesame operation again and one would probably choose theprocedure.

Conclusions: The presented surgical technique is easier than theTorode and Gillespie modification and it is safe. The clinicalresults and the quality of life in all patients are satisfactory.

Significance: There are few papers presenting results of rotation-alplasy procedures for PFFD. No reports are given on the qualityof life after this treatment.

185

Treatment for slipped capital femoral epiphysis using pins

(Wagner Method)

Author: Horacio Fernando Miscione (Argentina)

Co-Authors: Horacio Fernando (Argentina)

Purpose: The purpose of the present study is to introduce amodification to the technique described by Wagner to treat slip-ped capital femoral epiphysis and show the development of thosepatients who have undergone this procedure.

Methods: Between July 1997 and July 2003, 15 patients (6female and 9 male) were treated with this procedure at theHospital Garrahan. All patients had clinical and radiographi-cally acute-on-chronic slip. Out of 21 hips, 6 had a bilateraldisease (Type I and II). The mean age of the patients was

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10.8 years. Technical modifications consisted of performing alateral femoral approach under the great trochanter, exposingthe lateral femur and placing three 3 mm pins fixing the fem-oral head in situ. The pins were cut and bended on the femoralsurface through the same approach using a simple twist, cutterand bender system. The distal end of the pins was fixed using asmall plate placed perpendicular to the diaphyseal axis withonly one pin of 3.5 mm.

Results: Patients were diagnosed as primary hyperparathyroidism(1), renal osteodystrophy (5), hypothyroidism (1) and idiopathics(8). Excellent results were obtained in 13 hips and good results in8 (according to Heyman and Herndon Classification). The maincomplication presented by this technique was that pins had to bereplaced in 6 patients because as patients grew they became short.The mean follow up was 3 years.

Conclusions: This technique proves to be successful when treatingpatients with this pathology. We obtained excellent results in shortpatients or with delay of epiphyseal closure. The advantages of-fered by this technique are that it allows residual growth of theproximal femur, a minimal approach and the removal of the pinswithout complications. The disadvantage is the need to replacepins as patients grow.

Significance: This procedure demands the use of non complexdevices to treat small bones and non expensive materials, such asmechanical cutter and pins, that can be easily found in themarket.

186

Percutaneous plating after distraction osteogenesis:

A new Wagner method

Author: Chang-Wug Oh (Korea, Republic of)

Co-Authors: Hae-Ryong Song (Korea, Republic of), Hyun-DaeShin (Korea, Republic of), Byung-Chul Park (Korea, Republic of)

Purpose: Although limb length discrepancy or large bone defecthas been successfully treated by distraction osteogenesis, manycomplications arise from the long duration of external fixationand even after its removal. We tried a novel method ofpercutaneous plating over the distraction callus, to removeexternal fixators earlier or to correct deformity after its re-moval.

Methods: In eleven children of limb lengthening (6 cases) orbone transport (5 cases) by distraction osteogenesis, there were7 of growth arrest, 2 of congenital pseudoarthrosis of tibia, and2 of fibula hemimelia. In the purpose of plating, 8 were treatedto remove external fixator earlier after achieving of the targetlength, and 3 were treated as a salvage operation of deformitiesafter removal. Using the locking compression plate, submus-cular plating was done over the distraction callus percutane-ously.

Results: Mean age of index procedure was 11 years-old (range, 5to 14 years-old), and mean amount of distraction was 5.4 cm(range, 4.3–7 cm). In all patients, the distraction callus healed withmaintaining its length or correcting into the original alignment.The external fixation index was 34.3 days/cm in average andhealing index was 52.6 days/cm in average. In 8 patients with theearly removal of external fixator, the external fixation index was26.9 days/cm in average, which is nearly a half of healing index(51.7 days/cm). No one developed deep infection or implantfailures. All patients recovered the preoperative joint motion andsatisfied their function.

Conclusions: Since external fixator can be removed earlier than thetraditional method, percutaneous plating over the distraction

callus may be a successful method with fewer complications andmakes patients to return to daily life earlier.

Significance: Different from classic Wagner technique, percuta-neous plating after distraction osteogenesis don’t need bone graftand has less complications.

187

Femoral Lengthening with an Intramedullary Telescopic Nail:

Does Lengthening Along the Anatomic Axis Create

Malalignment?

Author: Dror Paley (United States)

Co-Authors: Rolf Burghardt (Germany), Stacy Specht (UnitedStates), John Herzenberg (United States), Ashish Ranade (UnitedStates)

Purpose: The purpose of the study was to see whether length-ening over the anatomic axis of the femur induces malalignmentof the lower extremity. The development of new intramedullarylengthening devices makes this an important question toconsider.

Methods: Twenty-four patients (27 femora) underwent isolatedfemoral lengthening with the intramedullary skeletal kinetic dis-tractor (ISKD). The age of the patients ranged from 16 to57 years, and three patients underwent bilateral lengthenings. Weexcluded patients who underwent simultaneous realignment pro-cedures of the tibia/femur. The amount lengthened ranged from1.5 to 8.0 cm (average, 4.4 cm). Preoperative, immediate postop-erative, and 6-month postoperative radiographs were used tomeasure the alignment of the lower extremity. We measured themechanical axis deviation (MAD), the anatomic-mechanical angle(AMA), and the amount of length obtained.

Results: Femoral ISKDs were inserted through the piriform fossain 21 femora, and tibial ISKDs were inserted through the greatertrochanter in six femora. On average, the level of the osteotomywas 5.5 cm distal to the lesser trochanter (range, 3.3 to 8.9 cm).Ten limbs experienced no change of the MAD (no change wasdefined as an overall change of less than 2 mm). Sixteen limbsexperienced a lateral shift of the MAD (average change, 1.6 mm/cm of lengthening; range, 0.5–2.8 mm/cm of lengthening). Theone remaining limb experienced a medial shift of the MAD(1.4 mm/cm of lengthening).

Conclusions: Lengthening with an intramedullary telescopic nailalong the anatomic axis can result in significant changes to theMAD. Lateral shift of the mechanical axis occurs when themechanical and anatomic axes are convergent distally beforelengthening. Medial shift of the mechanical axis occurs when themechanical and anatomic axes are divergent distally beforelengthening.

Significance: The potential for the MAD to change should betaken into account when planning femoral lengthening of a sub-stantial amount, especially for cases in which lateral MAD is al-ready present.

188

Management of lower limbs dismetries secondary

to malignant long bone tumors

Author: Marıa Carmen Perez (Spain)

Co-Authors: Rosendo Ullot (Spain), Santiago Cepero (Spain),Ramon Huguet (Spain), Alicia Gargantilla (Spain)

Purpose: Treatment of lower limbs malignant long bone tumorsentails great resections and reconstructions with bank bone

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allografts. These resections often ablate the epi and metaphysealbone (including the physeal plates). Allografts can not grow up asthe contralateral limb does. Therefore, these children suffer greatdismetries upon completion of growth. Once the patients are freeof illness, thay complain of problems caused by these secondarydismetries. We describe the results of 4 bones lengthening bydistraction osteogenesis using a tibial external fixator to correctsecondary dismetries, in four femur sarcomas.

Methods: Four patients who were diagnosed since 1999 to 2000as having a malignant long bone tumor were treated. Three ofthem had a femur Osteosarcoma, and one of them had anEwing’s Sarcoma. Distal femur was involved in three cases, andproximal femur was involved in one of them. The male/femalerate was 3:1, and the mean patients age at the time of tumordiagnose was 11 years and 9 months old. In all of them, che-motherapy preceded the subsequent wide resection of theinvolved bone and the reconstruction using a bank bone allo-graft. In one case a knee arthrodesis was necessary. After thetotal physeal closure they had a lower limbs dismetry of 8.8 cm,10 cm, 10.5 cm and 12.5 cm, respectively. The lengthening wasperformed after total physeal closure in three of the four cases,and the mean age at the time of lengthening was 15 years old. Inall cases, tibial lenghtening by distraction osteogenesis wasperformed by using a unilateral external fixator (Orthofix). All ofthem were healed from the tumor when we enhanced thelenghtening.

Results: In three cases we achieved total lenghtening and boneunion. The fourth patient had a final dismetry of 2.5 cm. We didnot length the femur in any case. All cases subsequently receivedan Aquiles tenotomy. The healing index mean was 32.5 d/cm(range, 28–35.6). Three of them developed a superficial pin siteinfection. We did not have any important complication.

Conclusions: Malignant lower limbs tumor treatment often gen-erates great dismetries in children because of the physeal platessacrifice. In attempt to prevent non-union, lengthening must neverbe done in the tumoral bone.

Significance: We think that bone lengthening to correct lowerlimbs dismetries after treatment of a malignant long bone tumor isan innovating practice. Therefore, there are not many reportsabout such interesting challenge.

189

Bifocal Tibial Corrective Osteotomy

With Lengthening in Achondroplasia. An Analysis

of Results and Complications

Author: Hae-Ryong Song (Korea, Democratic People’s Republicof)

Co-Authors: Jae-Hyuk Yang, Sandeep Vaidya, Sameer Desai,Gautam Shetty

Purpose: To study the results and complications of Bifocal TibailOsteotomy.

Methods: Retrospective review of 47 tibiae in 24 achondroplasticpatients. Comparison was made between the parameters ofangular and torsional deformities of the tibia preoperatively, atfixator removal, and at last follow-up.

Results: statistically significant change was seen postoperatively inthe values of medial proximal tibial angle, lateral distal tibialangle, mechanical axis deviation, and tibial torsion, which chan-ged from 78.8 ± 7.05 degrees, 103.2 ± 11.8 degrees,25.1 ± 14.6 mm (medial), and 22.7 ± 10 degrees (internal) pre-operatively to 87.3 ± 6.3 degrees, 90.9 ± 5.4 degrees,5.3 ± 10 cm (medial), and 15.8 ± 4.2 degrees (external), respec-tively. at the time of fixator removal; and this correction was

maintained during the follow-up period. Mean total tibiallengthening was 6.84 ± 1.3 cm. Average healing index was26.06 d/cm. Complications observed were 15 pin tract infections,1 residual varus, 1 overcorrection into valgus, 2 recurrence ofvarus, 22 equinus contractures, 2 premature consolidations, and 3fibula malalignments. Recurrence of varus was observed in limbswith a residual abnormal medial mechanical axis deviation due tofemoral deformity. A hundred percent incidence of equinus wasobserved in limbs with tibial lengthening of more than 40%, withdistal tibial lengthening of more than 15%.

Conclusions: This procedure is safe and efficacious if performedwith strict adherence to prescribed technique. Fibula malalign-ment was not observed after double fibula osteotomy.

Significance: To minimize the risk for occurrence of equinus, werecommend restriction of distal tibial lengthening in achondro-plasia to less than 15%, although total tibial lengthening mayexceed 40%.

190

Deformity Correction with External Fixator

in Pseudoachondroplasia


Co-Authors: Seok-Hyun Lee, Sameer Desai, Gautam Shetty,Harry Matta, R Mahajan

Purpose: Patients with pseudoachondroplasia have complex, dif-ficult to correct deformities including angular deformity, rota-tional deformity, and ligament laxity.

Methods: We retrospectively reviewed seven patients (two chil-dren, five adults) with 26 segmental deformities (12 femora, 14tibiae). We performed bilateral femoral and tibial osteotomies insix patients and bilateral tibial osteotomies in one patient. Dis-traction osteogenesis was used in 20 segments and acute deformitycorrection was done in six segments.

Results: Of 26 segments, there were five good, 12 fair, and ninepoor radiographic results with nine major and 12 minor compli-cations. Recurrent deformity in children and refracture in adultswere related to poor results. Of 14 limbs, there were four good,five fair, and five poor clinical results with five major and 14 minorcomplications. Knee stiffness was the most common complicationrelated to poor results in our series, and occurred particularly inpatients with simultaneous correction of the ipsilateral tibial andfemoral deformities.

Conclusions: two-stage surgery including bilateral tibial osteoto-mies first and then bilateral femoral osteotomies is recommendedinstead of simultaneous correction of the ipsilateral tibial andfemoral deformities to avoid knee stiffness.

Significance: Risk of recurrence of deformity needs to be explainedto patient and staged lengthening is recommended.

191

Relative ability of young and adult muscle to respond

to limb lengthening

Author: Gyorgy Szoke (Hungary)

Co-Authors: Tamas Shisha (Hungary), Sandor Kiss (Hungary),Karoly Pap (Hungary), Hamish Simpson (United Kingdom)

Purpose: The response of the muscle during limb lengthening iscritical in determining the functional outcome. We hypothesised

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that the response of muscles would vary with age and that therewould be significant differences in the proliferative response of themuscle belly and the myotendinous junction region.

Methods: The response of the muscles was studied during tibiallengthening in both young (n = 10) and mature (n = 10) rabbits.A bromodeoxyuridine technique (indirect immunohistochemistry)was used to identify the dividing cells both in the muscle belly andthe myotendinous junction of each muscle.

Results: The young animals demonstrated a significantly greaterproliferative response to the distraction stimulus than the matureanimals. This was particularly pronounced at the myotendinousjunction but also evident within the muscle belly. However, duringthe distraction stimulus, though the proliferative response in themyotendinous junction remained greater than in the muscle belly,the ratio between the two decreased significantly. This change wasthe result of an increased contribution of the muscle belly toproliferation.

Conclusions: The results demonstrate that younger muscle adaptsbetter to lengthening. This suggests that, for patients in whom alarge degree of muscle lengthening is required, it may be beneficialto carry out the lengthening when they are young in order toachieve the optimal functional result.

Significance: No previous study compared the proliferative re-sponse of muscle cells in both the muscle belly and the myoten-dinous junction in young and adult animals as well. Theseexperiments help us understand the different mechanisms ofadaptation of young and adult muscle to distraction.

192

Great trochanter distal transfer and femoral lenghtening

in patients with DDH.

Author: Fabio Verdoni (Italy)

Co-Authors: Antonio Memeo (Italy), Gabriele Anelati (Italy),Emilio Regondi (Italy), Giovanni Peretti (Italy)

Purpose: Several abnormalities of the femoral neck and greattrochanter have been described after treatment for developmentaldysplasia of the hip (DDH). Cases of the DDH occur afterwalking age because of late or missed diagnosis and failed con-servative or operative treatment.

Deformities of the great trochanter result in clinical symptoms:hip instability, limping gait, shortening of the extremity in-volved and limitation of range of motion. All of these symp-toms derive from weakening of the hip abductor. Correction ofgluteal insufficiency due to the short femoral neck that usuallyhas a marked varus angulation, is achieved by distal transfer ofthe greater trochanter.

Methods: We have treat 12 patients performing a distal transferof the greater trochanter and a positioning a external axialfixator to correct the lengthening of the femur after diaphysalosteotomy.

Results: We obtained the correction of the dismetry of theextremity and no signs of instability of the abductor muscles.No palsy of femoral or ischiatic nerve was registered. Thesecomplications took place: fractures of the great trochanter in 1case, superficial infections in 3 cases, lumbar hyperlordosis in 9cases.

Conclusions: We believe that this procedure is characterized by asimple surgical technique with good results due to the fact thatexternal fixation allow to achieve the correct length of the extri-minity involved without having severe nerve complications.

Significance:

Sport injuries

193

Heely Injuries: A new epidemic warranting a government health

warning!

Author: Sinead Boran (Ireland)

Co-Authors: Brian Lenehan (Ireland), Orla Callender (Ireland),David Moore (Ireland), Esmond Fogarty (Ireland), FrankDowling (Ireland)

Purpose: To review all patients presenting to Trauma OrthopaedicServices at our institutions with injuries sustained while wearingHeelys were included in this study.

Methods: From April to June 2006, all patients presenting toTrauma Orthopaedic Services at our institutions with injuriessustained while wearing Heelys were included in this study.

Results: 39 patients are included in this study. The mean age was9.1 years(range 7–13, median 9 years. Of the 39 patients referredto the Orthopaedic Service 8 required admission to hospital. Onepatient admitted following a head injury required craniotomy andevacuation of extradural haematoma.

Conclusions: The public perception of safety is incorrect andmanufacturers rightly recommend strongly the use of safety gear.

Significance: The significance of the injuries encountered demon-strates the potentially devastating results from the use of heelys.

194

Optimizing athletic performance and minimizing injury

in adolescent females: performance and training effects

of an ACL prevention program

Author: Theodore Ganley (United States)

Co-Authors: Jeffrey Albaugh (United States)

Purpose: Participation in pre-practice knee injury preventionprograms have reported significant reduction in ACL injuries,however, strength and performance gains associated with this typeof prevention program have not been investigated. The purpose ofour investigation was to determine the effectiveness of a preven-tative, warm-up program to increase strength and performance infemale high school soccer players.

Methods: Subjects consisted of 45 female high school athletes fromtwo high schools participating on their school soccer team. Oneschool participated in a preventative, warm-up program(N = 33), while the other served as a control (N = 12). Prior toeach soccer practice, the preventative, warm-up group partici-pated in a 15-minute dynamic stretching, strengthening and plyo-metric program. The control performed their traditional warm-upwhich consisted of a light jog and static stretching. All subjectsunderwent pre- and post-testing after an eight week period.Testing included Biodex� assessment, vertical jump and triplehop testing as well as a subjective drop-jump screen.

Results: For all nine measures of performance and strength, thewarm-up group showed significant improvement. The controlgroup demonstrated significant gains for only two measures– peak quadriceps torque at 300o/sec and peak hamstring torqueat 180o/sec on the Biodex�. Actual difference in training effectbetween the preventative, warm-up and control group was notsignificant. Subjective assessment of the drop-jump screenrevealed a higher percentage improved their lower extremityalignment for the preventative, warm-up group.

Conclusions: A 15 minute on-field, warm-up prevention programperformed prior to practice provides similar strength and

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performance results as more time consuming traditional off-fieldprograms.

Significance: Increasing lower extremity strength is one of the fac-tors leading to improved neuromuscular control at the knee andlower extremity, which is the main biomechanical goal of theseprevention programs. Though injury prevention is the objective,application by coaches aswell as athlete compliance andmotivationmay improve if ancillary strength and performance gains are noted.

195

Nerve Block vs. Intra-Articular Anesthetics in Pediatric

Patients Undergoing Arthroscopic ACL Reconstruction:

Efficacy, Cost and Operative Time

Author: Theodore John Ganley (United States)

Co-Authors: Kristofer Jones (United States), Lawrence Wells(United States), Giovanni Cucchiaro (United States), John Flynn(United States)

Purpose: Post-operative pain management following ACL recon-struction may be achieved through femoral sciatic nerve block(FSNB) or intra-articular injection (IA) of combinations of localanesthetics or opioids. In this postoperative randomized study, weinvestigated the hypothesis that FSNB offers better postoperativeanalgesia than IA in patients undergoing ACL reconstruction.The overall cost and operative time for the two procedures wasalso evaluated.

Methods: 36 patients undergoing ACL reconstruction with a singleincision technique using either Achilles tendon allograft or ham-string autograft were randomized into two groups of 18 FSNBpatients and 18 IA patients. Age, sex, and weight were similar forboth groups. Standard anesthesia protocols were followed foradministering FSNB and IA. Patients received standardized mor-phine PCA and rescue morphine boluses postoperatively. Opioidrequirement and VAS pain scores amongst the two groups werecompared along with the time spent administering the anestheticand the relative cost of the two procedures.

Results: Patients treated with FSNB required less intraoperativeopioids. The mean pain score after FSNB was lower on PACUarrival and during the first 24 hours postoperatively. FSNB rescueopioid use in the first 24 hours postoperatively was significantlylower and the FSNB group when longer without initiating use ofthe PCA pump. Both OR time and the overall cost of the pro-cedure were higher in the FSNB group in comparison to IA. All ofthese results were statistically significant.

Conclusions: Combined femoral-sciatic nerve block providesgreater postoperative analgesia than the intra-articular injection ofcombined anesthetics and opioids, with significantly lower intra-operative and postoperative requirement of opioids. Increasedexperience administering FSNB may lead to potential improve-ments in cost and operative time for the overall surgical procedure.

Significance: Improvements in postoperative analgesia withnerve blocks was noted which can improve overall patientexperience.

196

Rising Trend in Paediatric Trampoline-related Injuries.

Author: Cyrus Jensen (United Kingdom)

Co-Authors: S Sandhu (United Kingdom), Robert Jarman(United Kingdom)

Purpose: Recently there have been several reports published in themedia and medical journals suggesting an increase in the number

of trampolining injuries. The aim of this study is to identify andquantify the trend in paediatric trampoline-related injuries in theUK.

Methods: A retrospective case note review of all children (under16 years) attending the Accident & Emergency Department in anurban district general hospital in the UK, during the same 5 weekperiod (May to June) in 2004 and 2005 was carried out. Patientswere included if their injuries were identified as being related totrampolining. Data collected from notes included patient demo-graphics and mechanism, site and severity of injury. Data onweather conditions during these two time periods were collectedfrom the UK Meteo Office.

Results: There was no statistical difference in the populations(age, sex, numbers) or weather conditions during the two timeperiods studied. A statistically significant 500% (95% CI221.6% - 1126.1%) increase in paediatric trampoline-relatedinjuries was noted from 2004 to 2005 (p < 0.0001.) In the2005 group of injured patients 64% were injured whilst on thetrampoline, 76% sustained injuries to extremities and 33%sustained fractures.

Conclusions: The exponential rise in trampoline-related injuriesseen in the USA following the popularisation of recreationaltrampolining in the 1990’s is now being repeated in the UK. Ourresults show a statistically significant five-fold rise in paediatrictrampoline-related injuries from 2004 to 2005. In addition, severalpatients would not have been injured had they followed the RoyalSociety of the Prevention of Accidents (RoSPA) guidelinesregarding safe use of trampolines - including age restrictions (over6 years old), trampolining ‘one at the time’ rule and avoidingunsupervised trampolining.

Significance: The authors suggest that there is a need for increasedpublic awareness of both the dangers associated with trampoliningand the guidelines issued by the RoSPA regarding responsible useof domestic trampolines.

197

Soccer Ball Velocity in Young Soccer Players

Author: Kevin G. Shea (United States)

Co-Authors: Kurt Nilsson (United States), Alex Homaechevarria(United States), Anthony Paris (United States), Derek McCool(United States), Jennifer Belzer (United States), Dennis Phelps(United Kingdom)

Purpose: Recent studies have suggested that subtle cognitive def-icits and degenerative cervical spine changes in soccer players maybe related to the cumulative affects of repetitive trauma fromhead-ball contact events. Some have suggested that the rules ofsoccer should be changed, to reduce the risk of head-ball contact,or to introduce protective head gear. Younger athletes may bemore vulnerable to head/neck injury at lower impact forces.Comprehensive ball velocity studies have not been conducted inyoung athletes. The purpose of this study was to determine soccerball velocity generated by youth soccer players.

Methods: IRB approval and consent was obtained. Using soccerathletes from an elite, 11 state tournament, ball velocities weremeasured for ages 12 through 19 years of age. 20 athletes from eachage group, and sex were evaluated. Demographic information forage, sex,weight, height, and years of experiencewere collected. Eachathlete was given 5 attempts at kicking a ball into a goal. Using aradar speed gun, the ball velocitywas calculated for each group. Theaverage and maximal velocity was calculated for each group.

Results: For male athletes, the lowest average velocity was 66 kphin the 12 year old age group – this age group demonstrated a peakvalue of 83 kph. The 16 year old group demonstrated the highest

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average value at 98 kph, and the highest peak velocity of 120 mph.For female athletes, the lowest average velocity was 59 kph in the12 year old age group – this age group demonstrated a peak valueof 75 kph. The 17 year old group demonstrated the highest aver-age value at 77 kph, and the highest peak velocity of 86 kph.

Conclusions: Recent studies have suggested that soccer ball headimpacts may produce measurable neuro-cognitive function deficitsand cervical spine degeneration. Additional studies will be nec-essary to confirm these findings. This study describes soccer ballvelocity in young athletes, and demonstrated that young athletescan generate very high peak velocities.

Significance: Recent studies have suggested the the immaturenervous system is more vulnerable to injury. This informationmay be used for future modeling studies of head-ball impact inpediatric and adolescent athletes.

198

Physeal injury of the proximal tibia during ACL reconstruction

in pediatric patients

Author: Kevin G. Shea (United States)

Co-Authors: NickHutt (United States), PeterApel (United States),Ron Pfeiffer (United States), Kurt Knilsson (United States)

Purpose: ACL reconstruction in pediatric patients has a risk ofproducing physeal arrest. Studies on physeal volume damage havesuggested that physeal injury below a certain threshold may havea small risk of producing a physeal arrest. This study used threedimensional computer generated models of the proximal tibia todetermine the location and magnitude of physeal arrest of theproximal tibia during ACL reconstruction.

Methods: MRIs of 10 skeletally immature knees were reviewed.(Average age = 8.1 years, range 5–10). The image files wereimported into MimicsTM. MimicsTM, a specialized imagingsoftware capable of constructing a 3D virtual surface modelfrom MRI or CT image data. The sagittal sections were digi-tized, and converted into images with separate designations forthe metaphyseal, physeal, and epiphyseal regions. These imageswere converted into three- The SolidworksTM software wasused to place drill holes in these models, simulating tunnelsused for ACL reconstruction. These tunnels were positioned toavoid injury to the apophyseal region of the physis, and to passthrough the central portion of the tibial physis. Drill holediameters were 6, 7, 8 and 9 mm. The software was used tocalculate total physeal volume and volume of physis removedby the tunnel. Excel was used to analyze these variables, anddetermine the ratio of physis volume removed/total physisvolume.

Results: The average physeal volume for this series 7085 mm3(range 3087 to 11126 mm3). For 6, 7, 8, and 9 mm diameter drillholes, the average physis volume removed/total physis volume was1.6, 2.2, 2,9, 3.8 % respectively. For all subjects, the volume re-moved was less than 7.% for all subjects using an 6–9 mm drillholes.

Conclusions: Drill hole placement during ACL reconstructionproduces a zone of injury to the proximal tibial physis. Withcareful drill hole placement, the region of injury is central, and thetotal volume of injury can be less than 5 % of the total volume ofthe tibial physis. Both of these factors (non-peripheral locationand volume of injury less than 5%) suggest that the risks ofproducing a clinically significant physeal arrest is small, althoughfurther clinical study will be necessary to confirm this.. Largerdiameter drill holes, and more peripheral drill hole injury to thephysis may increase the chance of producing a physeal arrest. The

starting point of the drill hole should avoid the apophyseal regionto reduce the volume of damage to the physeal/apophyseal regionsof the physis.

Significance: A better understanding of the relationship betweenthe ACL and physis may guide the placement of tibial drill holeswhich have a lower risk of producing physeal arrest.

199

Heelys� – a potential hazard for the ‘walk and roll’ generation

Author: Mihai Vioreanu (Ireland)

Co-Authors: Eoin Sheehan (Ireland), Aaron Glynn (Ireland),Noelle Cassidy (Ireland), Michael Stephens (Ireland), DamianMcCormack (Ireland)

Purpose: Heelys� are the only shoes with a removable wheel inthe heel. Concerns have been raised by the media regarding thesafety of children wearing Heelys�. We highlight an increasingtrend in orthopaedic injuries in children as a result of ‘heeling’.We report the incidence and costs of ‘heeling’ injuries duringsummer holiday in inner-city population requiring orthopaedictreatment.

Methods: We prospectively recorded the data of all ‘heeling’injuries referred to the orthopaedic department in our hospitalduring the summer school holiday. Using a Data CollectionSheet we recorded demographical data (sex, age), type of injury,mechanism and place of injury, ‘heeling’ experience,using of safety equipment, methods of treatment and the chil-dren intention to continue ‘heeling’ after recovery from theirinjury.

Results: From 1st of July to 15th of September this year, 67children with orthopaedic injuries resulted from ‘heeling’ werereferred to our service for treatment. There were 56 girls and 11boys with a mean age of 9.6 years of age (from 6.2 to14.9 years). Upper limb were by far the most common type ofinjury, resulting from either forward (22) or backward falls (36).Forearm fractures were the most prevalent (49 fractures in 48children) followed by supracondylar fractures (5), elbow dislo-cations (2) and hand fractures (2). There were 5 ankle fractures,2 tibial fractures and 2 knee injuries. The majority (76%) ofchildren suffered the injury while ‘heeling’ outdoors and 16injuries happened indoors, either in the house (7) or in shop-ping centres (9). Interestingly 20% of the injuries happenedwhile trying Heelys� for the first time and 36% of the injurieswhile learning (using 1–5 times) how to ‘heel’. None of thechildren used any sort of protection gear at the time of theinjury and only 12% (8) were familiar with the instructions touse. From all injuries 38% required emergency admission tohospital and manipulation under anaesthetic in the operatingtheatre. The cost of these injuries was estimated around 1.500eper injury. The estimated cost for management of the remaininginjuries (52, 62%) was around 300e. The majority (58%) of theinjured children (38) expressed their intention of continuing‘heeling’ after complete recovery of their injury.

Conclusions: Our study shows that the majority of children withinjuries from ‘heeling’ are girls. Most children suffered injurieswhilst using Heelys� for the first time or while learning to usethem. We recommend close supervision of children usingHeelys� during the steep learning curve and usage of protectivegear at all times whilst ‘heeling’. ‘Heeling’ injuries have a seri-ous impact on children health and constitute a burden for thepaediatric orthopaedic service.

Significance: We report the single largest epidemiological study oforthopaedic injuries in children during the summer holiday re-sulted from the increasingly popular new craze: ‘heeling’.

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200

Management of symptomatic discoid lateral meniscus

in children

Author: Moshe Yaniv (Israel)

Co-Authors: Michael Fishkin (Israel), Eli Ezra (Israel), ShlomoWientroub (Israel)

Purpose: Symptomatic discoid lateral meniscus in children is acommon condition requiring surgical intervention and use ofarthroscopic technique. Findings in the arthroscopic evaluationmandates different surgical solutions. Avoidance of completemenisectomy is recommended, while repair of the detachedattachment with saucerization of the discoid morphology is thepractice of choice. The study is an overview of our experience withthe clinical presentation, arthroscopic treatment findings and re-sults of symptomatic discoid lateral meniscus in pediatric patients.

Methods: We retrospectively analyzed the charts and surgical find-ings of 38 pediatric patients with discoid lateral meniscus whopresented consecutively since 1999 and were treated arthroscop-ically. Evaluation of the clinical presentation, arthroscopic find-ings and procedures, and evaluation of the ability to return tofull functional and sport activity. Mean age at surgery was11.8 years (5–17), mean postoperative follow-up period was3.4 years (6 m-7y).

Results: Nine children (24%) had complete discoid lateral menisci,and 29 (76%) incomplete. Instability of the meniscus was found in7 knees (18%). An associated tear was found in 21 knees (55%).Partial menisectomy and meniscal reshaping was done to all knees.Two knees with a deformed and unstable meniscal tissue under-went subtotal menisectomy leaving a small rim of the meniscus.Repair of the unstable peripheral rim attachment was performed in6 knees. Associated lateral femoral condyle osteochondral lesionswere found in 3 knees and were treated by reshaping of the discoidmeniscus without addressing directly the osteochonral lesions, allof which showing complete clinical and radiologic resolution. 33patients reported no symptoms and return to full functional andsport level, 4 patients had minor symptoms like click sensationwith no pain or limited activity. One patient developed a symp-tomatic osteochondral lateral femoral condyle lesion. Two patientsneeded a second arthroscopic procedure due to symptoms recur-rence (12 and 6 months after the first procedure, respectively).

Conclusions: Management of symptomatic discoid lateral menis-cus is dictated by the arthroscopic findings. The importance ofmeniscal tissue preservation and the variability of the discoidlateral meniscus arthroscopic findings compel the surgeon toconsider different surgical techniques and solutions. Associatedconditions such as osteochondral lesion of the femoral condyle ormeniscal instability should be diagnosed prior to and intraoper-atively and addressed with an adequate procedure.

Significance: The importance of surgeon’s awareness and skills toaddress the various expressions of this complicated pathology ishighlighted.

Spine

201

Treatment of C1-C2 injuries in very young children

Author: Massimo Balsano (Italy)

Co-Authors: Antonio Villaminar (Italy), Marta Comisso (Italy)

Purpose: Cervical spinal injuries in the very young child are rel-atively uncommon compared with older children, adolescents, and

adults. The increased soft tissue elasticity and anatomic differ-ences in children younger than 8 years make upper cervical spineinjuries more likely.

Methods: We have collected 3 cases of C1-C2 injuries inour department, all of them following a car crash. 2 female and1 male. The patients had respectively 2, 2,5 and 3 years old atthe admission in the hospital. 2 lesions were classified asunstable and treated with posterior sublaminar wiring fixationand arthrodesis C1-C2 and external immobilization, 1 patientclassified as stable lesion and treated with halo-vest. 2 lesionswere neurological intact, 1 patient was classified as Frankel B.

Results: All the patients had full neurological recovery. The 2patients treated with posterior surgical synthesis healed with asolid fusion. The minimum follow-up is 1 year.

Conclusions: The child who has sustained a considerable traumamust be very carefully investigated, immobilized on a spinalboard and studied with standard radiographs, MRI and CTevaluations. In the lateral x-ray view rupture of the transverseatlantal ligament allows more than 4 mm of anterior displace-ment of the atlas. The alar ligaments prevent further displace-ment, but when there is 10 to 12 mm of displacement, theseligaments are ruptured and cord compression can result. MRI isuseful for delineate bone and soft tissue injury and permitspredictive classification of spinal cord injuries. The majority ofthese injuries can heal with external immobilization with halo-vest. Close reduction must be done with general anesthesia,neurologic monitoring (SSEP, MMEP) after halo placement withfluoroscopic control. In case of unstable lesions, surgery ismandatory. A posterior approach to C1-C2 and the reductionusing a reabsorble wire is, in our opinion, one of the best choicefor treat these very young patients. Fusion must be alwaysperformed with autologous grafts to prevent pseudoarthrosis.External immobilization after posterior open reduction permitsto reach a solid arthrodesis.

Significance: The significance of this paper is to explain thedefine the modalities of these particular kind of injuries in veryyoung children where the upper cervical spine is more involvedthan the lower and to update the modalities of modern treat-ment.

202

Shoulder height after surgical correction of thoracic adolescent

idiopathic scoliosis.

Author: Sinead Boran (Ireland)

Co-Authors: Brian Lenehan (Ireland), Caroline Goldberg(Ireland), David Moore (Ireland), Esmond Fogarty (Ireland),Frank Dowling (Ireland)

Purpose: To determine the incidence and extent of shoulder-imbalance before posterior spinal surgery and to ascertain itsoutcome, using radiographic and topographic measures.

Methods: Patients with right thoracic adolescent idiopathicscoliosis who had undergone corrective posterior spinal fusionby one surgeon were identified. Pre- and all postoperative spinalradiographs and surface topography were evaluated and corre-lated. Any effect from concomitant anterior release procedureswas sought. The Quantec System consists of a desktop com-puter, a video camera and a slide projector that throws aspecially designed pattern on the child’s back. The subjectstands free in a customised frame, with feet separated by astandard wooden blocks, arms by sides and looking straightahead. The dimples of Venus, Spinous process of T1 aremarked with paper stickers, The image is captured. The axillary

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skin crease is mapped. The computer analyzes the image andmap 3 further points. ½ way between T1 and the axilla, 1/3way between axilla and dimples of venus ½ way to midline and2/3 way between axilla and dimples of venus. The image is thenanalyzes by customised software according to several parame-ters.

Results: Sixty six patients were identified, 56 girls and 10 boys.Their mean age was 15.14 yrs ± 1.72 Their pre-operative majorCobb angle was 73� ± 14.0 and the mean correction was38.8� ± 12.333 (56%). Their pre-operative minor Cobb angle was36.35� ± 13.83 and mean correction was 22.0� ± 2.72(62%).Before surgery, surface topography showed the mid-point of theright shoulder to be at a mean of 18.57 mm. ± 11.24 higher thanthe equivalent left point; 1 week later, the difference was–6.0 mm. ± 9.91, a mean change of 24.57 mm ± 11.8. At sixmonths, it was –4.52 ± 8.02, statistically unchanged. At two years,it was –2.55 ± 7.2(p = 0.051) and at three years, 1.76 ± 6.53 andindistinguishable from zero or perfect balance. The differencebetween pre-operative and final shoulder level difference was19.54 mm. ± 9.09. The Cobb angle of the compensatory upperthoracic curve was not significantly changed throughout. Therewas no statistically significant difference in shoulder height betweenpatients undergoing single or two-stage surgery, either before or atany stage after.

Conclusions: Correction of post-operative shoulder imbalancedoes occur spontaneously.

Significance: Correction of post-operative shoulder imbalance isa function of spinal accommodation to the new anatomy.

203

Sagittal Spine Characteristics as a Predictor of Proximal

Junctional Kyphosis


Co-Authors: Eric Henderson (United States)

Purpose: Familial Dysautonomia (FD) is a neurological diseaseseen in Ashkenazic Jews. Severe kyphoscoliosis is common in FDpatients who have a high incidence of excessive proximal junc-tional kyphosis (PJK) following surgical correction. Proximal endscrew pullout is not uncommon. A retrospective radiographicstudy of the sagittal spine in FD patients was undertaken toinvestigate a causal relationship with PJK.

Methods: Preoperative, postoperative, and most recent follow-uplateral radiographs of eighteen pediatric FD patients were mea-sured for kyphosis, lordosis, sagittal balance, and proximaljunctional alignment. The scoliotic curve was also measured.Measurements of patients found to have PJK (‡20�) were com-pared to those who had normal junctional measurements.

Results: Nine of the eighteen patients developed PJK. Three pa-tients required revision surgery for proximal hardware pulloutfollowing onset of PJK. Seven of nine patients who developed PJKwere in positive sagittal balance preoperatively while seven of ninepatients who did not develop PJK were in negative sagittal balancepreoperatively; this was statistically significant (p = 0.025). Nostatistically significant difference in the patients’ preoperativescoliosis, kyphosis, or lordosis was found. Seven of the nine pa-tients who developed PJK did so within two months of surgery.

Conclusions: Positive sagittal balance is a significant risk factorfor development of PJK in patients with FD and should beconsidered when planning corrective surgery for scoliosis. Theresulting PJK increases cantilever bending forces on the proxi-mal hardware and can lead to failure. These findings mayprovide clues as to the cause of PJK in patients with idiopathicadolescent scoliosis.

Significance: Positive sagittal balance is a significant risk factor fordevelopment of proximal junctional kyphosis in patients withFamilial Dysautonomia and should be considered when planningscoliosis surgery.

204

Multiplier Method for the Prediction of Sitting Height

and Spinal Height

Author: John Eric Herzenberg (United States)

Co-Authors: Mordchai Shualy (United States), Maya Goldberg(United States), Dror Paley (United States), Amanda Gelman(United States)

Purpose: The purpose of this study is to develop multipliers for thespine and for sitting height that predict spinal height and sittingheight at maturity.

Methods: Using cross-sectional and longitudinal clinical data-bases, we divided the total sitting height, cervical length, thoraciclength, and lumbar length at skeletal maturity by the sittingheight, cervical length, thoracic length, and lumbar length at eachage for each percentile given. These multipliers were then com-pared with each other, compared between percentiles, and com-pared between different racial, national, and ethnic groups.

Results: The multipliers calculated for sitting height had littlevariability and correlated with those calculated for the thoracicand lumbar spinal heights. The cervical spinal multipliers werenearly identical to the multipliers for the upper extremity. Themultipliers of different racial, national, and ethnic groups werealso the same.

Conclusions: The multiplier method has been proven to beindependent of percentile, generation, ethnicity, and race. It is asimple and effective method of predicting spinal height andsitting height. The multiplier for sitting height can be used topredict sitting height at maturity, the heights of the cervical,thoracic, and lumbar spine, and the height lost as a result ofspinal fusion.

Significance: The sitting height multiplier will determine a child’ssitting height at maturity. Additionally, the total height lost as aresult of spinal fusion can easily be determined by using both thespinal and sitting height multipliers.

205

Analysis of preexistent vertebral rotation

in the normal spine - MRI study in humans with situs

inversus totalis (SIT)

Author: Jan-Willem M Kouwenhoven (Netherlands)

Co-Authors: Lambertus Bartels (Netherlands), Koen Vincken(Netherlands), Max Viergever (Netherlands), Abraham Verbout(Netherlands), Tammo Delhaas (Netherlands), Rene Castelein(Netherlands)

Purpose: An important component of idiopathic scoliosis isvertebral rotation – thoracic curves rotating to the right sidepredominate. Recently, the authors demonstrated that a similarpattern of vertebral rotation is also an anatomical feature in thenormal spine – in humans, as well as in quadrupeds. Since thethoracic organs in humans and in quadrupeds are asymmetri-cally situated, we postulate that this asymmetrical anatomycould play an important role in the development of this preex-istent rotation. The purpose of this study was to investigatevertebral rotation in humans with a complete mirror image

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reversal of the internal body organs – called situs inversus totalis(SIT).

Methods: Twenty males and 17 females, mean age 32.1 years,underwent MRI examination of the thoracic and lumbar spine.There was no clinical or radiological evidence of scoliosis or otherspinal pathology. Vertebral rotation was analysed from level T2 toL5 by using the same measurement method as used in our pre-vious studies.1;2 The longitudinal axis of the vertebrae was definedas the line through the Centre Of Mass (COM) of the vertebralcanal and the COM of the anterior half of the vertebral body.The reference line was defined as the line through the COM of thevertebral canal and the COM of the sternum at level T5. Thereference line was defined as zero degrees rotation; rotation tothe right was defined as a positive angle, rotation to the left as anegative angle.

Results: A predominant rotation to the left side was found of themid and lower thoracic vertebrae – the observed frequencies ofright and left vertebral rotation differed significantly from anequal right-left distribution (P < 0.05). Measurement of thevertebral rotation angles showed a significant mean rotation angleto the left side at levels T5 to T11, with a maximum rotation of 2.7at level T7 (P < 0.001).

Conclusions: Our study shows a predominant rotation to the leftside of the mid and lower thoracic vertebrae in the normal, non-scoliotic spine of persons with SIT. This rotational pattern isopposite to what was found in humans and quadrupeds withnormal organ anatomy. Based upon these results, it seems likelythat the asymmetrical position of the thoracic organs is animportant causative factor in the development of this preexistentrotational tendency.

Significance: Despite years of extended research the etiology ofidiopathic scoliosis has still not been resolved. The results of ourstudies show the existence of a pre-existent pattern of vertebralrotation in the normal nonscoliotic spine. We assume that thisrotational tendency determines the direction of curvature oncescoliosis starts to develop.

206

Cervicothoracic Myelopathy In Children With Morquio

Disease


Co-Authors: Mihir Thacker (United States), Leslie Grissom(United States), Mohan Belthur (United States)

Purpose: Previously reported causes of myelopathy in Morquiodisease (MD) include atlanto-axial instability and / or soft-tissuehypertrophy, as well as thoraco-lumbar cord compression. To thebest of our knowledge, there are no reports of cervicothoracicstenosis (CTS) in these patients reported in literature. The purposeof this study was to report the presence of cervico-thoracic com-pression as a cause of myelopathy in children with Morquio dis-ease and evaluate the outcome of surgical decompression in thesecases.

Methods: This was a retrospective, IRB approved clinical andradiolographic review of four patients with MD with CTS whohad undergone decompression and fusion, at our center between1990–2005.

Results: All patients had previously undergone occipito-cervicalfusion for atlantoaxial instability. There were 3 girls and 1 boywith an average age of 76 months (54–112) at presentation forneurological symptoms. All had upper motor neuron signs inlower and / or upper limbs. MRI demonstrated CTS with anteriorvertebral wedging, platyspondyly and posterior disc bulges at thelevels of cord compression in all 4 patients. Three patients

underwent posterior decompression and fusion. The fourthunderwent an anterior corpectomy with an anterior and posteriorfusion. All patients had neurologic improvement post-operatively.Two of 4 patients required subsequent surgery for compressiondistal to the cervicothoracic junction.

Conclusions: Cervicothoracic stenosis can be a cause of neuro-logical deterioration in patients with Morquio syndrome. MRImaging of the entire spine is essential to identify the site of cordcompression and to plan appropriate surgical management.

Significance: Cervicothoracic stenosis can be a cause of neuro-logical deterioration in patients with Morquio disease; MRI of theentire spine is essential to identify the site of cord compression andto plan surgical management.

207

The Safety of Pedicle Screw Fixation in the Thoracic Spine

Author: Heather McCann (United States)

Co-Authors: Richard Gross (United States)

Purpose: The objective of this study was to report the safety ofthoracic pedicle screw fixation using the anatomic method forspinal deformity surgery.

Methods: The authors retrospectively reviewed medical recordsfor patients with pediatric spinal deformity surgery from Jan-uary 2002 to May 2006 for one pediatric orthopaedic surgeonat one institution. Following a one day tutorial, the seniorauthor (RHG) used pedicle screw fixation placed by the ana-tomic method described by Lenke for spinal deformity surgery.Instead of CT scan documentation of pedicle anatomy andscrew fixation, a true AP radiograph of the most rotated seg-ment of the curve was made to assess pedicle shape and size.Multiple fluoroscopy images were made intraoperatively priorto rod placement, obtaining a true AP view at all instrumentedlevels.

Results: Pedicle screw fixation was used in 75 cases of pediatricspinal deformity correction. A total of 1714 screws, 1275 tho-racic screws and 439 lumbar screws, were placed withoutcomplication.

Conclusions: Thoracic pedicle screws can be successfully insertedeven when preoperative radiography indicated the pediclesize was inadequate. The tutorial is an effective method ofinstruction for learning the technique of thoracic pedicle screwinsertion.

Significance: Thoracic pedicle scres can be successfully placedwithout complication with adequate preoperative planning.

208

Classification of Chance fracture in children using MRI

Author: Jerome Sales de Gauzy (France)

Co-Authors: Jean Jouve (France), Philippe Violas (France), JeanGuillaume (France), Anne Coutie (France), Franck Accadbled(France), Franck Launay (France), Gerard Bollini (France), JeanCahuzac (France)

Purpose: Flexion distraction fracture of the spine (Chance frac-ture) are rare in children. Several classifications were described inadult, but they might be inappropriate in children because of thepresence of a growth plate. Rumball and Jarvis identified 4 dis-tinct patterns of injury based on a radiographic study in a series of10 paediatric cases. Nevertheless, standard X-rays do not enabledisc or growth plate lesions of the spine to be investigated. Weperformed a retrospective study based on MRI examinations in

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order to define the different lesions which can occur in paediatricflexion distraction fractures of the spine.

Methods: From 1995 to 2005, the data of 31 flexion distractionfractures from 3 centres were collected. Among these patients, 18(12 male, 6 female) were evaluated with an MRI before anytreatment. Mean age at injury was 7.5 years (3–17). 17 had caraccidents and 1 a motor-bike accident. Associated intra-abdomi-nal injuries were noted in 11 cases. None of the 18 patients pre-sented peripheral neurological complications. The initial X raysand MRI of each patients were analysed.

Results: The level of injury was located between T12 and L4.On X-rays, a bony fracture passing through the pedicle and thevertebral body was noted in 6 patients. A wide inter vertebraldisc space and kyphotic deformation was observed in 12 pa-tients. On MRI, in all cases, no abnormal signs were noted onthe vertebral disc either on T1 or T2 sequences. As on X-rays 6real Chance fractures were diagnosed. In the other 12 cases, wenoted a physeal injury on the superior end plate (8 cases) or theinferior end plate (4 cases). In these 12 cases the posteriorlesions were always located either above or below the pedicleand damaged the soft tissue and/or the articular facet (supe-rior or inferior). Consequently 3 fracture patterns were identi-fied according to the location of the lesion in relation to thepedicle.

Type I (8 cases): physeal injury of the superior growth plateassociated with posterior lesion above the pedicle (soft tissue orsuperior facet).Type II (6 cases): osseous type. Fracture through the vertebralbody, pedicle, lamina and spinous process.Type III (4 cases): physeal injury of the inferior growthplate associated with posterior lesion below the pedicle (softtissue or inferior facet)There was no correlation between frac-ture type and age, gender, level of injury or associatedcomplications.

Conclusions: Adult classifications are not available for childrensince they described disc lesions without physeal injuries. Ourfindings based on MRI examination are different from the pae-diatric classification reported by Rumball and Jarvis based on Xrays. MRI is useful in the diagnosis of paediatric flexion-distrac-tion injuries of the spine.

Significance: MRI allows physeal injury to be clearly identifiedfrom disc injury. A proper diagnosis using MRI can be useful totreat these patients.

209

Adolescent idiopathic scoliosis surgery. Rod rotation versus

translation versus in situ contouring.

Author: Jerome Sales de Gauzy (France)

Co-Authors: Franck Accadbled (France), Nicolas Lapie (France),Maxime Cournot (France), Jean Cahuzac (France)

Purpose: Since the introduction of Cotrel-Dubousset instrumen-tation, several types of instrumentation and correction manoeu-vres have been used for the surgical treatment of adolescentidiopathic scoliosis (AIS). By now correction may be achievedusing three main strategies: derotation, translation or in situcontouring. The goal of the present study is to investigate whetherone of these 3 operative procedures leads to a better correction ofAIS than the other.

Methods: 60 AIS operated on using one of the three strategieswere analysed: group I rod rotation (20 cases), group IItranslation (20 cases), group III in situ contouring (20 cases).Mean age at surgery was similar in each group (14.9, 15.5,

14.2 years). All surgeries were performed by the same surgeonusing the respective recommended techniques. Arthrodesis wasachieved using bone substitute in all cases. Neurologic compli-cations did not occur. For each patient, we measured cobbangle of the instrumented curve, the upper non instrumentedcurve and the lower non instrumented curve. Measurementswere performed preoperatively on frontal X rays and onbending, and postoperatively at a minimum follow-up of2 years. Sagittal X rays were also analysed preoperatively andpost-operatively.

Results: Measurements of the instrumented curves as well as thenon instrumented curves showed no significant difference betweenthe groups either preoperatively or at follow-up. In the threegroups an improvement in the instrumented curves as well as inthe non instrumented curve was achieved.

Instrumented curve :

Preop: I 53.5� ± 10.5, II 53.8� ± 14.8, III 52.7� ± 10.1. P = 0.91Bending: I 25.9� ± 11.6, II 27.7� ± 19.2, III 25.8� ± 12.9. P = 0.95Follow-up : I 21.8� ± 11.9, II 24.4� ± 13.2, III 23.4� ±10.2. P = 042

Upper non instrumented curve

Preop: I 22.4� ± 12.6, II 21.2� ± 13.6, III 22.2� ± 13.2. P = 0.95Bending: I 11.5� ± 10.5, II 13.9� ± 12.6, III 11.9� ± 11.1. P = 0.79Follow-up: I 11.8� ± 10.3, II 14.1� ± 9.1, III 13.9� ± 10.5. P = 0.75

Lower non instrumented curve

Preop: I 31.5� ± 6.7, II 27.1� ± 9.4, III 26.5� ± 15.8. P = 0.76Bending : I 1.75� ± 3.3, II 4.15� ± 4.84, III 3.1� ± 5.4. P = 0.43Follow-up: I 14.1� ± 9.0, II 9.4� ± 7.2, III 11.5� ± 9.0. P = 0.39

In contrast, the sagittal profile of the vertebral column was notimproved by the operation.

T5T12 preop: I 19.2� ± 9.8, II 18.7� ± 9.2, III 21.9� ± 8.8. P = 0.49T5T12 follow-up: I 20.6� ± 8.1, II 23.2� ± 8.0, III 22.2� ±9.9. P = 0.61L1L5 preop : I 46.4� ± 10.9, II 42.1� ± 9.4, III 44.5� ± 11.2. P = 0.39L1L5 follow-up : I 41.6� ± 12.1, II 43.0� ± 8.9, III 39.6� ±10.2. P = 0.56

Conclusions: Derotation, translation and in situ contouringachieve a similar correction of the scoliotic deformities in frontaland sagittal plane.

Significance: The use of either a rod rotation, a translationmanoeuvreor an in situ contouring method does not result in any measurabledifference both in instrumented and non instrumented curves.

210

Cervical Spine in Pseudochondroplasia:Characteristics

and Rationale of Management


Co-Authors: Gautam Shetty, Jae-Hyuk Yang, Seung-Woo Suh

Purpose: Little has been mentioned in literature regarding thecharacteristics of cervical spine in Pseudochondroplasia,a rareautosomal dominant skeletal dysplasia.The purpose of this studywas to analyse the relation between the incidence of upper cervicalinstability and the os odontoideum and to define the character-istics of upper cervical spine instability in patients with Pseudo-chondroplasia.

Methods: Fifteen patients of Pseuochondroplasia were evaluatedfor upper cervical spine instability having mean age of 23.7 yrs(range 3–44 yrs). Evaluation of neurological status was done by

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Nurick’s Grading System and evaluation of myelopathy by JOAScoring.Group1(n = 9)with os odontoideumandGroup2(n = 6)without os odontideum. InstabilityIndex, RotationalInstability,AtlantodensInterval(ADI), Space available for cord(SAC) weremeasured by computed tomographic (CT)studiesThe followupperiod was 1–5 years (mean 2 yrs).

Results: There was significant difference when the 2 groups werecompared on the basis of Space available for cord(SAC). Rota-tional Instability and JOA (Japanese Orthopaedic Association)scoring. Incidence of Os odontoideum was 66% in our studypopulation. The presence of Os odontoideum led to increase in theincidence of upper cervical spine instability and the incidence ofinstability increased with age of the patient. Only 3 patients inGroup 2 had features of cervical myelopathy with no deteriora-tion of their neurological status and no patient required surgicalstabilization.

Conclusions: Cervical instability in the presence of os odontoide-um has a linear relationship with age and myelopathy. Prognosisfor patients with instability depends on early diagnosis and thesepatients should undergo clinicoradiological evaluation of theirupper cervical cervical spine at regular intervals.

Significance: (—)

211

Transcranial Motor Evoked Potential Monitoring

for Pediatric Spine Surgery


Co-Authors: Dan Emerson (United States), Mark Balvin (UnitedStates), James Chen (United States), Adam Bergeson(United States), Nathalia Jiminez (United States), Jefferson Slimp(United States), Klane White (United States)

Purpose: Review our early experience and learning curve in theimplementation of TcMEP monitoring at our center using totalintravenous anesthesia (TIVA) with propofol infusion. To identifyfactors related to positive changes, identify strategies for dealingwith positive strategies, and to determine the sensitivity of TcMEPto SSEP for true positive changes.

Methods: With IRB approval, we reviewed our first 3 yearsexperience in 137 consecutive spinal surgery cases using TcMEP.We specifically reviewed anesthetic agents given, rate of propofolinfusion, fluctuations in blood pressure at 15 minute intervals,spinal manipulations being performed, neurologic outcome aftersurgery, age of child being studied, other diagnoses and co-mor-bidities present, and number of positive TcMEP changes over timewith no neurologic deficit.

Results: 80 pateints were neurologically normal preop and nor-mal postop. 52 patients were neurologically abnormal preop andhad no change postop. 5 patients were abnormal preop and weremore abnormal postop. TcMEP was 100% predictive of a per-sistent deficit postoperatively. The rate of positive TcMEPwithout deficit postop was 20% in the first year, but decreased toless than 5% after 3 years of experience. Of those with intra-operative TcMEP changes where there was full recovery by theend of the case, only 12% has associated SSEP changes. 3/5subjects with true neurologic change had TcMEP change, but noSSEP change. The use of inhalational agents, high propofolinfusion rates, younger age, and hypotension led to TcMEPchanges. Reversal of the above in most cases led to normaliza-tion of the TcMEP.

Conclusions: TcMEP is safe and reliable for the detection ofchanges in the spinal motor pathways. With experience overtime and close collaboration between surgeon, monitoring team,

and anesthetic staff, the stability of the technique can be greatlyincreased. The use of inhalational agents, very high levels ofpropofol infusion, excessive hypotension, and very young age ofpatient are associated with reversible positive changes inTcMEP.

Significance: TcMEP is physiologically more accurate thatNMEP and SSEP for detection of evolving motor deficits inchildren undergoing spinal surgery. With experience, it shouldbecome the standard for electorphysiologic monitoring in spinalsurgery.

212

Fusion Rates Following Thoracoscopic Release And Bone Graft

Substitutes In Idiopathic Scoliosis

Author: George Harman Thompson (United States)

Co-Authors: Jochen Son-Hing (United States), Brett Weinzap-fel (United States), Douglas Armstrong (United States),Laurel Blakemore (United States), Connie Poe-Kochert (UnitedStates)

Purpose: To compare fusion rates between allograft bone andGrafton DBM Flex in thoracoscopic anterior spine surgery.

Methods: Between 1998 and 2004, thoracoscopic anterior discec-tomy and fusion followed by instrumented posterior spinal fusionwas performed in 47 patients with idiopathic scoliosis. Forty pa-tients have been followed more than one year. Twelve patients hadmorselized allograft bone (allograft group) while 28 patients hadGrafton DBM Flex contoured and folded into ‘‘tacos’’ to fill thedisc spaces (DBM group). Patients were evaluated at one month,one year, and at last follow-up. Major curves were measured usingthe Cobb method and interbody fusion was assessed using thegrading scale as reported by Newton et al. for standard radio-graphs (1–100% fusion, II - greater than 50% fusion, III -less than50% fusion, IV - no fusion).

Results: The mean follow-up was 4.3+/–1.8 years in the allograftgroup and 2.6+/–1.1 years in the DBM group. There were nosignificant differences in age at surgery, number of vertebraefused, or estimated anterior blood loss. There were no significantdifferences in preoperative major curve, initial correction, orcorrection at last follow-up. There was minimal postoperative lossof correction. No patient had crankshaft, pseudarthrosis orhardware failure. At most recent assessment, 160 of 182 discspaces (88%) were rated grade I or II and there were no significantdifferences between the two groups.

Conclusions: Grafton DBM flex ‘‘tacos’’ are an effective bonegraft substitute in thoracoscopic surgery for idiopathic scoliosis.

Significance: Autograft harvest is traditionally associated withincreased operative time, blood loss and pain. Grafton DBM Flex‘‘tacos’’ avoid these issues and are easy to insert, more flexible,expand when hydrated with blood, and are less likely to dislodgeor block correction.

213

The efficacy of preoperative erythropoietin administration

in pediatric neurogenic scoliosis patients


Co-Authors: Hiroko Matsumoto (United States), David Privitera(United States), Joshua Hyman (United States), Linda Waters(United States), David Roye (United States)

Purpose: The preoperative use of recombinant human erythro-poietin (rhEPO) has been shown to decrease perioperative

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transfusion requirements in many adult and pediatric patients. Arecent study at our institution demonstrated the efficacy of rhEPOin pediatric idiopathic scoliosis patients, but suggested the possi-bility of an ‘‘erythropoietin resistance’’ in the pediatric neurogenicscoliosis population. The purpose of this study is to investigatethis finding further by analyzing the effect of rhEPO on hemato-crit (Hct) and transfusion rates in patients with neurogenicscoliosis.

Methods: This is a retrospective cohort study examining 61 pa-tients with neurogenic scoliosis who underwent anterior and/orposterior spinal instrumentation at the age of 18 years andyounger. The decision to use rhEPO was on the preference of thetreating surgeon, though there was a trend toward increased useover time. Thirty five children received preoperative rhEPO andiron, while 26 patients did not receive the treatment with rhEPO inthis study. We found no significant difference in comorbidities,numbers of level fused, Cobb angle or rates of pelvic fixation intwo groups.

Results: Neurogenic scoliosis patients who received RhEPO had asignificantly higher preoperative Hct level (p = 0.01) and post-operative Hct level (p = 0.02) than their non-RhEPO counter-parts. Patients treated with rhEPO had a 57.1% rate oftransfusion while those without rhEPO had a 50.0% rate althoughthere was no significant difference (p = 0.613).

Conclusions: The administration of rhEPO had no significant ef-fect on reducing the likelihood of transfusion in neurogenic pa-tients in this study. While we acknowledge that selection and timebias, these data stand in stark contrast to previous work exam-ining the efficacy of rhEPO in averting transfusion in idiopathicpopulations. We hypothesize that anemia of chronic disease,rhEPO resistance, preexisting coagulopathies, and the nature ofsurgery in these children all play a role in obscuring the rela-tionship between preoperative Hct and transfusion rates.

Significance: Neurogenic scoliosis patients who received RhEPOhad a significantly higher preoperative Hct level and postoperativeHct level than their non-RhEPO counterparts. However, theadministration of rhEPO had no significant effect on reducing thelikelihood of transfusion in neurogenic patients in this study.

214

Health Related Quality of Life in Children with Thoracic

Insufficiency Syndrome


Co-Authors: David Roye (United States), Hiroko Matsumoto(United States), Betz Randal (United States), Emans John (UnitedStates), David Skaggs (United States), John Smith(United States), Kit Song (United States), Robert Campbell(United States)

Purpose: The traditional surgical or non-surgical techniques totreat Thoracic Insufficiency Syndrome (TIS) are not able to sta-bilize or improve chest wall size or pulmonary function whileallowing spine growth. To this end, Vertical Expandable Prothe-stic Titanium Rib (VEPTR) was specifically designed to treat TISby allowing growth of the thoracic cavity and control/correctionof spine deformity. The purpose of this study was to comparequality of life (QOL) of children with TIS and impact on theirparents prior to and after implantation of the VEPTR. We alsocompared the QOL of children with TIS and the parental impactprior to implantation of the VEPTR with previously publishedQOL of healthy children.

Methods: As part of the original multi-center evaluation of theVEPTR, Child Health Questionnaire (CHQ) was collected

preoperatively on forty five patients who were subsequentlytreated with expansion thoracoplasty using the VEPTR. Theaverage age was 8.2 ± 2.6 and parent form of the CHQ was filledout by the primary caretaker. Patients were divided in to threebroad diagnostic categories; Rib Fusion (RF, N = 15), Hypo-plastic Thorax Syndromes (HT, N = 17) and Progressive SpinalDeformity (PS, N = 13).

Results: There were significant differences between the study pa-tients and healthy children in physical domains. Compared withparents of healthy children, parents of children with TIS experi-enced more limitations on their time and emotional lives due totheir children’s health problems. In addition, they had poorexpectations for their children’s health. There were no significantdifferences in CHQ scores in these children before and after thesurgery except for a significant decrease in the Self-Esteem scoreamong patients with HT. None of the domains in the CHQ hadmoderate or large degree of responsiveness across the all threediagnostic categories.

Conclusions: The children with TIS had lower physical domainscores and higher caregiver burden scores than healthy chil-dren. However, the scores in psychosocial domains were sim-ilar to those in healthy children. Since responsiveness of theCHQ was small, it can be concluded that our study demon-strates the lack of ability in the questionnaire to reflect clini-cally important minimal changes in response to the VEPTRinstrumentation in this population. Therefore, a Disease Spe-cific Instrument (DSI) may be needed in order to detect theminimal changes in this population. Current efforts areunderway to better understand the clinical features that havethe most profound effects on the life of these children and todevelop a DSI for this population.

Significance: The children with TIS had lower physical domainscores and higher caregiver burden scores than healthy children.None of the domains in the CHQ had moderate or large degree ofresponsiveness. A DSI may be needed in order to detect theminimal changes in this population.

215

Development of the thoracic kyphosis and lumbar lordosis

in normal children and adolescents.

Author: Jose Batista Volpon (Brazil)

Co-Authors: Carlos Giglio (Bulgaria)

Purpose: To establish the limits of the angular variation of tho-racic and lumbar curves in normal children and adolescents ofboth genders.

Methods: A pantograph was developed to measure the dorsalspinal curves. In short, it consisted of a tripod and a verticalbar that held a mobile arm. This arm was placed on the spi-nous process of C7 and ran down to L5 while moving forwardor backward, according to the spinal curves. A laser beansystem was used to get the proper positioning of both thepantograph and the subjects. Such movements were captionedand processed by computer software so that the spinal contourwas drawn on screen, thus allowing the measurement of thekyphotic and lordotic angles. Before performing the populationstudy, the performance of the pantograph was assessed in 20normal individuals by comparing data obtained with the pan-tograph with data obtained from sagittal X-rays for the tho-racic and lumbar curves and no statistical significance wasfound (p < 0.005). For the population survey, 718 normalsubjects of any race and with normal weight and stature wereselected. Furthermore, individuals with past history of spinalproblems or presenting either generalized laxity, or muscular

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shortening were not included. The data were analyzed for agerange and gender. Proper statistical study was performed andregression analysis was obtained.

Results: The comparison between genders showed no statisticaldifference. The kyphotic curve steadily increased from 26� at05 years of age to 36� in 20 year-old individuals (kyphoticangle = 25.14� + 0.58 x age). The lordotic curve increasedfrom 22� at 05 years of age to 32� in 20 year-old individuals(lordotic angle = 24.22� + 0.51 x age). The best statisticalmodel that represented the progression for both curves was thelinear regression.

Conclusions: The pantograph developed for this research accom-plished its finalities and both the kyphotic land lordotic curves inthe normal population showed a clear tendency to increase withage with no difference between genders.

Significance: The sagittal profile of the lordotic and kyphoticspinal curves was established and it is possible to determinatethe normal range of variation for different age groups. Thesedata can be used to identify normal and abnormal spinal cur-vatures in the sagittal plane and can contribute to evaluateposture.

16 - Musculoskeletal infections

216

Surgical treatment for the sequelae of meningococcal sepsis

Author: Lucas Pena (Spain)

Co-Authors: JL. Barroso (Spain), JL. Monasterio (Spain), JL.Beguiristain (Spain)

Purpose: Introduction: Meningococcal sepsis is responsible forphyseal plates disturbances at multiple sites affecting axial andlongitudinal limb growth and therefore requiring correction withdifferent surgical techniques.

Methods: We carried out a retrospective study of 14 patientssuffering sequealae of meningococcal sepsis (8 excluded due tofailure to attend follow up). 6 patients were treated, 2 girls and 4boys with an average time of 12 months before the diagnosis ofsepsis was established (8–20 m) and 4 years before the first visit tothe clinic (2–10 years). We reviewed the symptoms, radiologicalfindings, types of treatments realized, complications and clinicalsituation at the last follow up. The average follow up was 12 years(5–17 years).

Results: The most common reason for attending the clinic wasvarus deformity of the knees (10), ankles(2) and hips (1), followedby lower limb length discrepancy (2). The most frequent surgicaltechniques were valgus osteotomies of the tibia (18) and femur (3)leg lengthening with correction of tibial (4) and femoral (3) axis,physeal distractions (2) and 2 epiphysiodesis (distal femoral andproximal tibial). For the ttreatment of complications we carriedout 1 calcaneo-stop procedure for a valgus foot and a Krogius-Lecene procedure for a recurrent patella dislocation. Amongst thesequelae found at last follow up were 2 patients with minimal leglength discrepancy (1,6 cm), a valgus knee, a varus knee and avarus ankle deformity all of them being followed up at that time.

Conclusions: Conclusions: We want to remark the importance ofappropriate follow up of these patients until skeletal maturity inorder to avoid the high number of musculoskeletal disturbancesthat they can present and their tendency to recur and thereforereduce the number of surgical procedures required.

Significance: *

217

Primary sternal osteomyelitis in a 40 days old infant.

Case report presentation

Author: Nikolaos Pettas (Greece)

Co-Authors: Maria Fragaki (Greece), Alexandros Apostolopou-los (Greece), Georgios Skarpas (Greece), Nikolaos Voutsas(Greece), Helen Kyrikou (Greece)

Purpose: Primary sternal osteomyelitis is extremely rare in chil-dren and only very few cases have been reported in the interna-tional literature. The purpose of our abstarct is to present a casereport of a 40 days old infant where its diagnosis and managementare discussed.

Methods: A 40 days old infant was referred to our clinic with a4 days history of fever and malaise, accompanying a painfulswelling of 4 days duration involving the lower end of the ster-num. Examination revealed a 2 cm swelling which was fixed to theunderlying bone. A full blood count, ESR, CRP were measuredand X-Rays (Anterior and Lateral views) and Ultrasound wasperformed. Blood cultures were also taken. The patient wascommenced empirically to Vancomycin and Cefotaxime iv. Thevalues of WBC (16,720), ESR (132 mm) and CRP (108 mg/dl)were elevated, the X-rays showed bone destruction and disloca-tion of the 3rd sternal nuclei and in the U/S performed appeared asoft tissue mass measuring 2.37 cm/1.02 cm related to the peri-osteum. Surgical debridement was then performed and swabcultures were taken intraoperatively. The infant grew Strepto-coccus Pneumoniae and Enterococcus Spp. The later microor-ganisms have never been reported before to cause primary sternalosteomyelitis in children.

Results: The infant was discharged after 25 days from thehospital. She gradually improved over a period of 2 months,became pain free and repeated X-Rays showed significantbone resolution. The infant was examined 3 years after her dis-charge from the hospital in the outpatient’s department ispain free and in the X-Rays performed, there was a total boneresolution.

Conclusions: Diagnosing sternal osteomyelitis can be difficult, butfailure to clinically recognize this type of infection in its earlystages can lead to serious sequelae. The diagnosis should be sus-pected in a young patient presenting with acute inflammatoryswelling over the sternum. Primary osteomyelitis in infants is avery rare condition that usually resolves with antibiotic therapyand surgical debridement.

Significance: There are only very few cases of primary sternalostemyelitis in infants reported in the international literature.

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Osteomyelitis of head of humerus presenting as Erb palsy: 2

case reports.

Author: Manuel Resende Sousa (Portugal)

Co-Authors: Filipe Silva (Portugal), Delfin Tavares (Portugal),Francisco sant’Anna (Portugal), Manuel Cassiano Neves (Portugal)

Purpose: Osteomyelitis occurring during the neonatal period isuncommon. Hematogenous dissemination is responsible for mostof these cases. Brachial plexus pseudopalsy is a well recognizedcomplication of shoulder osteomyelitis / septic arthritis. Our aimis to report 2 cases of brachial plexus palsy in the neonate.

Methods: Two neonates with previous normal neurologic exami-nation presented with reduced movement and pain of the upper

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extremity. There was no history of fever or signs of constitutionalillness. Shoulder osteomyelitis was diagnosed from clinical, hae-matological and radiological findings. Pus culture grew staphy-lococcus aureus.

Results: Following surgical drainage and intravenous antibiotics,resolution of the symptoms was progressive and complete.

Conclusions: Neonatal osteomyelitis affecting the humerus canpresent as Erb palsy. It results from hematogenous spread andskin/umbilical sepsis are a predisposing factor. Diagnosis is oftendifficult and delayed. We suggest that such infection should beconsidered in every neonate with acute paralysis of the arm be-yond the perinatal period.

Significance: Diagnosis is often difficult and delayed. Wesuggest that such infection should be considered in everyneonate with acute paralysis of the arm beyond the perinatal period.

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Septic Physeal Separation of Proximal Femur

in a Newborn

Author: Roberto Schiavon (Italy)

Co-Authors: Andrea Borgo (Italy), Andrea Micaglio (Italy),Naldo Chiaramonte (Italy)

Purpose: Physeal separations in newborns are a problem indiagnosis and treatment. In developed countries, septic osteo-myelitis and septic arthritis in newborns are unusual and rep-resent a problem in differential diagnosis among severaldiseases, often far away from the orthopaedics and frequentlyneeding all diagnostic resources to obtain the correct diagnosis.This in order to get the best knowledge of the actual conditionand to avoid an unsuitable treatment or to avoid an unexpectedanatomical situation in case of surgical exposition. Therapyneeds to be carried out as soon as possible in order to preventthe possible negative anatomical and functional consequences.Association between septic event and physeal separation isreally rare.

Methods: We report a 28-days female, admitted for persisting ele-vated temperature, shudder, irritability and abdominal symptomswith abdominal levels on the abdominal X-ray. At the time ofadmission, when first evaluated by the paediatric surgeon, andinguinal hernia was reduced. For the persistence of clinical condi-tions, in the following days she underwent to two surgical explor-ative laparoscopy with no regression. Four days later becomevisible, at the left groin plica, a swelling extending to the posteriorproximal thigh; a needle drainage performed by the paediatricsurgeon evidenced pus presence. At this time she underwent toorthopaedic surgeon evaluation and after a correct exposition ofthe pelvis to direct X-ray (that evidenced a lateralization of thefemoral shaft) and an ultrasonography of the left hip (that showedan indefinable morphology of the hip, the presence periarticularand proximal parostal femoral shaft liquid collection) a diagnosisof septic arthritis with consequent hip dislocation was formulatedand surgical open drainage was indicated. Actually, only at thetime of surgery was possible to observe the presence of a separationbetween the connected epiphysio-great trochanteric nuclei and thefemoral shaft, with unexpected close and clear hip joint. Afterdrainage a reduction between the epiphysio-trochanteric complexand the femoral shaft was obtained and a stabilization with Kirs-chner wires was performed.

Results: When 4-years last reviewed, the two hip joints weresymmetric on X-ray image and in range of motion.

Conclusions: Association of musculo-skeletal septic event andphyseal separation is rare, difficult to diagnose, and need aprompt surgical treatment.

Significance: The interest in that case consists of the difficultyin the differential diagnosis at the first evaluation (the new-born underwent 3 non orthopaedic surgical procedures beforecorrect localization of the disease was established), in theorthopaedic misdiagnosis based on the lack of a completepreoperative imaging where a MR was not performed (a septicarthritis was supposed at the time of orthopaedic evaluation),and finally in the long term excellent result after a promptsurgical treatment.

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Acute pyogenic arthritis in neonate: prognostic factors

and outcome

Author: Jong Sup Shim (Korea, Republic of)

Co-Authors: Hee Pyo Jang (Korea, Republic of), Eun Jin Sul(Korea, Republic of)

Purpose: The aim of this study were to investigate relationship ofthe multiple prognostic factors and outcome of acute pyogenicarthritis in neonate.

Methods: Thirty neonates (13 females and 17 males) underwentoperative procedure under diagnosis of an acute pyogenicarthritis and survived until final follow-up were included in thisstudy. Ages ranged from 10 days to 2 months (mean 43 days).The most common sites of involvement were hip (21 patients).Twenty-three patients (77%) had definite intraoperative pusdrainage. Ten (33%) had an underlying disease. Thirteen (43%)had a concomitant septicemia. The symptom duration beforetreatment ranged from 1 day to 30 days (mean 5.7 days).Twenty-five children (83%) were febrile. Nine patients (30%)had a radiographic change on preoperative plain X-ray. WBCcount was elevated in twenty-three patients (77%). The ESRincreased in fifteen patients (50%) and CRP increased intwenty-six patients (87%). Fourteen cases (47%) had positiveculture from joint fluid. The predominant causative organismwas Staphylococcus aureus (11/14), six of which were methi-cillin-resistant. We rated final result as good, fair, and pooraccording to the range of motion of the joint and radiographicfindings (Good: full range of motion and no radiographicdeformity, fair: mild limitation of motion or mild radiographicdeformity, bad: limitation of motion and deformity requiredcorrection). The average follow up period was 5 years 2 months(2–9 years). Seven cases were good, seventeen were fair and sixwere bad. Possible prognostic factors including gender, age,prematurity, birth weight, fever, symptom duration and labo-ratory findings, site, pus, sepsis, radiographic finding, culture,underlying disease and pathogens were evaluated. Statisticalanalysis was evaluated by Krusskal-Wallis test and v2 test.

Results: Our results showed that the prognosis is worse in the caseof who showed preoperative radiographic change in plain X-ray,premature, low birth weight and who had underlying disease.Outcome did not depends on other factors, including gender, age,fever, symptom duration, laboratory findings, site, pus, sepsis,culture and pathogens.

Conclusions: Unhealthy neonates with low birth weight, pre-mature or comorbidity have the poor general condition thatnecessitated several invasive procedures such as catheterizationand monitoring, which made them more susceptible to invasion ofthe microorganism. Also, radiographic change means that thediagnosis is delayed. These factors may predispose to the devel-opment of infection sequelae and poor end result.

Significance: The progressive joint destruction in the neonate withseptic arthritis do not correlated with the severity of the periop-erative clinical manifestations.

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221

The use of polymerase chain reaction (PCR) for the detection

and speciation of bacterial bone and joint infections in children


Co-Authors: Karl Boatright (United States), William Nilsson(United States), Jeff Drassler (United States), Mark Strom(United States), Jane Burns (United States), Wesley Bevan (NewZealand)

Purpose: To develoop and test an accurate, rapid, and easily ap-plied PCR/RFLP techique for detecting and differentiating bac-terial species causing osteomyelitis and septic arthritis in children.To compare the ability of PCR/RFLP to standard bacterial cul-tures in detecting and identifying bacterial pathogens in bone andjoint infections in children.

Methods: We prospectively enrolled 36 consecutive patients withopen physes who met our inclusion criteria for probable infection.Blood and body fluid/joint aspirate specimens were collectedsterilely with half the specimen undergoing routine processing forbacterial cultures and the other half frozen for later PCR/RFLPanalysis. Extracted genomic material was amplified using a fluo-rescent labeled universal primer for the small subunit 16S gene.The resultant amplicons were purified and were then digested withselected restriction endonucleases to yield characteristic fragmentswhich were then compared to a library of common organisms forpediatric bone and joint infections that had undergone the samePCR amplification and endonuclease digestion. Positive controlsused blood and synovial specimens from control patients knownto be free of infection. Negative controls were from patientsundergoing routine arthroscopy, elective osteotomy with sterilemarrow aspirates, and blood draws from patients undergoingelective surgical procedures.

Results: Of 36 enrolled patients, 3 had contaminated specimens andwere excluded from analysis. Five were found to have diagnosesother than a bacterial bone or joint infection. Of the remaining 28patients, site-specific bacterial cultures were positive in 15/28 pa-tients (53.5%). Nine of 15 were PCR positive for the same organismand one of these had a polymicrobial infection based upon PCR.Of6patientswhowere culture positive andPCRnegative, 4were StaphAureus and 2 were Kingella Kingae. Five of 13 culture negativepatients had a positive PCR and one of these was polymicrobial. 27of 28 hadblood cultures and 7of thesewere culture positive. Four ofthese were PCRpositive for the same organism.No culture negativeblood cultures were PCR positive.

Conclusions: The use of PCR/RFLP with a universal primerwas not found to be more sensitive than standard bacterialcultures, but was found to be complementary with culture negativespecimens being PCR positive and polymicrobial infections beingdetected that were not detectable by standard culture techniques.

Significance: The use of PCR/RFLP methods may be of usein situations in unknown or polymicrobial infections whereorganism specific probes or direct sequencing of amplified geno-mic material may not be feasible to use.

Other

222

A Method of Coding Children’s Orthopaedics

Author: George Bennet (United Kingdom)

Co-Authors: Alistair Murray (United Kingdom), Neil Wilson(United Kingdom)

Purpose: Most work in our speciality is not admitted to hospital.Because of this, much is not captured by the ICD coding system.As a result it is difficult to use such methods to adequately reflectwhat we do and to recall patients for research purposes.

Methods: We have developed, and used for some 13 years, asimple method of coding all the patients we see. The coding systemhas been designed specifically for children’s orthopaedic surgery.

Results: We now have some 53,000 patients coded by this simplesystem. Sampling has revealed it to be 97.5% accurate.

Conclusions: By augmenting the more usual methods of codingby a system specifically designed fro our speciality, we haveproduced a method of recall fro all patients seen in thedepartment.

Significance: Such method of recall is vital both for audit of whatwe do and as a research tool. It enables easy recall of all patientsseen and thus allows easy retrospective study both of workloadand of specific conditions. We would recommend the developmentof a standardised coding system for our speciaity and suggest thatthis is something which EPOS might undertake.

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Williams syndrome in childhood: the role of the orthopaedic

surgeon.

Author: Enrica Cristini (Italy)

Co-Authors: Chiara Comelli (Italy), Antonio Memeo (Italy),Angelo Silicorni (Italy), Alessia Fraponi (Italy), Giovanni Peretti(Italy)

Purpose: Williams syndrome (WS) is a rare genetic conditionwhich causes medical and developmental problems. It is presentat birth, and affects males and females equally. The prevalenceof WS is about 1/7500. The clinical presentation is variable, withdifferent degrees of severity. It is characterized by: mentalretardation and/or learning difficulties, developmental problems,cardiovascular disease, a distinctive facial appearance and,sometime, hypercalcemia. WS is due to a random geneticmutation (deletion of a small piece of chromosome 7).The mainorthopaedic problems include: scoliosis, flat foot, genu valgum,kyphsis, ligamentous laxity and muscular hypotonia.

Methods: We reviewed 115 patients with WS that were treat in DeMarchi Syndromologic Centre of Milan University.

Results: Scoliosis with variable degrees of severity occurred in 14patients, flat foot in 15, valgus knees in 28, kyposis in 11, toe walkingin1, cavus foot in1, permanent patellardislocation in1, halluxvalgusin 4, clinodactylia of the fifth finger in 4 cases, minor orthopaedicproblems in 11 and no musculoskeletal involvement in 14 patients.

Conclusions: All the child presented a generalized muscularhypotonia and a retardation in physical development and gener-ally a low stature. Surgical treatment was reserved only to reallysevere scoliosis and to permanent patellar dislocation. All patientsunderwent a rehabilitation program to improve tone and mus-cular control.

Significance: We can conclude that orthopaedic surgeons play animportant role in carefully monitoring children with WS.

224

Pediatric trauma related to motor-vehicle accident

Author: Mahzad Javid (Iran, Islamic Republic of)

Co-Authors: Gholam Shahcheraghi (Iran, Islamic Republic of)

Purpose: To find the patterns and common mechanisms ofmotor –vehicle related pediatric trauma in a metropolitan city

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(Tehran-Iran), to guide the health planners of the city in properplanning and resource application and distribution.

Methods: A pilot study was started in three major pediatric –trauma referral centers in Tehran by the Iranian OrthopaedicAssociation. All the cases below age 14 who visited the emergencydepartment of those three hospitals, with body trauma resultingfrom a vehicle-related accident were studied. Cases were collectedon a 24-hour basis in 1 month of each four seasons of the lastyear. The data collection was done by contracted physicians withthe use of a detailed questionnaire.

Results: A total of 318 cases (74.2% male, 25.8% female) with themean age of 8.32 years (4 months to 14 years) had the seasonaldistribution of: 22.1 % spring, 30% summer, 20.9% fall, and 27%winter. 12.6% of the accidents happened on roads, 71.1% on citystreets, and 16.4% on alleys. 56.9% happened at night and 43.1%during the day. Motorcycle hitting pedestrian accounted for 33%,car-pedestrian accident for32.1%, and car-motorcycle for 11.6%.The rest were combinations of car to car, car to bike, motorcycleto bike, etc. The injury types consisted of 86 (65.2%) lower, 38(28.8 %) upper, and 8 (6%) combined upper and lower extremityfractures. 106 (33.8%) of cases had multiple trauma, 183(57.5%)had head injury (22 unconscious, 5 confused), 5.7% pelvic, 4.7spinal, 5% abdominal, 1.6% chest and 0.6% vessel injury. In thelower extremity, tibia /fibula fractures were the most common(64.5%), followed by femur (26.6%). In the upper limb radius/ulnafracture with incidence 39.1% was the followed by and humerusand clavicle (23.9% and 15.2%). 24.8% of the cases had beenbrought in by ambulance and 75.2% by friends, family or bystanders. The recommended safety support was not in use at thetime of accident in 83%. 12.3%of children were holding parents’ orguardian hands when the accident happened. 68.6% of childrenwere crossing the width of the road, alley, or highway when theywere hit.

Conclusions: Vehicle related fractures happen more in malechildren, more in summer after school closing. Crossing thestreets, especially at night is dangerous for children. Motorcyclesand cars hitting the walking or running kids are common eti-ologies for fractures. (either due to lack of respect for trafficrules by the drivers or from children not obeying pedestriantraffic rules).

Significance: Children become disabled far too frequently in thecity, from lack of proper training, proper enforcement of trafficrules by the children and the drivers. Appropriate measures ofsafety in the crowded metropolitan city of Tehran are essential,and this report can be a guide for the other major cities of thethird world.

225

Time cost of digital imaging (CD) in orthopaedic clinics

Author: Stephanie Juenemann (Switzerland)

Co-Authors: Carol Hasler (Switzerland), Reinald Brunner(Switzerland)

Purpose: X-Rays are presented on CD‘s in a digital format withincreasing frequency. The impression is that this techniquerequires more time to present a given x-ray compared to con-ventional pictures.

Methods: Time was measured for 6 orthopaedic residents pre-senting the most recent ap-view out of a given set. Ten sets of 6 x-rays for each case were saved in the conventional and digitalformat each. The order was randomised. As a precondition thecomputer was on and the same viewer software was used for alldigital sets. The results were compared using a non linkedstudent‘s t-test (significance level p = 0,05).

Results: Presentation of conventional x-rays required 21 sec(+-7,46), of digital x-rays 90 sec (+- 27,56) respectively (p < 0,001).

Conclusions: In spite of ideal conditions digital x-rays on CD needsignificant more time in the orthopaedic clinic. In major centrespatients present with different software and software in otherlanguages which increase the required time even furhter. Thislatter problem will be assessed in another study.

Significance: This increase of preparation time used by a highlyqualified staff member has implications on economics andlogistics.

226

Characteristics of the fractures in children who were presented

to the emergency department of the hospital

Author: Onder Kalenderer (Turkey)

Co-Authors: Tanzer Gurcu (Afghanistan), Ali Reisoglu(Afghanistan), Haluk Agus (Afghanistan)

Purpose: This study concerns the breakdown and frequency offractures in children by recording the children who were diag-nosed with and treated for fractures at Tepecik Egitim ve Arastırma (Education and Research) Hospital and time of fracture,age, sex, mechanism of fracture, fracture time and type.

Methods: Children, who age between 0–14 and were presented toemergency department with fracture diagnoses on even numbereddays were included in this prospective, random study. Formsincluding information about characteristics of the fractures werefilled in for each case. For 3 years, age, sex, date and time offractures, how they occurred, fracture place and type have beenrecorded for the cases and child fracture case frequency andbreakdown were determined.

Results: Total number of cases was 1706 (992 boys and 714 girls).The most frequent age for fractures were 7 and 3 (9 % and 8 %)for the boys, whereas it was 4 and 5 (9 % and 8.5 %) for the girls.Most frequent cause of fracture was domestic accidents. School(22 %), traffic (17 %) and sport (8 %) accidents follow in order.Fractures took place most frequently in summer months (35 %)especially in July and then in order in autumn (24 %), spring (20%) and in winter (21 %). Fractures were brought to the emer-gency department most frequently between 16:00 – 20:00 (32 %)and secondly 20:00 – 24:00 hours (25 %). Most frequent caseswere observed around distal radius. In order, elbow, forearm,clavicula, tibia, femur, hand and foot small bone fractures follow.

Conclusions: In our area, child fractures generally take placeduring summer and spring months and at play hours as a result ofa fall. Generally conservative methods are applied for the treat-ment. Distal radius fractures are observed most frequently andthese fractures are observed at younger ages despite the currentliterature data.

Significance: Child fractures generally take place during summerand at play hours.

227

The aetiology and short-term morbidity of fasciotomy

for acute or impending compartment syndrome in children.

Author: Kevin Lim (Singapore)

Co-Authors: Tero Laine (Finland), Unni Narayanan (Canada)

Purpose: To study the aetiology of acute or impending compart-ment syndrome (AICS) in children, and to describe the earlymorbidity associated with fasciotomy for AICS.

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Methods: The surgical database of a large tertiary children’shospital was used to identify all patients who underwent fasciot-omy for acute or impending compartment syndrome from April1992 to March 2005. The medical records were reviewed todetermine the aetiology and reasons for fasciotomies, the location,the timing, number of subsequent operations, method of woundclosure, length of hospital stay and short term complications.

Results: 112 faciotomies were performed in 104 children for AICS.Mean age was 10.2 years (SD:4.6). 70% were male. The aetiologyfor AICS was trauma in 93 cases (89%), elective osteotomies in 4(4%); and vascular/hematological or infection related in 7 (7%).Fasciotomies were performed in 53 lower legs (47%), 43 forearms(38%), 12 feet (11%), 2 thighs and 2 hands. Eight children (7.7%)had fasciotomies at two different sites. In 63 (60%) cases, fasci-otomy was performed at, or as, the index operation, while 41(40%) underwent fasciotomy as a secondary procedure. Com-partment pressures were recorded only in 51 cases (49.0%).Median number of additional operations (for wound closure) was2, with 16 requiring 4 or more procedures. 33 (32%) needed a skingraft, including 4 requiring flap coverage. Mean inpatient stay was15.7 days (SD 11.7). 7 patients (6.7%) developed fasciotomywound infections, and 8 patients (7.7%) required blood transfu-sion following fasciotomies.

Conclusions: Fasciotomy for AICS is associated with significantearly morbidity including multiple operations for delayed woundclosure and prolonged hospital stays.

Significance: Fasciotomies are the only effective way to preventirreversible ischemic necrosis associated with untreated or missedAICS. The decision to intervene is influenced by some combina-tion of clinical signs and symptoms, measurement of compartmentpressures and/or clinical judgment. However, fasciotomies areassociated with significant morbidity and utilization of health careresources that have not previously been quantified. Developmentof reliable, sensitive and highly predictive diagnostic tests mightreduce the number of unnecessary fasciotomies. More efficientmethods of wound closure might also reduce morbidity, hospitalstay and complications.

228

The Gonad Shield in Pelvic X-Rays - Covering a Multitude

of Sins?

Author: Aaron Hugh McManus (United Kingdom)

Co-Authors: Naomi Davis (Consultant in Paediatric OrthopaedicSurgery, Booth Hall Children’s Hospital, Central Manchester andManchester Children’s University Hospital NHS Trust) (UnitedKingdom)

Purpose: To determine the value of the gonad shield in paedi-atric pelvic x-rays by considering the effectiveness of theirplacement.

Methods: A retrospective study of paediatric pelvic and hipradiographs Manchester Children’s Hospitals (MCH). The focuswas on gonadal shield use in paediatric patients, with specificreference to areas of bone obscured by the shields and whether thegonads were effectively shielded. Each X-ray was examined forshield presence and (when present,) correct placement. If bone wascovered, this was recorded using a numerical system for bonyareas of the pelvis. In total, 1720 radiographs were reviewed (508hip, 1212 pelvic); 53.3% (n = 917) were female and 46.7%(n = 803) male.

Results: The National Radiation Board (NRPB), European Com-mission andMCH request gonadal shield use in 100%of paediatricpelvic radiographs, except for the first radiograph in emergency/trauma cases for fear that any important bony abnormality is

obscured by the radiopaque gonadal shield. All of the studiesmentioned here have used these guidelines and aim for 100% shieldusage in eligible cases. 79.0% of radiographs had a shield present.81.5% were female, and 76.2% male. 65.4% of radiographs wereconsidered to have unprotected gonads. This compares well withDoolan et al (2004), Sikand et al (2003) andKenny andHill’s (1992)results, which showed presence of a shield in 2%, 33% and 60% ofradiographs respectively, When a shield was present, only 43.8%were considered fully protected. 29.01% of females were protectedadequately. For males, only 40.97% were satisfactorily shielded.Female patients were significantly more likely to have a shieldpresent than males (p < 0.05). When a shield was used, femaleswere significantly less protected than male patients (p < 0.05), aresult echoed by Kenny and Hill (boys v girls; 64 v 45; p < 0.012).51.4% had an area of bony pelvis covered when a shield was used.Male patients were significantly less likely to have bones coveredthan female patients (p < 0.05).

Conclusions: Standard protocols for gonadal shield usage in pelvicand hip x-rays in children appear to fall below a reasonable stan-dard. Recommendations for improvement have been made.

Significance: The form of gonadal shields widely available and theguidelines involved in their usage are resulting in a higher thannecessary radiation dose in children. This is the largest study of itskind to date and highlights the need for new designs and tech-niques that are required to reduce gonadal radiation dose andsubsequent side-effects in children.

229

Paediatric trauma in an tertiary referral centre.

Author: Patrick O’Toole (Ireland)

Co-Authors: Orla Callender (Ireland), Brendan O’Hare (Ireland),Sean Walsh (Ireland), Esmond Fogarty (Ireland)

Purpose: To assess the epidemiology of major paediatric traumaattending a paediatric tertiary referral unit in Ireland.

Methods: We prospectively collected data on 153 major traumapatients admitted to our tertiary level paediatric facility, over aseven year period. 112 patients were secondary referrals fromother hospitals, with 41 patients primarily presenting to theEmergency Department in our hospital. 153 children were in-cluded. There were 14 deaths (9%).

Results: There were 99 males and 54 females. RTA’s (road trafficaccidents) were consistently the commonest cause of admission(39%) followed by thermal injuries (32%), and falls (12%). Othersincluded bicycle injuries (6%), non accidental injuries (3%) andmiscellaneous (8%). Of the occupants 68% were either unre-strained or incorrectly restrained. 9 cyclists were involved in roadtraffic accidents. Only one cyclist was wearing a helmet. 19 ther-mal injuries were due to scalds, with the remaining 30 cases beingas a result of injuries sustained due to fire and flames. Scaldinjuries peaked between 1 and 5 years of age, while injuries causedby flammable materials were seen mainly in the older age groups.The majority of falls were from a height <20 ft representing 80%with the remaining 20% falling from a greater height. Themajority of the children who sustained a fall were in the 1–5 yearage group (65%). There were 5 admissions with a diagnosis ofnon-accidental or intentional injury.The average length of stayin the intensive care unit was 4.1 days with a range of 1 to 36 days.The majority of patients were discharged home (83%). 14patients (9%) died. The overall mean ISS (Injury Severity Score)in this study was 27.6. The average age of the fatalities was5.2 years.

Conclusions: This study captured all seriously ill children referredfrom multiple centres around the country and also in our own

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catchment area. However our unit is not the only tertiary referralhospital for paediatric trauma in the country. 68% of the occu-pants of vehicles involved in an accident in this study were eitherunrestrained or incorrectly restrained.Despite the effectiveness ofbicycle helmets, rates of helmet wearing in this study were low atjust 11%.

Significance: Improving trauma care should lead to better out-comes which will have major social consequences and reduceavoidable death and unnecessary morbidity. Preventative strate-gies are needed as well as enforcement of current legislation.

230

Is major paediatric trauma decreased by the introduction

of a penalty point demerit system for speeding?

Author: Patrick O’Toole (Ireland)

Co-Authors: Orla Callender (Ireland), Brendan O’Hare (Ireland),Sean Walsh (Ireland), Esmond Fogarty (Ireland)

Purpose: The aim of this study was to evaluate the impact of thepenalty points system on the number and severity of major pae-diatric trauma caused by road traffic accidents.

Methods: We prospectively collected data on 64 patients whosuffered major trauma, as a result of a road traffic accident, over aseven year period (1999–2005 inclusive). We collected data on anumber of different variables including patient age, type, site andmechanism of accident, transport to hospital, complete evaluationof patient history and examination findings, management, andoutcome. We specifically looked at the patients in two groups,those who were injured pre penalty points and those injured postthe points system respectively. We used Fischer’s Exact Test whencomparing the different variables pre and post introduction ofpenalty points. We compared the two groups using the Chi-Squared Test.

Results: There were a total of 64 patients in total admitted to thePaediatric Intensive Care Unit (PICU) over the 7 year time peri-od. 42 patients were admitted before October 2002, while theremaining 22 were admitted after this time. There was no differ-ence in the two groups, mean age pre 6.4 yrs, post 6.41 yrs(p = 0.99), number of males pre 29, post 11 (p = 0.18), numberof females pre 13, post 11 (p = 0.18). The percentage of the totaladmissions to the PICU that each group represented for theirgiven time period was 48.8% and 34.9% pre and post pointsrespectively. This was not significant, (p value 0.1). There was nostatistical difference in the pre and post groups in relation towhether those injured were cyclists, pedestrians or vehicle occu-pants. There was no significant difference in the number of injuriessustained in the two groups respectively.

Conclusions: Despite previous studies showing a decrease in thenumber of injuries sustainedwith the introductionof a penalty pointssystem for speeding, we have shown no difference in the number ofmajor paediatric trauma cases post introduction of the system.

Significance: We have shown that there is no difference in thenumber and seerity of paediatric trauma with the introduction ofa penalty points system for speeding.

231

Musculoskeletal Involvement in Patients

with Hypopigmentation Along the Lines of Blaschko

(Hypomelanosis of Ito)

Author: Vito Pavone (Italy)

Co-Authors: Martino Ruggieri (Italy)

Purpose: Hypomelanosis of Ito (HI) (OMIM # 300337) is a rareneurocutaneous disorder characterized by hypopigmented skinlesions arranged in whorls and/or streaks along the lines ofBlaschko (a non-random developmental system of cutaneousmarkings characterizing the distribution of various linear andsegmental skin disorders). Even though Ito’s original report in1952 described a purely cutaneous disease, subsequent case re-ports and case series have recorded a significant associationwith multiple extra-cutaneous manifestations. Cytogeneticstudies have revealed a wide variety of mosaic chromosomalabnormalities in about half cases: thus, it has been suggestedthat this group of conditions is rather a non-specific manifes-tation (i.e., a phenotype) reflecting genetic mosaicism whichlikely disrupt expression or function of pigmentary genes.Musculoskeletal anomalies are considered the second most fre-quent extra-cutaneous alterations, after nervous systeminvolvement, in HI. However, rather non-specific limb andskeletal defects and miscellaneous radiographic findings areusually associated to HI, whilst there is no systematic study onskeletal involvement in HI. The aim of study was to define thefrequency and the degree of musculoskeletal involvement inchildren and adults with HI.

Methods: Ninety-eight white Italian subjects (46 M, 52 F), aged16 months to 34 years, with the typical clinical features of HI wereexamined at the University Departments of Paediatrics andOrthopaedics in Catania, Italy over a sixteen-year longitudinalfollow-up which included clinical, laboratory and imaging exam-ination (CT and/or MRI of the head and spine and skeletalradiographs).

Results: We recorded macrocephaly (n = 11) or microcephaly(n = 2); asymmetry of length or size of limbs and body partsalong with joint contractures particularly talipes (n = 22); heightat or below the 3rd percentile (n = 19); delayed skeletal matu-ration (n = 18); dystrophic (n = 5) or idiopathic (n = 18) ky-phoscoliosis or scoliosis; pectus excavatum (n = 23) or carinatum(n = 12); small hands and feet (n = 2); pes valgus (n = 4) orvarus (n = 5), genu valgus (n = 3) or congenital hip dislocation(n = 3); polydactyly (n = 2); ectrodactyly (n = 1); or syndactyly(n = 5).

Conclusions: All these defects are likely related to the age depen-dant effect of the genetic mosaic abnormality. Notably, the boneabnormalities were usually seen on the same side/area as thehypomelanotic skin and the most severe cases were associated tochromosomal mosaicism.

Significance: This is the first systematic study, which estimates theextent of musculoskeletal involvement in a large HI series fol-lowed for a long period of time in the same geographical area. Allthe recorded abnormalities were congenital and only mildly pro-gressive.

232

Validation of the AO paediatric Comprehensive Classification

of long - bone Fractures: a web-based multicenter agreement

study

Author: Theddy Slongo (Switzerland)

Co-Authors: Laurent Audige (Switzerland), Jean-Michel Clavert(France), Nicolas Lutz (Switzerland), Steve Frick (United States),James Hunter (United Kingdom)

Purpose: The first AO comprehensive paediatric long bonefracture classification system has been proposed following astructured path of development and validation with experiencedpediatric surgeons. This study was conducted to assess the

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reliability and accuracy of this classification among a wide rangeof surgeons with various level of experience.

Methods: A web-based multi-centre agreement study was con-ducted between 2004 and 2005 involving 70 surgeons in 15 clinicsand 5 countries. Training was provided on each clinic prior to thesession. Using the internet, participants classified at their ownpace 275 supracondylar, radius and tibia fractures based onstandard pre-treatment radiographs.

Results: Kappa coefficients for the single-surgeon diagnosis offracture type E (epiphyseal), M (metaphyseal) or D (diaphyseal)were 0.66, 0.80 and 0.91, respectively. Median accuracy estimatesfor each bone and type were all above 80%. Pediatric training andat least 2 years experience were associated with significantimprovement in reliability and accuracy. Using simulation, clas-sifying fractures by consensus among surgeons within each clinicsimproved reliability with kappa above 0.80. Kappa coefficients fordiagnosis of specific child patterns were 0.51, 0.63 and 0.48 for E,M and D fractures, respectively. Results supported the coding offracture severity in just two categories (simple vs complex), andthe need to conduct additional pilot agreement studies for theevaluation of exception codes for supracondylar fractures (vonLaer) and fractures of the radial head.

Conclusions: This classification system received wide acceptanceand support among involved surgeons. As long as appropriatetraining could be performed, the system classification was reliable,especially among surgeon with a minimum of 2 years clinicalexperience, and when a consensus among all surgeons withinclinics was considered.

Significance: We encourage a wide consultation among surgeons’international Societies, and the use of this classification system inthe context of clinical practice as well as prospective for clinicalstudies.

233

PHEX Gene Mutations and Genotype–Phenotype Analyses

of Korean Patients with Hypophosphatemic

Rickets

Author: Hae-Ryong Song (Portugal)

Co-Authors: Sung-Chul Jung (Afghanistan), Joo-Won Park(Afghanistan), Dae-Yeon Cho (Afghanistan), Jae Hyuk Yang(Afghanistan), Hye-Ran Yoon (Afghanistan), Gautam Shetty(Afghanistan), Sameer Desai (Afghanistan)

Purpose: X-linked hypophosphatemic rickets (XLH) results frommutations in the PHEX gene.

Methods: Mutational analysis of the PHEX gene in 15 unrelatedKorean patients with hypophosphatemic rickets.

Results: The study revealed eight mutations, including five novelmutations, in nine patients: two nonsense mutations, two missensemutations, one insertion, and three splicing acceptor/donor sitemutations. Of these, c.Ala22Ser, c.Arg567X, c.466_467insAC,IVS10-1G>A, and IVS17 + 5G>A are novel mutations. Toanalyze the correlation between genotype and phenotype, pheno-types were compared between groups with and without a mutation,in terms of mutation location, mutation type, and sex. Skeletaldisease tended to bemore severe in the group with a mutation in theC-terminal half of the PHEX gene, but no genotype–phenotypecorrelation was detected in other comparisons.

Conclusions: Further extensive studies of the PHEX gene muta-tions and analyses of the genotype–phenotype relationships arerequired to understand PHEX function and the pathogenesis ofXLH.

Significance: Skeletal disease tended to be more severe in thegroup with a mutation in the C-terminal half of the PHEX gene.

Upper extremity

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WITHDRAWN

235

Modified green’s procedure for sprengel deformity; Resection

of anterior curvature of the supraspinous portion

is important

Author: Toshio Fujii (Japan)

Co-Authors: Akifusa Wada (Japan), Kazuyuki Takamura(Japan), Haruhisa Yanagida (Japan), Noriko Urano (Japan)

Purpose: To evaluate the surgical results for Sprengel deformitywho were treated by the modified Green’s procedure.

Methods: We reviewed 32 patients with Sprengel deformitywho were treated by the modified Green’s procedure in which wedissected fibrous bands in serratus anterior muscle radically.The age of the patients at surgery ranged from two to sixyears. We sutured the inferior angle of scapula to thespinous processes of thoracic spine in stead of wire traction.Twenty nine patients had omovertebral bones and Klippel-Feilsyndrome.

Results: Postoperatively, shoulder abduction improved well. Thecosmetic results were also good in all the patients except two whohad severe Klippel-Feil syndrome. We found marked anteriorcurvature of the supraspinous portion which was clearly shown on3DCT. The resection of this portion is essential to obtain goodresults in descending scapula procedure.

Conclusions: We found that radical release of strong fibrousbands, which connected scapula to chest wall, and resection ofanterior curvature of the supraspinous portion are important toobtain good results and it could be easier to look at those directlyby Green’s approach.

Significance: Green’s approach gives us a good advatage to obtaingood surgical results for Sprengel deformity patients.

236

Congenital pseudarthrosis of the clavicle

Author: Alicia Gargantilla (Spain)

Co-Authors: Marıa Perez (Spain), Rosendo Ullot (Spain), Santi-ago Cepero (Spain), Ramon Huguet (Spain)

Purpose: Congenital pseudarthrosis of the clavicle (CPC) is a raremalformation of the scapular waist, of unknown etiology verylittle frequents of wich 220 cases published at the present timehave been reported. The lesion is usually right-sided and unilat-eral. Due to his etiopatogenia, probably the congenital pseu-darthrosis of the clavicle undergoes a lack of fusion of the bothcenters of ossification embryonic stages, due to posicion of theright artery subclavia and/or malformations vasculares. The thurdmeans appear in form of tumoracion to clavicle. The diagnosis isconfirmed by plain radiology. Differential diagnosis includespostraumatic pseudarthrosis, cleidocranial dysostosis and neuro-fibromatosis. Surgical treatment is indicated in symptomatic pa-tients or major deformity.

Methods: Retrospective review of clinical chart of the 17 patientswith 18 CPC followed in our hospital from 1986 to the 2005.

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Results: Of the 17 patients who presented PCC 9 they were girlsand 8 boys with unilateral right CPC side in all the cases, except ina patient who was bilateral and brother of another patientaffection of PSC. Seven patients they referred pain, withoutfunctional impairment and in other seven alterations estetics.They present one clavicular assymetry in x-ray ranged from 0.5 to1 cm, without accompanying pathologic findings. Surgical treat-ment has been performed in 11 cases, with resection of fibrouspseudarthrosis, internal fixation and iliac bone graft. In 10 pa-tients callus response was achieved in 2 months; the remaining onerequired withdrawal of orthopaedic material 2 months later be-cause of its protrusion through the skin, no further surgicaltreatment having been necessary so far.

Conclusions: The indications of the surgery treatment are as muchthe deformities estetics that usually they present these patients,like functional impairment The ideal age to carry out this surgeryto the 4–5 age. The treatment with actual surgery techniques withinternal fixation and iliac bone graft obtains good results to solvethis malformation.

Significance: CPC is a rare disease, therefore, reports on objectiveresults or surgical techniques and problems are limited. Wedescribe 17 cases over the 200 cases reported.

237

Current concept for treatment of obstetrical brachial plexus

lesions

Author: Werner Girsch (Austria)

Purpose: For a long time the treatment of obstetrical brachialplexus lesions (OBPL) consisted of conservative treatmentmainly. Surgery was indicated only in severe cases sufferingfrom persistant complete flail arm. Gilbert introduced a muchmore aggressive concept with surgical intervention whenever thebiceps is not working at three months of life, a strategy whichcaused discussions permanently. As a result of this discussionand with respect to Clarkes work the concept was modified inthe last years again.

Methods: The diagnosis of an OBPL has to be followed bymonthly clinical examinations. Testing for muscle regeneration isnot only focussed on biceps muscle but also on time and topo-graphic course of regeneration. Lack of shoulder and bicepsactivity at three months of life or negative ‘‘handkerchief-test’’ atsix months represent indications for immediate surgical revision ofthe brachial plexus (primary early nerve surgery). In cases showingongoing regeneration the conservative treatment is maintained.Relevant deficiencies in motor function (less than 50% of ROM orpower in correlation with the unaffected side) at twelfe months oflife represent an indication for brachial plexus surgery again(primary late nerve surgery). Further nerve procedures, usuallyisolated nerve transfers (secondary late nerve surgery), can beperformed in selected cases up to two years of life. After that timemusle transfers and osteotomies (secondary procedures) areperfomed to achieve further increase in function.

Results: In brachial plexus surgery new concepts of ‘‘extraplexualneurotisation’’ and ‘‘end-to-side neurorraphy’’ have increased thepossibilities of reconstruction by increasing the amount of nervesources. Secondary procedures, including free functional muscletransplantation, have become an integrative part of the overalltreatment strategy.

Conclusions: Although obstetrical techniques have improved in theindustrialized countries, there still exists an incidience of 1–2 OBPLper 1000 newborns, last but not least with regard to an increasingnumber of babies weighing more than 4500 g. It is known that 8 of

10 OBPL recover spontaneously. New investigations have revealedrelevant deficiencies in 4 out of 10 of these children at an age of15 years. Actually the number of children requiring surgery is small.

Significance: But for these children it is important to make theright decisions in time to minimise deficiencies and achieve opti-mal results.

238

Muscular Pathology in Brachial Plexus Birth Injury

with Elbow Flexion Contracture

Author: Tiina Poyhia (Finland)

Co-Authors: Antti Lamminen (Finland), Jari Peltonen (Finland),Aarno Nietosvaara (Finland)

Purpose: To determine whether limited range of motion of theelbow and the forearm in patients with permanent brachial plexusbirth injury (BPBI) is correlated with specific patterns of muscularpathology.

Methods: For 15 BPBI patients with a mean extension deficit of31 (10–90) of the elbow joint, total active motion (TAM) of theelbow (extension–flexion) and the forearm (pronation–supina-tion) were clinically measured. MR imaging of both elbowjoints and musculature of the arms and forearms allowedassessment of congruency of the elbow, grading of fatty infil-tration and size reduction of the muscles. Statistical analysiswas performed with the Wilcoxon Signed-Rank Test andSpearman’s two-tailed correlation test.

Results: The mean TAM of the elbow was 113 (50–140) and thatof the forearm 91 (10–165). The higher the age and the greater thesize reduction of the brachioradial muscle, the more diminishedwas TAM of the elbow. The more extensive the BPBI and musclepathology of the pronator teres, the more limited was the TAM ofthe forearm. Muscle pathology of the supinator and brachialmuscles appeared in every patient.

Conclusions: Extensive permanent BPBI may result in markedlimitation of TAM, especially when both the agonist andantagonist muscles are affected. Elbow flexion contractureseems to be caused mainly by brachial muscle pathology.Rotation of the forearm is better preserved when the pronatorteres is not severely affected.

Significance: Elbow flexion and forearm rotation contractures inBPBI are secondary to the primary nerve injury. The most pro-found permanent changes affect the most distal target muscles ofthe injured roots.

239

Remodeling of the lateral condylar prominence after

supracondylar lateral closing wedge osteotomy in children

with cubitus varus

Author: Jong Sup Shim (Korea, Republic of)

Co-Authors: Eunjin Sul (Korea, Republic of)

Purpose: We tried to evaluate the effectiveness of the suprac-ondylar lateral closing wedge osteotomy, and the remodeling ofthe lateral condylar prominence.

Methods: Supracondylar lateral closing wedge osteotomy forcubitus varus deformity was performed in 48 children.The average age of patients was 8.7 (5~14) years. The opera-tion was performed through a lateral approach. A wedge ofbone was removed as much as assessed preoperatively andintraoperatively with fluoroscopy. In all cases, the medial

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cortex of wedge was kept intact and acted as a lever.Medial translation for decreasing lateral prominence ortransposition of ulnar nerve was not performed. Fixation wasdone by an average 3.2 Steinmann pins with long-arm castimmobilization. After follow-up (av. 29 months; 12–74 months), Humero-Ulnar(HU) angle, Shaft-Condylar (SC)angle, lateral prominence index, and lateral prominenceamount were measured on radiographs and the range of mo-tion was measured by physical examination. The results wereanalyzed with SPSS version 12.0.1(created by SPSS inc.)through Wilcox on, Spearman, Pearson, Mann-Whitney, andRascal-Wallis test.

Results: No major complication such as bone infection, malunion,nonunion or loss of correction occurred. Range of motion of theelbow improved from an average 136.9 degrees to 139.2 de-grees(p = 0.050). HU angle improved from an average –17.4degrees to 10.3 degrees (p = 0.000). SC angle improved from anaverage 25.8 degrees to 36.0 degrees (p = 0.000). The lateralprominence index and the lateral prominence amount significantlyimproved from 2.27 (range 1.65~3.87) and 34.2 percent (range20.4~50.7 percent) to 1.17 (range 0.89~1.83) and 8.7 percent(range 0.4~24.1 percent), respectively (p = 0.000, p = 0.000).These were correlated to preoperative HU angle (p = 0.000,p = 0.000). Remodeling of the lateral prominence index wascorrelated with preoperative HU angle, SC angle, and the lengthof follow-up (p = 0.000, p = 0.000, p = 0.023, respectively).Also remodeling of the lateral prominence amount was correlatedwith preoperative HU angle, SC angle, age, and the length offollow-up (p = 0.000, p = 0.000, p = 0.000, p = 0.000,respectively).

Conclusions: Supracondylar lateral closing wedge osteotomy ofthe humerus is a safe and effective operative method for correc-tion of cubitus varus in children. Also, good results on the cos-metic aspects can be expected with excellent remodeling of lateralcondylar prominence of the humerus in most of the patients.

Significance: Considering the remodeling capacity of the children,extensive operative procedures to eliminate the lateral condylarprominence are usually unnecessary.

240

Operative treatment for congenital radial head

dislocation

Author: Kwang Soon Song (Korea, Republic of)

Co-Authors: Chul-Hyung Kang (Korea, Republic of), Byung-Woo Min (Korea, Republic of), Ki-Chul Bae (Korea, Republicof), Chul-Hyun Cho (Korea, Republic of)

Purpose: Congenital radial head dislocation (CRHD) is consideredthat a definite diagnosis followed by observation is most appro-priate. There have been only a small number of published cases ofopen reduction of CRHD. The purpose of this study is to investi-gate an effectiveness of early operative treatment for CRHD.

Methods: We retrospectively analyzed charts and radiographs of35 elbows in 25 patients with CRHD. 7 cases were performedsurgical treatment including open reduction, ulnar osteotomy,annular ligament reconstruction, or ulnar lengthening or correc-tive ostetomy of distal humerus for excessive valgus deformity ofelbow. 10 patients were involved bilaterally and 14 patients werecombined with other congenital anomalies including congenitalradial deficiency(3 cases), congenital radioulnar synostosis(3cases), osteochondroma(2 cases), Rett’s syndrom, Polandsyndrom, congenial below elbow amupation, multiple pterysiumsyndrome, clindactyly,microdactyly, and idiopathic brachialplex-us injury (1 case in each disease). The radial head displaced

anteriorly in 15 cases, posteriorly in 12 cases, anterolaterally in 4cases, laterally in 3 and posterolaterally in one case.

Results: 4 elbows treated with open reduction, ulnar osteotomyand annular ligament reconstruction were reduced and main-tained for more than 3 years. One case with severe valgus defor-mity was corrected with distal humeral open wedge osteotomy.One case was failed in open reduction due to deformed head andshortening of the ulna. One case treated with ulnar lengtheningwas failed due to fracture of the ulna (too small to insert the pins).

Conclusions: We considered that early operative treatments(including the open reduction, ulanar osteototmy and recon-struction of annular ligament) may be justified for treatment ofsimple CRHD without combined anomaly around the elbow.However, this is a little limited cases due to rarity of disease,further study is needed to obtain more definite conclusion.

Significance: Early operative tretment for congenital radial headdislocation is suitable treatment option in selected cases whichhave no combined anoamly in same elbow.

241

Polydactyly of the thumb with symphalangism

Author: Ruiko Takagi (Japan)

Co-Authors: Hidehiko Kawabata (Japan), Mayuko Wada(Japan), Daisuke Tamura (Japan)

Purpose: Polydactyly of the thumb is one of the most commonabnormalities of the hand. Most classifications including Wassel’sare based on the bifurcation level of two thumbs. We reviewed our200 patients with polydactyly of the thumb and found four casesin which the radial thumb was complicated with symphalangism.These four cases are difficult to categorize by traditional classifi-cations for polydactyly of the thumb. In this study we illustratesuch cases and discuss about those specific features.

Methods: There were one female and three male patients. All thecases were unilateral and right side was involved in three cases andleft in one case. Age at operation ranged from 8 months to 3 years6 months. Follow-up period was 10 years on average.

Results: In all four patients symphalangism was appeared in theradial thumb, which was more hypoplastic. Symphalangismtook place at the interphalangeal joint level in three cases andat the metacarpophalangeal joint level in one case. Intraoper-ative finding revealed both the extensor and flexor tendonhypoplasty in one case and abnormal insertion of the flexortendon in another case. Long term follow-up showed partialgrowth plate premature closure in one case and triphalangealthumb in another, both of which required secondary surgery.The range of motion of the interphalangeal joint was limited inthe other two cases.

Conclusions: Polydactyly of the thumb complicated with sym-phalangism is rare anomaly and surgical results were not so goodas typical polydactyly because of its unique anatomy.

Significance: Only four cases have been reported in the literatureso far. We added other four cases in this presentation.

242

Soft Tissue Reconstruction for Type IV-D Duplicated Thumb

Author: Yin-Chun Tien (Taiwan)

Co-Authors: Yin-Chih Fu (Afghanistan), Peng-Ju Huang(Afghanistan), Tai-Lung Wang (Afghanistan)

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Purpose: Type IV-D duplicated thumb has the most complexanomalies and difficulties for treatment among polydatyly. Doubleosteotomy is usually recommended to gain the best cosmetic andfunctional outcome. However, four cases of type IV-D duplicatedthumb were treated only by soft tissue procedure in this study.

Methods: At operation, a conjoined A2 Pulley was routinelyidentified and the FPL was found bifurcated distal to the con-joined pulley in every of these cases. Instead of double osteotomy,a soft tissue procedure which included centralization of FPL andA2 pulley reconstruction were pursued to correct these specialanomalies.

Results: The overall clinical results were evaluated by a modifica-tion of Tada’s scoring system based on the range of motion, jointstability, alignment of the remaining thumb, and subjective opin-ion regarding the reconstructed thumb after an average follow-upof 3.3(2.5–4.7) years. According to the scoring system, the resultswere rated as good in three cases and fair in one case.

Conclusions: The results demonstrated that a careful soft tissuebalance procedure can correct the type IV-D duplicated thumbsuccessfully and the postoperative alignments are maintained wellafter the deforming pathoanatomy is corrected.

Significance: When double osteotomy is used to correct this spe-cial deformity, the surgery usually should be postpone until bonegetting mature enough for purchasing pins to fix the osteotomy.We presented an alternative soft tissue method to allow correctingthe deformity in younger age.

Hip/Lower extremity

243

Management of complete absence of the femur with iliac

acetabuloplasty and rotationplasty at the walking-age.

Author: Olivier Francois Badelon (France)

Purpose: Complete absence of the femur without acetabulum isextremely rare. The classic management is prosthetic with orwithout above-knee amputation. The goal was to obtain firstly agrowing roof of the acetabulum using the growth cartilage of theiliac crest to give a stable hip with a functional range of motion towalk and to sit ; secondly a well balance and stable position of theleg to use the ankle as a knee into the prosthesis.

Methods: Two cases of unilateral total deficiency of the femur (classI of Pappas or type D of Aitken) with a normal foot were treated in1988 and 1992. An original Iliac Acetabuloplasty was performed at14 and 18 months of age with a periacetabular incision of the cap-sule and a resection of the transverse acetabular ligament, reductionof the femorotibial epiphysis in front of the paleoacetabulum, thenreconstruction of the acetabular roof with an enlarge shelf proce-dure using the lateral part of the iliac crest growth cartilage and ofthe ilium extending the decortication inferiorly to the superiormargin of the acetabulum. Borggreve rotational osteotomy wasperformed 3 and 6 months later with shortening of the tibia, andrepeated 3 and 1 year later. A second shelf procedure was performedin one case at 10 years of age with the contralateral iliac crest.

Results: At the last follow-up, they have 18 and 15 years old withcomplete radiologic data and a walking analysis. They have a wellbalancedwalkwith a below knee prosthesis and a simple ischial ringsupport. In both cases, the hip-knee joint is stable for the weight-bearing with a flexion authorizing the sitting position (80�&60�).They have a heel at the same level that of the normal knee with acomplete extension of the knee-ankle joint which is stiff in this po-sition in the first case with a full range of motion in the second.X-rays shows a a very good acetabulum in the both case.

Conclusions: The results shows that it is possible to obtain agrowing hip which is stable at adolescenthood. It is recommendedto use all the lateral part of the anterior iliac crest with the growthplate for the acetabuloplasty.

Significance: This early surgical procedure before the age of twoyears is an alternative to the classic prosthesis management.

244

Radiological evaluation of acute and acute-on-chronic slipped

capital femoral epiphysis treated by a single cannulated HDB

screw (proximal threading)

Author: J Berard (France)

Co-Authors: F Sailhan (France), O Brunet (France), R Parot(France), V Cunin (France), F Chotel (France)

Purpose: The treatment of slipped capital femoral epiphysis(SCFE) is still controversial with regard to the implants used forstabilization of the epiphysis. The objective of this study was todetermine whether stabilization of the epiphysis with the HDBscrew (with proximal partial threading) would allow furthergrowth of the femoral neck in the affected and unaffected side(after prophylactic transfixation of the epiphysis).

Methods: We retrospectively reviewed the charts of 23 patients withacute or acute-on-chronic SCFE treated in our unit with internalfixation of the epiphysis using a single cannulated HDB screw with aproximal 30 mm threading. Both the affected and unaffected sidewere always operated. The child’s sex, age, body mass index,symptom duration, and slip severity were recorded. Radiographicparameters were analysed on both hips of each patient at admissionand at last follow-up: CCD angle, length of the femoral neck, widthof the femoral neck, and the distance from the tip of the greatertrochanter to the tip of the epiphysis (GTTE). The width (in cm) ofthe epiphysis situated over the Klein line was also recorded for allhips. Statistical analysis (T test of Student) was performed tocompare results between the SCFE and unaffected side.

Results: The charts of 8 girls (mean age 10.25 years) and 14 boys(mean age 12.6 years) were analysed for a total of 23 affected and23 unaffected hips. The SCFE was diagnosed in the left side in59% of the cases. After a mean follow-up of 30 months we founda statistically significant increase in the length of the femoral neckin both the affected and unaffected sides (4.66 and 7.90 mmrespectively). This growth in length was significantly higher in theunaffected side (p = 0.03). On the affected side the CCD angleremained stable with time (134.2� to 133.9�). Evolution of thewidth of epiphysis over the klein line and of the distance GTTEbetween both sides showed the affected side presented importantremodelling. We did not encounter any cases of avascular necrosisor chondrolysis. All screws were removed without complicationsas removal is facilitated by the proximal theading.

Conclusions: Results are discussed and compared to other mainseries of the literature.

Significance: The HDB screw seems to be effective in stabilizingthe epiphysis in the SCFE. It allows growth of the femoral neckand effective remodelling of the epiphysis as the threaded part ofthe screw is proximal.

245

The Hip in Patients Lengthened for Proximal Focal Femoral

Deficiency.

Author: Silvio Boero (Italy)

Co-Authors: Maria Beatrice Michelis (Italy), Marco Stella (Italy),Francesca Vittoria (Italy)

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Purpose: Patients with severe congenital proximal focal femoraldeficiency have a higher risk of dislocation or subluxation of thehip joint during lengthening, which increases the longitudinalforces from the muscles that act on the hip. Acetabular dysplasiaresults in reduction of the anterior and lateral support to thefemoral head, and can be associated with other malformations,such as coxa vara with or without pseudarthrosis of the femoralneck, or proximal diaphyseal varus, which increase the likelihoodof dislocation or subluxation of the hip during lengthening.

Methods: The authors have reviewed the clinical records and x-rayresults of 48 patients with congenital proximal focal femoraldeficiency. The patients have been grouped according to Pappas’classification. The acetabular index and the pre- and post-opera-tive CE angles have been recorded with the procedures required toprevent articular complications.

Results: This study has shown that deficiencies graded IV and VIIin Pappas’ classification increase the risk of hip subluxation dur-ing lengthening, due to the diminished CE angle and an increasedacetabular index.

Conclusions: In Patients with severe congenital proximal focalfemoral deficiency it’s important to evalue the acetabular indexand the CE angle to avoid dislocation or subluxation of the hipduring the treatment.

Significance: The authors suggest adequate prevention measuresto avoid dislocation or subluxation of the hip when the CE angleis close to 20 degrees and the acetabular index close to 34 degrees.

246

The Utility of Computer Tomography to Assess Acetabular

Morphology in Morquio - Brailsford Syndrome

Author: Andrzej Borowski (United States)

Co-Authors: Aaron Littleton (United States), Mihir Thacker(United States), William Mackenzie (United States), LeslieGrissom (United States)

Purpose: Morquio - Brailsford syndrome (MS) is an inherited met-abolic lysosomal storage disorder, one of the large groups of muco-polysaccharidosis (MPS). Alterations in connective tissue lead toabnormal formation and growth of the skeletal system. Majortreatable concerns in patients with MS involve C1-C2 instability,genu valgum and hip subluxation. Untreated hip subluxation hasbeen shown to be a predisposing factor leading to early onset ofarthrosis of the hip.Early appropriate pelvic osteotomiesmay restore(improve) load transmission and retard the onset of osteoarthritis(OA). Computed tomographic measurements of acetabular mor-phology inMorquio –Brailsford syndromehavenot been reported inthe literature, although ultrasonographic evaluation of hip in os-teochondrodysplasias has been described. The purpose of this studywas to evaluatemorphology (shape) of the acetabulum inMorquio –Brailsford syndrome using two-dimensional CT scans.

Methods: In order to assess the acetabular roof, the acetabular indexwasmeasured onAP radiographs of the pelvis. VariousCTmeasureswere used to assess the acetabular anatomy in the axial plane.

Results: The average acetabular index on the antero-posteriorradiographs of the pelvis was 32.1� (average age-matched differencefrom normal = 11.6�). 2-D computer tomography (axial cuts)showed the average acetabular anteversion angle was close to nor-mal, measuring 11.5�. The average anterior acetabular index was60.3� (average age-matched difference from normal = 11.4�) andposterior acetabular indexwas 53.8� (averageage-matcheddifferencefromnormal = 3.2�).Calculated axial acetabular index ranged from90� to 133� (mean 114.1�, 14.6� average difference from normal).

Conclusions: 2-D computer tomography of the hip in patientswith MS demonstrated a severe dysplasia of the anterior

acetabular wall as well as the roof of the acetabulum. The ace-tabular version, though was normal. Treatment of hip dysplasiain Morquio – Brailsford syndrome should focus on increasingthe overall depth of the acetabulum to better contain the femoralhead. 2-D computer tomography is recommended prior to bonyacetabular procedures in order to assess the degree of acetabulardeficiencies.

Significance: 2-D computer tomography of the acetabulum helps inpreoperative decision making and planning prior to an acetabularprocedure in patients with Morquio- Brailsford syndrome.

247

Surgical treatment of dislocating patella in children

Author: Morris Duhaime (Canada)

Co-Authors: Benoit Benoit (Canada), Yves Laflamme (Canada),Dominique Rouleau (Canada), Benoit Morin (Canada), GuyGrimard (Canada)

Purpose: Patella alta is a major cause favouring patellar dislocation,either recurrent, or habitual. Because of open growth plates, thechoice of treatment of such a condition is always a challenge in thegrowing child. A controlled study using a specific technique is pre-sented.

Methods: The first case regarding this technique was done somethirty-five years ago. Follow-up was sparce for these long standingcases. This eventually led to a controlled study of twelve (12)knees in eight (8) patients, having had correction of patella alta, amajor predisposing factor causing patellar dislocation. The tech-nique used was the following: complete detachment of patellartendon, with adjusted lowering and re-insertion at proper heightand with proper tension. Lateral release and VMO advancement isadded. Patellar height was assessed using the Koshimoto andCaton Deschamps index.

Mean age at surgery: 10.9 yrs. Mean follow-up: 60 months.

Results: At follow-up, one patella had re-dislocated. Patient had asecond surgery and patella is now stable. At last follow-up, allknees were stable without any evidence of pain. Radiologicalassessment shows that the patellar height is improved. Minimalcomplications are reported.

Conclusions: The treatment of recurrent dislocation of the patellain subjects with open growth plate can be treated efficiently andsafely with a lateral release, a detachment of the patellar tendonand a VMO advancement.

Significance: The technique presents a reasonable alternative, andthis short study validates its use in the treatment of patellar dis-location, with patella alta, in the immature child.

248

Adolescent Blount’s disease: Is fibular osteotomy necessary?


Co-Authors: Alexander Katzman (Israel), Viktor Bialik (Israel)

Purpose: The standard treatment of adolescent Blount’s diseaseincludes proximal tibial valgus osteotomy and osteotomy of thefibula. Some believe that the fibula should also be fixed to preventmigration and subluxation. We performed correction of defor-mities in eight patients (10 tibiae) with adolescent Blount’s diseaseusing the Taylor Spatial Frame (TSF). In all patients, the origin(virtual hinge) was placed at the level of the proximal tibial fibularjoint. The purpose of this study was to review treatment outcomeof proximal tibial osteotomy without osteotomy of the fibula inpatients with adolescent Blount disease.

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Methods: Eight patients (ten tibiae) were treated by proximaltibial osteotomies and gradual correction by TSF without fibularosteotomy over a period of three years. All patients were maleswith a mean age of 14.6 years (range, 14–17 years). All patientshad severe proximal tibial varus, four had significant proximaltibial procurvatum, and six had internal tibial torsion. The fibulawas not fixed in five patients, and fixed distally in three.

Results: Frames were removed at an average of 12.8 weeks (range,12–15 weeks).Themeanpreoperativeproximal tibial varuswas16.2�(range, 12–19�), corrected to normal values in all patients. The meanpreoperative MPTA was 71.4� (range, 67–77�) and corrected to amean MPTA 87.1� (range, 85–89�). In four patients (5 tibiae) withproximal tibial procurvatum, the PPTA was corrected to normalrange. Mean correction of internal tibial torsion was 10� (range, 5–15�), performed in six patients (8 tibias). Preoperative MAD was55.8 mm medial to center of the knee (range, 44–77 mm), correctedto a mean MAD of 4.9 mm medial to center of the knee (range, 2–11 mm). Complications included superficial pin tract infections inseven patients. No complications related to the fibula were observedduring/after correction.

Conclusions: Based on our initial experience, we believe that mostpatients with adolescent Blount disease could have successful andpredictable correction of tibial deformities without a need forosteotomy and fixation of the fibula.

Significance: In most cases of late -onset tibia vara tibial defor-mities can be corrected without fibular osteotomy and thuseliminate potentional morbidity of this procedure.

249

Joint Arthropathy as a Study of Neuropathic Joints in

Hereditary Sensory and Autonomic Neuropathy Types III

and IV


Co-Authors: David Ruchelsman (United States), Daniel Spencer(United States), Joseph Straight (United States), Mark Schweitzer(United States), Felicia Axelrod (United States)

Purpose: To determine the etiology of the joint arthropathy seenin children with Hereditary Sensory and Autonomic Neuropathy(HSAN) Types III and IV and to differentiate osteonecrosis andCharcot arthropathy as seen in these groups of patients, both ofwhom suffer from decreased pain perception.

Methods: From a database of 547 patients with HSAN Type IIIand thirty-two patients with HSAN Type IV, we performed aretrospective chart review and radiographic analysis of all patientswho presented with joint swelling and deformity. Underlying jointpathology was classified as either osteonecrosis or Charcotarthropathy.

Results: In the HSAN Type III population, forty-four (twenty-twomales, twenty-two females) of the 547 patients (8%) had clinicalevidence of arthropathy. In forty-two patients, forty-eight jointsdemonstrated radiographic evidence osteonecrosis; forty-five of theforty-eight joints (94%) with osteonecrosis occurred in the lowerextremity. In each case of osteonecrosis of the knee (n = 19),isolated involvement of the lateral distal femoral condyle was seenconsisting of varying sizes of posterolateral osteochondral frag-mentation. In the thirty-two patients comprising the HSAN TypeIV population, eighteen (56%) were found to have radiographicfindings consistent with Charcot arthropathy in a total of thirtyaffected joints. One patient demonstrated Charcot arthropathy ofthe spine and subsequent progressive spondylolisthesis. Nine pa-tients (twelve joints) also demonstrated osteomyelitis.

Conclusions: In patients with HSAN Type III, osteonecrosis is theinitial lesion preceding destructive arthropathy. Osteonecrosis and

osteochondral fragmentation were always isolated at the lateraldistal femoral condyle in the knee. This pathology may beamendable to surgical reconstruction of the joint to stabilize theknee in severe cases. HSAN Type IV was most commonly asso-ciated with Charcot arthropathy or joint subluxation and dislo-cation. Late secondary changes at the articular surface may makeradiographic distinction difficult. Charcot arthropathy affectedboth sides of the involved joint with evidence of collapse andfragmentation. With osteonecrosis, the articular process wasfound to be disproportionately mild.

Significance: There are two types of ‘‘neuropathic joints’’ seen inthese disease states. One is primarily osteonecrosis and the other isclassical Charcot arthropathy with joint subluxation. The differ-entiation of these types is critical for evaluation and treatment.

250

The Effect of Pelvic Positioning on Acetabular Measurements,

a CT Study


Co-Authors: Eric Henderson (United States), Debra Sala (UnitedStates), Zehava Rosenberg (United States), Harold van Bosse(Afghanistan)

Purpose: To investigate the effect of patient positioning on mea-sured acetabular parameters of CT scans of the pelvis.

Methods: A radioopaque model of a human pelvis with articulatedhips was attached to a plexiglass sheet, and suspended by fouradjustable struts. Positioning of pelvis in coronal, sagittal, andtransverse planes allowed for changes in pelvic obliquity, tilt, androtation, respectively. CT images of pelvis were taken at 3 mmincrements. Acetabular anteversion (AA), as well as anterior,posterior, and horizontal sector angles (AASA, PASA andHASA) were measured. Effects of single and multi planar devia-tions on these parameters were determined by multiple regression.

Results: For every 5� of increased pelvic obliquity, the measuredAA would decrease by 2.2�, and the AASA, PASA and HASAwould increase by 9.7�, 5.0� and 14�, respectively. Obliquity toother side would have opposite effect. Every 5� of anterior pelvictilt would decrease the measured AA by 3.8� and the PASA by2.6�; it would increase the AASA and HASA by 5.4� and 2.6�,respectively. Posterior pelvic tilt would have the opposite effect.All findings were significant, p < 0.0005. Pelvic rotation causedno measurement error.

Conclusions: Redirectional acetabular procedures require accurateknowledge of pre-operative acetabular parameters. Significantmeasurement error may result from relatively small changes inpatient positioning during a pelvis C.T. study, leading to incorrectinterpretation of acetabular anteversion and coverage. Strictattention must be paid to anatomical pelvic alignment in CTscanner. Alternatively, post-scan reorientation of a 3D pelvicmodel can be performed.

Significance: Changes in pelvic alignment in the CT scanner werefound to create significant error in acetabular measurements.

251

The hip in femoral proximal focal defect: Stabilize or not

stabilized? When? How?

Author: Federico Fernandez-Palazzi (Venezuela)

Co-Authors:

Purpose: To evaluate our experience in 22 patients treated from1981 to 1990. Plus, 3 years early results, in 2 cases - 1 bilateral-

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with a technique developed by us (Funnel-cone) for Fixen LLoydRoberts III cases

Methods: We use Fixen and Lloyd Roberts classification due toits easiness of interpretation and prognostic value. We com-pared the results obtained in Fixens and our grouping in A. tipof foot was above the knee.5 patients treated by hip stabiliza-tion and orthesis. Group B tip of foot at upper tibia level . 14patients treated by hip stabilization and leg lengthening andgroup C with tip of foot at lower tibial level. 3 patients. Hipwas stable and were treated by orthesis or raise in boot. A newtechnique of hip stabilization developed by us by means of afemoro-iliac arthrodesis (Funnel – cone) used on 2 cases, onebilateral, of Fixen-Lloyd A with unstables hips is presented andits 3 years early results exposed.

Results:

Group A (5) Group B (14) Group C (3)

F.and LL. R.I (stables) 2 (40%) 7 (50 %) 0 (0%)II 2 (40 %) 5 (35.7 %) 0 (0%)III 1 (20%) 2 (14.3%) 3 (100%)

Conclusions: FPFD patients should be evaluated very early inorder to stabilize the hip, should this be required and plan thefuture or futures procedures that will be required to convert his orher limb in a functional one.

Significance: The aim of treatment is to obtain a ‘‘functionalLimb’’ in FPFD, even in cases of unstable hips - thus the tech-nique proposed by us- and not an amputated limb child.

252

Importance of clinical examination in diagnosing

paediatric knee problem, a comparison with MRI

and arthroscopy

Author: Harvey Lappakkaran George (United Kingdom)

Co-Authors: Ravi Pydisetty (United Kingdom), Jabeen Jalalud-hin (United Kingdom), Jay Sampath (Afghanistan)

Purpose: The aim of this study is to determine the accuracy ofclinical diagnosis and MRI based on arthroscopic findings indetecting paediatric knee pathologies.

Methods: 95 patients admitted in our institute between 1997 and2004 were analysed. We retrospectively looked at case notes,operative notes and radiology reports. Correlation betweenClinical Vs Arthroscopic finding and MRI Vs Arthroscopicfindings were evaluated using positive predictive value, negativepredictive value, sensitivity and specificity.

Results: The clinical and MRI diagnosis were same in 69.47 %of patients, partially same in 6.31% of patients and different in24.21 % of patients, were as MRI and arthroscopic findingswere same in 49.47% of patients partially same in 4.21% anddifferent in 46.31%. Correlation between clinical and arthro-scopic findings was same in 47.36 %of patients, partially samein 6.31% of patients and different in46.31% of patients. ForACL injuries based on arthroscopy findings positive predictivevalue for clinical examination were 40 and of MRI were 50,were as specificity was 97 for clinical examination and 98 forMRI. Negative predictive value and sensitivity was 100 forboth. For meniscal injuries based on arthroscopy findings po-sitive predictive value for clinical examination were 27 and ofMRI were 37, were as sensitivity was 53 for clinical examination

and 82 for MRI. Negative predictive value was 87 for clinicalexamination and 95 for MRI and specificity was 68 for both.For osteochondral defects based on arthroscopy findings posi-tive predictive value for clinical examination were 64 and ofMRI were 68, were as specificity was 78 for clinical examinationand 81 for MRI. Negative predictive value was 93 and sensi-tivity 87 for MRI.

Conclusions: The clinical diagnosis and arthroscopic findingswere same in half of the patients, but this was almost same asthe number of patients who had same MRI diagnosis andarthroscopy findings. For detecting anterior cruciate ligamentinjuries clinical examination is still the gold standard and MRIshould be used only as an adjunct. The efficiency of MRI indetecting meniscal and osteochondral injuries is slightly betterthan clinical examination, but the risks of surgery need to beconsidered.

Significance: To show the importance of clinical examination inthe diagnosis of paediatric knee problem.

253

Lower limbs rotational profile in bladder exstrophy


Co-Authors: Giorgio Perrone (Italy), Walfro Rigamonti (Italy),Sisto Turra (Italy)

Purpose: To investigate the rotational profile of lower limbs inbladder extrophy.

Methods:We studied 19bladder and 1 cloacal extrophies (aged from2 to 49 years at the follow-up). Direct closure of the bladder andabdominal wall was obtained in 10 newborns; 6 posterior verticaliliac osteotomies (O’Phelan’s technique), 3 ischio-pubic osteoto-mies (Frey’s technique) and 3 anterior and horizontal osteotomies(Gibbon’s technique) were associated in the oldest patients. Therotational profile of the lower limbswas assessed both clinically andradiologically; pubic diastasis, CE andCAangles weremeasured bydirect x-rays. Iliac wing angle, acetabular version, femoral ante-version, tibial torsion and patellofemoral congruency were mea-sured by CT in 14/20 patients.

Results: Out-toeing was seen in 13/20 patients. The average foot-progression angle was 9� (min. 0�, max. 45�). The average value ofpubic diastasis was 37.8 mm. in immature patients and 100.8 mm.in adults. The average iliac wing angle was 42.9� in immature pa-tients and 53.5� in adults. Discrepancy > 10� in the right /left iliacwing angle was observed in 1 patient with evident pelvic asymmetry.The average acetabular versionwas –17� in immature patients (min.–4�; max. –31�) and –14� in adulthoods (min. +2�; max. –25�). Nohip dysplasia was seen. In adulthoods the average CE angle was 36�and the averageCAanglewas 51�. TheTCrotational profile showedthat the average femoral anteversion was 27� in immature patients(min. 16� in a 14 years aged adolescent ; max. 44� in an 8 years agedchild) and 24� in adulthoods (min. 8�; max. 41�). The averageexternal tibial torsion was 42� (min. 35�; max. 47�) in childrenyounger than 10 years, 41� in adolescents (min. 29�; max 53�) and40� (min. 27�; max. 51�) in adulthoods. The patellofemoral con-gruencywas abnormal in 4/14TCviews showing lateral subluxationof the patella in 7/8 knees of 4 adult patients (2 of them com-plained anterior knee pain). In these patients the average femoralanteversion was 30� (20� in patients with normal patellofemoralcongruence) and the average external tibial torsion was 43� (37� inpatients with normal patellofemoral congruence.

Conclusions: Despite pubic diastasis the waddling gait ismild inmostpatients. The increased iliac wing angle and acetabular retroversionarepartially compensatedby increased femoral anteversionand tibial

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torsion. This altered rotational profile of the lower limbs may lead topatellofemoral instability and knee pain in adult patients. No sig-nificant secondarydysplasticordegenerative alterationof the hipwasobserved both in young and mature patients.

Significance: The compensatory rotational profile of the lowerlimbs minimizes the effects of the persistent pubic diastasis inbladder extrophy but a serious patellofemoral instability and kneepain may occur in the adult patients with the most evident alter-ation of femoral anteversion and tibial torsion.

254

Parametric study of geometrical factors related to slipped

capital femoral epiphysis

Author: MªJose Gomez-Benito (Spain)

Co-Authors: Oscar Paseta (Spain), Jose Garcıa-Aznar (Spain),Carlos Barrios (Spain), Jose Gasco (Spain), Manuel Doblare (Spain)

Purpose: Different anatomical and mechanical factors inducinggrowth plate overloading have been implicated in the etiology ofSlipped Capital Femoral Epiphysis (SCFE). So far, loads at theepiphyseal growth plate of the femoral head has been poorlyinvestigated. In this work, we analyse SCFE from a biomechanicalpoint of view. Themain objective of this research is to determine theinfluence of the proximal femur geometry on the femoral slippage bymeans of Finite Element Analysis (FEA).

Methods: A parametric femur was created by a 3D Cad software(Catia) basedona set ofCT scans froma child affected bypre-SCFEin his left hip. In this parametric model of the proximal femur allgeometrical parameters could bemodified.Themodelwas validatedcomparing the results with these obtained from the real geometriesof the pre-SCFE hip and the healthy one of the child. Next, anadolescent standard femur was modelled based on the values of themean geometrical parameters collected in literature. Severalgeometrical parameters, as the Physis Sloping Angle (PSA), thePosterior SlopingAngle of the Physis (L), theNeckDiaphysisAngle(NDA) or the Growth Plate Area, were varied with respect thestandard femur. In each model the same loads corresponding towalking, stairs climbing and sitting were applied.

Results: The computed results showed a strong dependence of thegrowth plate failure on the geometry of proximal femur. Highervalues of the Physis Sloping Angle (PSA) and the PosteriorSloping Angle and lower values of the growth plate area are re-lated to higher growth plate stresses and therefore more proba-bility of slippage. The highest stress level was always found in theposteromedial region of the physis that is the site where usuallygrowth plate begins to fail.

Conclusions: Based on these results we could conclude that geomet-rical factors have a strong influence on growth plate failure.

Significance: This study contributes to a better understanding ofmechanical factors implicated in the etiopathogenesis of the SCFE.

255

Prediction of Change in Effective Leg Length Discrepancy after

Angular Deformity Correction by Hemiepiphyseal Stapling

Author: Ho-Joong Jung (Korea, Republic of)

Co-Authors: Tae-Joon Cho (Korea, Republic of), In Ho Choi(Korea, Republic of), Chin Youb Chung (Korea, Republic of),Won Joon Yoo (Korea, Republic of)

Purpose: The purpose of this study was to predict effective leglength change in angular deformity correction of lower extremitiesby hemiepiphyseal stapling.

Methods: Inhibition of longitudinal growth in the operated limbsegment and change in the effective leg length by angular correctionwere analyzed. From this analysis, a trigonometric formula wasderived to predict effective leg length change (DELLD) by hemi-epiphyseal stapling. This formula was verified in seven cases inwhich a unilateral angular deformity of lower extremity was cor-rected by hemiepiphyseal stapling.

Results: Contributing parameters on DELLD were magnitude ofangular deformity to be corrected (h), width of the operated physis(d), lower limb length distal to the operated physis. DELLD =(1-cosh) x L - (d x tanh) / 2. Among the cases tested, angular cor-rection by unilateral hemiepiphyseal stapling predicted to increaseeffective leg length of the affected limb in four cases and todecrease inthree cases. This prediction was in good accord with the clinicaloutcome. As L/d ratio was in narrow range in most cases, h practi-cally determined whether effective leg length increased or decreased.

Conclusions: Angular correction by hemiepiphyseal stapling mayincrease effective leg length in a certain condition. In practice, themore severe angular deformity is corrected, the more likely iseffective leg length gained.

Significance: This study shows that hemiepiphyseal stapling caneither increase or decrease effective leg length depending upon theamount of correction and anatomical parameters of the operatedlimb. This phenomenon needs to be taken into consideration whendeciding upon the surgical options for angular deformity correc-tion in growing children.

256

The relationship between the physeal line and joint surface

in the skeletally immature lower extremity: An MRI study


Co-Authors: Muharrem Inan (Turkey), Mary Nagai (UnitedStates), Leslie Grissom (United States)

Purpose: Accurate measurement of an angular deformity of thelower extremity is crucial to achieve satisfactory correction. In thepediatric population it is difficult to determine the orientation of thejoint line of the distal femur, and the proximal and distal tibia priorto complete ossification of the epiphysis because much of the con-dyle is cartilaginous. The purpose of this study was to evaluate therelationship between the physeal line and its respective articularsurface in the lower extremity in children 10 years of age andyounger.

Methods: Magnetic resonance imaging (MRI) studies of 15 anklesand 42 knees indicated to investigate septic arthritis or a tumor butfound to be normal were reviewed. The average age of the patientswas 7.5 years (range, 2 months to 10 years). The relationship be-tween the physeal line and the articular surface was determined inboth the coronal and sagittal plane MRIs.

Results: The distal femoral articular surface was found to be in5.0 + 2.4 degrees of valgus relative to the orientation of the distalfemoral physis. The proximal and distal tibial physeal lines wereparallel to the joint surface in the coronal and sagittal planes. Sta-tistical analysis showed excellent consistency between observers forthe orientation of the proximal tibia in the coronal plane (0.940),proximal tibia in the sagittal plane (0.981), and distal femur in thecoronal plane (0.890).

Conclusions: This study illustrates that the proximal and distal tibialphyseal lines and the joint surfaces are parallel to one anotherand hence are interchangeable for measurement purposes. Thedistal femoral physis and its respective articular line are notinterchangeable because the distal femoral articular surface is in5.0 degrees of valgus relative to the orientation of the physeal line.The physeal lines of the distal femur and proximal and distal tibia

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can be used to analyze a lower extremity deformity and aid inthe preoperative planning in children before ossification of theepiphysis.

Significance: The physeal lines of the distal femur and proximaland distal tibia can be used to analyze a lower extremity deformityand aid in the preoperative planning in children before ossificationof the epiphysis.

257

Imaging of tibial hemimelia

Author: Andreas H. Mahnken (Germany)

Co-Authors:

Purpose: Tibial hemimelia is associated with a broad spectrum ofthe osteochondral and extrasosseous abnormalities.

Methods: Radiology has to provide detailed information onthe abnormalities in the osteocartilaginous and the extraos-seous structures, i.e. articular or periarticular componentssuch as ligaments, tendons, menisci and muscles as well as thearteries.

Results: As either form of lower limb hemimelia is typicallyassociated with abnormalities of the adjacent joints, muscularvariations and vascular abnormalities, conventional radiographyalone is not sufficient for assessing the extent of disease.

Conclusions: MR imaging is the only imaging modality that providesdetailed information on the hemimelia itself as well as concurrentpathology. Therefore, the combination of conventional radiographyandMR imaging including contrast enhanced studies and lower limbMRangiography has to be considered the standard of reference at thepoint of diagnosis. While conventional radiography is sufficient forroutine follow-up, MR imaging also provides valuable 3-dimensionalinformation on the position and the perfusion of the osteocartilagi-nous and muscular structures after surgery.

258

Complications of hip screw removal following proximal femoral

osteotomies in children.

Author: Richard John Montgomery (United Kingdom)

Co-Authors: James Webb (United Kingdom), MohammedAlmaiyah (United Kingdom)

Purpose: Proximal femoral osteotomies in children are usuallyfixed internally. Arthroplasty may follow childhood hip disease,and retained metalware can cause technical problems. It hap-pens often enough for routine removal of metalwork to be highon the ‘wish list’ of arthroplasty surgeons. However, removal ofmetalwork can be associated with significant complications,such as 1% fracture with devices such as the fixed angle bladeplate. There are no reports in the literature of the extent ofcomplications associated with the removal of compression hipscrews.

Methods: We retrospectively reviewed the records following removalof 75 compression hip screws in a paediatric population.There was aminimum 2 year follow-up post-operatively.

Results: There were two superficial wound infections whichresolved with antibiotics. In another the metalware couldnot be removed.In one case a haematoma was surgicallyevacuated.

Conclusions: This gives a overall complication rate of approxi-mately 5% including a reoperation rate of 1%. There were nofractures, and no long-term harmful effects.

Significance: We conclude that removal of compression hip screwsin children is safe enough to recommend it as routine procedure.This will avoid making a later arthroplasty more difficult than itneeds to be.

259

Hip arthrodesis in the XXI st century. Still Valuable? Still up

to date?

Author: Manuel Resende Sousa (Portugal)

Co-Authors: Delfin Tavares (Portugal), Francisco Sant’Anna(Portugal), Manuel Cassiano Neves (Portugal)

Purpose: The last 35 years have been rich in the development ofnew techniques and improved implants for hip replacement sur-gery. For some, hip fusion has become neglected and even obsolet.Nevertheless, hip prosthesis have a variable lifetime and youngpatients will be submitted to several revision arthroplasties. Ourgoal is to review the short-term outcome of 6 adolescents with hiparthrodesis.

Methods: Six patients aging between 13 and 16, with DDH orseptic arthritis sequelae, were submitted to hip arthrodesis. In 2 ofthem the fusion was accomplished with 2 cannulated screws, inother 2 with the cobra plate and the last 2 with external fixation.The exposure was through a Watson-Jones approach preservingthe pelvi-trocanteric muscles, thinking of a future conversion in ahip arthroplasty. The minimum follow-up between surgery andthe clinical review was 14 months (one patient had 12 years pos-op). Every patient had pre-op x-ray of the pelvis and hip, andblood tests to rule out infection. The follow-up was at 2, 4, 6 and12 months and then after annually.

Results: Hip fusion was succeed in every patient between the14th and the 26th week except for one patient with septic arthritissequela. This patient was initially treated with DHS then anexternal fixator and 16 weeks after convertion to a cobra plate, thearthrodesis was successful. All patients were satisfied with the finaloutcome and one kept performing as an actress.

Conclusions: Hip arthrodesis allows a good functional result ifcorrectly performed and in selected cases, such as young patientswith septic arthrtis sequelae or large asseptic necrosis of the fe-mural head.

Significance: Hip arthrodesis is still up to date because it delays theneed for a hip prosthesis for as much as 30 years.

260

Does Hip Arthroscopy Play a Role in Reconstructive Surgery

of the Hip in Adolescents and Young Adults?

Author: Dennis Robert Roy (United States)

Co-Authors: Khaled Emara (Egypt)

Purpose: To evaluate the role of hip arthroscopy in planningreconstructive surgery in adolescents and young adults.

Methods: A provisional reconstructive procedure was planned in51 adolescent and young adult patients based on physicalexam and imaging studies. All patients had mechanicalsymptoms and/or signs and had residual deformity or dysplasiafrom a childhood or adolescent hip disorder. All patientsunderwent arthroscopy of the hip, after which, a definitivesurgical plan was made. The influence of the arthroscopicfindings on the subsequent reconstructive surgery was then as-sessed.

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Results: The provisional surgical plan was compared to thedefinitive plan with the influence of hip arthroscopy being nochange in plan; minor modification of plan (change in amountof angulation or rotation); or major modification (change inosteotomy, salvage procedure or cancel plans for reconstruc-tion). In 22 of the 51 patients (47%) there was no change to theprovisional plan. In the 22 patients with hip dysplasia, therewere 11 changes; 6 minor and 5 major. In the 18 patients withLegg-Calve-Perthes disease, there were 13 changes; 9 minor and4 major.

Conclusions: In addition to treating the intra-articular pathology,hip arthroscopy provides a safe way to effectively assess the pat-tern of joint damage to assist in planning reconstructive surgery ofthe hip.

Significance: For proper planning of treatment in patients withadolescent and young adult hip disorders.

261

Correction of proximal tibial deformity with the Orthofix

T-Garches external fixator

Author: Noriko Urano (Japan)

Co-Authors: Toshio Fujii (Japan), Akifusa Wada (Japan),Hideaki Kubota (Japan), Kazuyuki Takamura (Japan), HaruhisaYanagida (Japan)

Purpose: Developmental angular and rotational deformities showvery rapid change with growth. We reviewed our experience usingthe T-Garches fixator for correction of 11 proximal tibial defor-mities in 11 patients.

Methods: The mean age of the patients at the time of the osteot-omy was 11.3 years, and the mean duration of follow-up was1.8 years. Etiology of the deformities was Blount disease in four,bone dysplasia in three, osteomyelitis in two, and exostosis andvitamin D-resistant rickets in one patient each.

Results: Results: Bone consolidation was completed in all cases.Neurovascular complications were observed in one patient. Callusdistraction lengthening was followed by the correction of thedeformity in seven patients. The corrections ranged from 10 to 35degrees in angulation and from 10 to 20 degrees in rotation, andthe lengthening ranged from 10 to 40 mm.

Conclusions: Early mechanical axis correction has great possibil-ities for preventing further deformity with growth.

Significance: The use of the T-Garches fixator was safe andeffective for correction of proximal tibial deformity.

262

Our experience in treating children’s genu valgum

by temporary medial hemiepiphysiodesis

Author: Dana Vasilescu (Romania)

Co-Authors: Dan Cosma (Romania), Dan Vasilescu (Romania)

Purpose: Children’s idiopathic genu valgum may cause anteriorknee pain, patellofemoral instability, circumduction gait and dif-ficulty running. If the deformity persists or increases it can cause along-term cosmetic or functional problem. The purpose of thisstudy was to evaluate and discuss the treatment of children’s genuvalgumusingmedial stapling of the growth plates around the knees.

Methods: We reviewed 20 patients (29 legs) who underwenttemporary stapling of the medial femoral and/or tibial physes,between 1998–2005.Clinical evaluation included assessment of gait,limb length, alignment, patellofemoral stability and intermalleolar

distance. Radiographic evaluation included measurement of thedistal femoral angle, the anatomic femoral tibial angle and themechanical axis before stapling and at the time of staples removal.The time of staples removal was calculated using the Paley’s mul-tiplier method. Average age at the time of surgery was 12.9 yearsand the mean follow-up period was 4.6 years.

Results: Correction rarely took more than one year (mean period11 months). After stapling we noted improvement in gait, clinicalsymptoms and all radiographic parameters. At skeletalmaturity themedian intermalleolar separation was 3 cm for boys and 2 cm forgirls. The median frontal angle before operation was 14 degrees forboys and 6 degrees at follow-up, the corresponding figures for girlsbeing 14 degrees and 4 degrees.

Conclusions: The timing of epiphysiodesis remains a difficultproblem and the physician should be very cautious in determiningthe good time for surgery. At least one year of knee growth isrequired to achieve correction and care is needed to avoid overcorrection. Hemiphyseal stapling addresses the anatomic mal-alignment, alleviating symptoms while offering a high degree ofpatient satisfaction. It has proved to be a safe, effective and pre-dictable operation for genu valgum in children.

Significance: 3b.

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Open reduction of teratologic hip dislocation

Author: Akifusa Wada (Japan)

Co-Authors: Toshio Fujii (Japan), Noriko Urano (Japan),Kazuyuki Takamura (Japan), Haruhisa Yanagida (Japan)

Purpose: Teratologic dislocations of the hip joint show advancedchanges in the hip joint at the time of birth and are much morerigid than the vast majority of typical dislocations of develop-mental dysplasia of the hip. We reviewed our experience of openreduction for this condition.

Methods: Open reduction was performed in 20 patients with 3hipdislocations. The age at surgery ranged from one to three years.There was an association with other severe malformations such asarthrogryposis multiplex congenita, Larsen syndrome, meta-trophic dysplasia, cat-crying syndrome, chromosomal abnormal-ities, and other rare syndromes.

Results: Follow-up duration ranged from one to 16 years. Fem-oral derotation varus and/or pelvic osteotomies were combinedwith open reduction according to the severity of the femoral an-teversion and acetabular dysplasia.

Conclusions: Although the reduced hips had some limitation ofmotion, all the patients acquired stabilized hip joints.

Significance: It remains controversial as to whether bilateral ter-atologic hip dislocations should be reduced, but successful resultsof open reduction were obtained in this study.

DDH

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Measurement errors in acetabular index and center-edge angle

according to pelvis position - 3-D image analysis


Co-Authors: Hwan Seong Cho (Korea, Republic of), In Ho Choi(Korea, Republic of), Chin Youb Chung (Korea, Republic of),Won Joon Yoo (Korea, Republic of)

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Purpose: Acetabular index and center-edge (CE) angle are themost important parameters in evaluating pediatric hip dysplasia.Measurement errors can arise from intra- or interobserver vari-ability, irregularity in ossification, and non-standardized pelvicpositioning. We investigated the change in measurements of ace-tabular index and CE angle according to pelvic rotation andtilting, using 3-D CT images.

Methods: 3D-CT images of the pelvis of 21 LCP patients wereused in this study. Age at the time 3D-CT study averaged7.5 years (range, 4 ~ 11). 3-D Maximum Intensity Projectionimage was placed in the anatomical position. Then, it was rotatedaround the superoinferior axis in 3� increments to 15� of bothsides, and tilted around the mediolateral axis in 3� increment to 9�of both directions. Acetabular index, CE angle, foramen obtura-tor index (FOI) and pelvic tilt index (PTI) were measured in eachpositions, and compared with those measured in the anatomicalposition.

Results: FOI correlated well with the amount of pelvic rotation,whereas PTI did not. Acetabular index and CE angle wereunderestimated when externally rotated, while overestimatedwhen internally rotated. Forwardly tilted pelvis produced under-estimation of these parameters in most range rotation, but moreoverestimated in maximal internal rotation than backwardly tiltedpelvis. Rotation of the pelvis within 6� (FOI:0.66~1.43) producedmeasurement error of the acetabular index less than 2�. Change ofacetabular index measurement according to the rotation wasexaggerated when forwardly tilted, while it remains relativelyconsistent when backwardly tilted.

Significance: Measurement error of these parameters according tothe pelvis position should be taken into consideration whenevaluating hip dysplasia. Frog-leg lateral projection of the hipjoints may provide more accurate measurement of the acetabularindex.

265

Neglected D.D.H.: Treatment with a one stage surgical

procedure. What we have learned after long term observations.

Author: Rozalia I Dimitriou (Greece)

Co-Authors: John Dimitriou (Greece)

Purpose: The purpose of this study is to analyze the long termoutcome at ten to thirty eight years postoperatively, after a onestage procedure for the treatment of neglected D.D.H. in childrenover three years of age.

Methods: From 1963 to 1990, 112 cases of neglected D.D.H. inchildren over three years old at presentation were treated in ourinstitution, with the majority (85%) being from 4 to 9 years old.In all cases, a one stage surgical procedure was performed,consisting of open reduction, subtrochanteric femoral shorteningwith simultaneous correction of neck-shaft angle, anteversion andacetabular reconstruction by means of Salter’s pelvic osteotomy, ifneeded.

From all cases, 45 (39 girls and 6 boys) for which full records areavailable and with a minimum follow-up of 10 years (range: 10 to38 years) are reviewed.

Results: We consider the femoral shortening as the fundamentalstep of the procedure, as it makes reduction easier, avoiding thusthe catastrophic pressure on the femoral head. The clinical andradiological results seem to be more than satisfactory in themajority of cases. We also noticed that the results obtained at5 years postoperatively, had hardly altered at the later follow-upexamination.

Conclusions: Following up our cases for such a long period oftime, we support the view that the described method of treatmentof these cases is the treatment of choice. Certainly, we expect anumber of patients to develop eventually osteoarthritic changes ata later age, but according to our observations, all patients can livea normal or satisfactory life for years in their adolescent and earlyadult life.

Significance: Given that modern techniques of diagnosis and earlytreatment of D.D.H. offer the possibility of a much more effec-tive control of the disease, the neglected cases will certainly beextremely rare. Even so, missed cases still appear and probablywill continue to do so. Thus, it is worthwhile for physiciansinterested in treating D.D.H. to also be familiar with thedescribed method.

266

Influence of caeserean section on the incidence of ddh

in breech infants

Author: Martin Murphy (Ireland)

Co-Authors: Damian McCormack (Ireland), Frank McManus(Ireland)

Purpose: Breech presentation is an established important riskfactor for developmental dysplasia of the hip (DDH). It was thesenior author’s personal observation that there appeared to be areduced rate of DDH in the Caesarean section breech group ascompared to the Vaginal delivery breech group. We wished toestablish whether delivery by Caesarean section influenced theincidence of developmental dysplasia of the hip in breech infants.

Methods: All infants with the risk factor of breech presentationare routinely referred to our dedicated weekly DDH clinic atChildren’s University Hospital, Temple Street. We prospectivelyfollowed all Breech infants referred to our clinic. All had ABIRradiographs performed at age 4/12. We used the Chi-squared testto compare the Normal vs DDH numbers in both the CaesareanSection and Vaginal Delivery Groups. The null hypothesis wasthat mode of delivery has no influence on the incidence of DDH inbreech presentation.

Results: We prospectively followed 192 singleton term breech(>= 37 weeks gestation) infants born in our region over oneyear. 177 were born by caesarean section while 15 were deliveredvaginally. Of the infants delivered by caesarean section DDH wasdiagnosed on radiographs at 4/12 of age in 37 of the infants(21%). While the remaining 140 infants were passed normal onradiographs at 4/12 of age (79%). Of the 37 DDH cases 7 weredislocations while the other 30 were cases of acetabular dysplasia.Of the vaginally delivered group (15 infants) 7 were normal (47%)at 4/12 radiograph while 8 (53%) demonstrated acetabular dys-plasia at 4/12 radiograph. Using the Chi-squared test (see table)we were able to demonstrate a statistically significant differencebetween the normal and DDH numbers in the Caesarean sectionbreech group p < 0.001, rejecting the null hypothesis. Howeverthere was no statistically significant difference in the Vaginaldelivery breech group.

Conclusions: Our findings indicate that the mode of deliveryinfluences the incidence of DDH in infants with breech pre-sentation. However this study is limited by the ever decreasingnumbers of breech infants delivered vaginally. We suggest thatthe force of labour on the fetal hip contributes to DDH. Theresting intrauterine pressure is 4 to 5 mmHg but during theactive phase of labour this can increase to as much as100 mmHg.

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Significance: Conclusion Thus it would appear that caesariansection for breech infants has a protective influence for thedevelopment of DDH.

267

Salter innominate osteotomy for avascular necrosis following

treatment of developmental dysplasia of the hip

Author: Shinichi Satsuma (Japan)

Co-Authors: Daisuke Kobayashi (Japan)

Purpose: To assess the efficiency of Salter innominate osteotomyfor avascular necrosis following treatment of developmental dys-plasia of the hip, we analysed the radiographic outcomes oftwenty-nine patients.

Methods: There were 27 women and 2 men. The right hip wasinvolved in 12 patients and the left in 17. The mean age atfollow-up was nineteen years old (range, 14 to 24). We dividedpatients into three groups according to treatment and location ofthe insult when ischemic change was radiographically detected.Group A included 17 patients. In this group, insult occurred onlyin the proximal femoral epiphysis and Salter innominate oste-otomy was performed. In group B, there were 4 patients and inthis group the insult occurred only in the proximal femoralepiphysis and Salter innominate osteotomy was not performed.Group C included 8 patients. There the insult occurred both inthe proximal femoral epiphysis and metaphysis, and Salterinominate osteontomy was performed. At the final follow-up, wemeasured the center-edge angle, Sharp?s acetabular angle, ace-tabular-head index, and articulo-trochanteric distance. We alsoused Kalamchi?s and Severin?s criteria. And we performed aStatistical analysis with one-way analysis of variance to comparevalues among the three groups and between the affected and theunaffected side.

Results: Differences in CE angle, Sharp’s angle, and AHI be-tween the affected and the unaffected side in each group were notstatistically significant. However the ATD between the affectedand the unaffected side in all groups did have a significant dif-ference. In each radiological measurement among the threegroups, the CE of the affected side between group A and Cshowed a significant difference. And the ATD of the affected sidealso showed significant difference between groups A and B andgroups A and C. In group A, twelve hips (70.6%) were classifiedas Kalamchi’s group I. In group B, only one hip (25%) wasclassified as Kalamchi’s group I, and three hips (75%) as groupIII. In group C, seven hips (87.5%) were classified as Kalamchi’sgroup IV, only one (12.5%) as Kalamchi’s group III. The rate ofSeverin’s group I or II was 88.2%, 75%, and 50% in group A, Band C respectively.

Conclusions: In group A, all indexes except ATD were good. Ingroup B, the coverage of the acetabulum was good. However thegrowth of proximal femoral physis tended to be poor and thefemoral head couldn’t be molded spherically. And althoughthere were no statistical differences among indexes in group C,the growth of acetabulum and the proximal femoral physistended to be poor and the femoral head also tended to beaspherical.

Significance: We concluded that when ischemic insult is limited tothe proximal femoral epiphysis, Salter innominate osteotomyshould mold the femoral head spherically and form a good ace-tabulum.

268

Operative Treatment in Congenital Dislocation of the Hip

in the Older Child

Author: Guillermo Oscar Hernandez Tierno (Brazil)

Co-Authors: Milena Cruz (Brazil), Jose Pedreira (Brazil)

Purpose: The most important thing is to know that an earlydiagnosis, made during the neonatal stage or the first months oflife can prevent more uncomfortable and difficult treatmentsthan the simple Pavlik’s harness. But when we have a latediagnostic always will be a challenge for the orthopaedist.Difficulties posed in managing developmental dysplasia of thehip diagnosed late include a high-placed femoral head, con-tracted soft tissues and a dysplastic acetabulum. A combinationof open reduction with femoral shortening of untreated con-genital dislocations is a well-established practice. Femoralshortening prevents excessive pressure on the located femoralhead which can cause avascular necrosis. Instability due to acoexisting dysplastic shallow acetabulum is common, and so apelvic osteotomy is performed to achieve a stable and concen-tric hip reduction.

Methods: We retrospectively reviewed 20 patients presentingwith developmental dysplasia of the hip aged four years andabove who were treated by a one-stage combined procedureperformed by the senior author. The mean age at operation wasfive years and tree months (5 years to 7 years). The mean fol-low-up was six years .All patients were followed up clinicallyand radiologically in accordance with Ponseti criteria and themodified Severin classification.

Results: According to the Ponseti criteria, every hips were assin-tomatics. The Severin classification demonstrated 12 hips of gradeI, 6 of grade II, and 2 of grade III. Two patients haved avascularnecrosis and one required revision.

Conclusions: One-stage correction of congenital dislocation of thehip in an older child is a safe and effective treatment with goodresults in the short to medium term.

Significance: test t-student.

269

One stage surgical treatment of the developmental dysplasia

of the hip after the walking age.


Co-Authors: Luis Mandarano Filho (Brazil), Manoel Chagas Jr(Brazil)

Purpose: To evaluate the results of the surgical treatment of thedevelopmental dysplasia of the hip in the walking age.

Methods: Twenty-four children (32 hips) with developmentaldysplasia of the hip in the walking age were treated between 1986and 2003 with a standard surgical procedure which basicallyconsisted of open reduction, acetabular cleaning, psoas length-ening, femoral shortening and correction of excessive rotation,pelvic osteotomy and capsuloplasty. The surgical procedure wascarried out through one anterior approach to the hip and onelateral proximal femoral approach. Reduction was maintainedwith a Kirschner wire and a hip spica cast. No previous tractionwas used. The results were assessed on x-ray plain films before,just after the operation and at the latest evaluation. The follow-ing parameters were obtained: Wiberg angle and Shenton line.The results were evaluated by criteria of Severin and clinical

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complications were recorded. Proper statistical analysis was done(Spearmann, Wilcoxon, Mann-Whitney).

Results: The mean age at the operation was three years and sevenmonths and the mean follow-up was six years and two months.Seventy two per cent of the hips showed excellent or good results.The Salter pelvic osteotomy was performed in 15 hips (46.9%), thelateral Tonnis osteotomy in 14 hips (43.8%) and the Pembertontype in 2 hips (6.2%). Statistical analysis showed no difference inthe results for the osteotomy type. The mean surgical femoralshortening was 1.6 cm and the mean derotation was 20 degrees.The acetabular index changed from 40� to 20� after the treatment.No avascular necrosis of the femoral head ossific nucleus oc-curred. Complications occurred in four hips: 3 reductions werelost and one superficial infection occurred. All of these cases werereoperated but one of them ended in poor result.

Conclusions: The one stage surgical treatment of developmentaldysplasia of the hip in the walking age could correct the mainpathological alterations and gave good overall results.

Significance: One stage surgical treatment of DDH after thewalking age can approach all the main pathological changes andcan shorten the period of treatment as previous traction is notnecessary.

Legg-Calve Perthes disease

270

Prognostic factors of perthes’ disease: implication of lateral

subluxation index

Author: In Ho Choi (Korea, Republic of)

Co-Authors: Dong Yeon Lee (Korea, Republic of), Chin YoubChung (Korea, Republic of), Tae-Joon Cho (Korea, Republic of),Won Joon Yoo (Korea, Republic of)

Purpose: The purpose of this study was to determine the impli-cations of the LSI (combination of epiphyseal extrusion ratio,type of acetabular margin, medial joint space widening, and cal-cification lateral to epiphysis) as a prognostic factor in the man-agement of Perthes’ disease.

Methods: In a case series of 527 unilateral Perthes’ patients,demographic features and radiographic findings including Wald-enstrom stage at initial presentation, the severity of involvementand lateral pillar collapse, epiphyseal extrusion ratio, type ofacetabular margin, medial joint space widening (difference), cal-cification lateral to epiphysis were evaluated retrospectively. Fourlatter indices were considered reflecting subluxation of femoralhead. All four indices had complementary weak points. So wecombined four indices with a scoring system (LSI, total scores1~9). Final outcomes at healing were classified radiographicallyaccording to the modified Stulberg classification.

Results: All four indices reflecting subluxation were closelycorrelated with the severity of lateral pillar collapse andradiographic outcomes at the latest followup. When foursubluxation factors were considered as an independent factor,stepwise regression analysis revealed that lateral pillar collapsewas the highest predictor followed by age at symptom onset,medial joint space widening in order. But, when subluxationfactors were combined and depicted as LSI, LSI was thehighest predictor followed by lateral pillar collapse, age atsymptom onset in order. The scores of LSI strongly correlatedwith final outcomes in the non-surgical treatment group. Inthe hips with higher LSI (‡6), only less than 20% were clas-sified as spherical femoral head (Stulberg I or II); when LSI

was lower (£4), more than 90% of hips healed in sphericalfemoral heads at healing. Conservative containment treatmentincluding Atlanta brace and hip abduction cast had limitedrole in terms of preventing progression of subluxation. But,surgical containment appeared to increase the chance to obtainspherical head at healing in hips with higher LSI (‡6)(p < 0.05).

Conclusions: LSI is considered to be a better measurement of theextent of subluxation and a strong predictor of outcome.

Significance: LSI may be used for guidance for decision-making ofsurgical containment.

271

Radiographic and MRI dissociation in Legg-Calve-Perthes

disease.

Author: J C Di Sicco (Brazil)

Co-Authors: E Dobashi (Brazil), P Yamane (Brazil), A Ishida(Brazil), C Milani (Brazil)

Purpose: The purpose of this paper is to demonstrate the results ofthe acetabulum-femoral-head index in 60 hips of 60 children withLCP disease using plain x-rays and MRI. Then compare the ob-tained results to demonstrate if there is correlation or not of thecalculated index between these two different methods as we calleddissociation.

Methods: Our material is constituted by 60 patients (60 hips) withLegg-Calve-Perthes disease with 46(76,67%) male and 14(23,33%) female with the mean age of 6 y10 m (2 y6 m to12 y10 m), 46 white patients and 14 non-white. Regarding to theaffected side 34 (56,67%) were on the right side and 26 (43,33%)on the left. We applied the classification proposed by WALD-ENSTROM (1922) and modified by JONSATER (1953). Thisway, 34(56,67%) hips were considered in necrotic phase, 13(21,67%) in fragmentation, 9 (15%) in reossification and 4(6,67%) in the final stage of the disease. To measure de femoralhead coverage index we applied the knowledge of HEYMAN &HERDON (1950) using a computed program software developedfor this purpose in x-ray and in MRI images.

Results: We observed that in 23 hips (38,33%) there aredisagreement in the information concerned to the femoralhead coverage because there were considered sufficient accord-ing to plain x-ray but insufficient whenMRI images were analysed.

Conclusions: Many orthopedic services use to apply plain x-rayfor diagnosis even for treatment and follow-up. But the infor-mation regarding this method does not provide the real state ofthe femoral head concerning the femoral head cartilage andlabrum coverage. Then, the results obtained for us suggest thatMRI provides trustworthy information to conduct the treat-ment of LCP disease, independent of the chosen method.

Significance: (empty).

272

Staheli’s shelf acetabuloplasty in the treatment

of Legg-Calve-Perthes disease: Indications and mid-term results

Author: Elias Haddad (Lebanon)

Co-Authors: Ismat Ghanem (Lebanon), Suha Haddad-Zebouni(Lebanon), Noel Aoun (Lebanon), Fernand Dagher (Lebanon),Khalil Kharrat (Lebanon)

Purpose: to evaluate the efficacy and safety of Staheli’s shelfacetabuloplasty in those LCP hips classically associated with poorprognosis.

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Methods: A retrospective study was conducted on 20 consecutivepatients (15 boys and 5 girls) with an average age of 6.65 years,presenting with a severe and progressive form of LCP disease(Catterall 3 and 4, Herring B and C) with ‘‘head at risk’’ signs andtreated by Staheli’s acetabuloplasty, with or without femoralvarus osteotomy between november 1997 and June 2004. The shelfwas done on hips presenting an aspherical uncongruency withflatenning, extrusion and lack of femoral head coverage, asdemonstrated on pre-operative radiographs and/or arthrography.All patients were reexamined at an average follow-up of51 months (18–96). A clinical (pain, limp, motion, leg lengthdiscrepancy), radiological (femoral head extrusion, femoral headsize, Sharp angle, Reimers index, Wiberg angle) and CT scanevaluation (with 2D and 3D reconstruction, 3D congruency, shelfmigration, offset, size of the shelf) was undertaken. Stulberg andMose classifications were applied as radiological indicators ofprognosis. Statistical analysis was performed using Pearson cor-relation test and variance analysis for repetitive measures; all testswere bilateral; a p value < 0.05 was considered significant. TheSPSSV13 software was used for analysis.

Results: At last follow-up, all patients are pain free and havenormal (17) or almost normal (3) hip motion. Eleven (55%) walknormally, 7 (35%) with mild limp and 2 (10%) with pronouncedlimp. LLD is found in 9 cases ranging from 1 to 3.5 cm. Threehips (15%) are classified Stulberg 1, 9 (45%) Stulberg 2, 6 (30%)Stulberg 3 and 2 (10%) Stulberg 4. The average neck-shaft angle is127� (107–145). A statistically significant improvement of femoralhead extrusion (p = 0.05), of Sharp angle (p = 0.000), of Rei-mers index (p = 0.000) and of Wiberg angle (p = 0.000) wasfound. The scannographic study found no offset nor migration ofthe shelves in any case. On CT, The femoral head was regular in14 patients (70%), flattened in 6 (30%). Despite 2 cases of Stul-berg 4 found on radiographs, the 3D congruency was good in allcases. The average coronal length of the shelf was 8 mm and theaxial one 16 mm. A positive correlation was found between Wi-berg angle improvement and the young age at the time of surgery(p = 0.050), which goes against the concept that Staheli’s shelfacetabuloplasty may interfere with growth of the acetabular roof.

Conclusions: Staheli’s shelf acetabuloplasty improves outcome of hipswith severe LCP. It insures a better and lasting coverage and remod-eling of the femoral head, while preserving acetabular roof growth.

Significance: Staheli’s shelf acetabuloplasty improves outcome ofhips with severe LCP. It insures a better and lasting coverage andremodeling of the femoral head, while preserving acetabular roofgrowth.

273

LCPD - The hunt for genetic associations

Author: Shlomo Hayek (Israel)

Co-Authors: Eli Ezra (Israel), Shlomo Wientroub (Israel), DavidSteinberg (Israel), Nurit Rosenberg (Israel), Dalia Waldman (Is-rael), Gili Kenet (Israel)

Purpose: The etiology of Legg-Calve Perthes disease (LCPD) is stillan unsolved enigma. The role of heritable thrombophilic riskfactors in the pathogenesis of this multifactorial disease is con-troversial. Since clinical and radiological findings of avascular hipnecrosis due to LCPD may be indistinguishable from Gaucherdisease, we previously studied the commonest Jewish N370SGaucher mutation among LCPD patients and found a threefoldincrease of its prevalence. Familial osteonecrosis of femoral headhas recently been found to be associated with variant mutations ofcollagen type II. Our aim was to study the potential role of all thoseabove mentioned genetic factors in a cohort of LCPD patients.

Methods: Genomic DNA of 119 radiologically confirmed LCPDpatients (diagnosed 1986–2004) was analysed for the followingthrombophilic polymorphisms: FVL, 677T-MTHFR and FII-G20210A. Results were compared with 276 pediatric controlsreferred for elective surgery. DNA was also analysed for the fol-lowing Gaucher mutations: N370S, G insertion (84GG), L444P,Intron 2(IVS2 + 1G>A) and R496H. Enzyme assays wereperformed for confirmation of Gaucher disease status. Collagen(COL2A1) mutations of 12q13 gene were analyzed as previouslydescribed (Liu et al, NEJM, 2005). Statistical analysis was per-formed using the chi-squared test with Yates’ correction.

Results: The prevalence of thrombophilic markers was similaramong cohort patients and controls. Gaucher mutations prevalencewas consistentwith the Israeli population carriership data anddidnotconfirm the associationwithLCPDfound ina smaller previous study.All our patients were negative for COLA21 mutations studied.

Conclusions: Our study did not confirm genetic association ofLCPD to Gaucher disease or collagen (COLA21) mutations.Thrombophilia was not increased among our patients as comparedto controls although a transient hyper-coagulability state during theearly phases of the disease cannot be ruled out. Further studies arewarranted in order to shed more light upon the genetic backgroundof LCPD.

Significance: Thrombophilia, Gaucher mutations have no etio-logical role in LCPD.

274

Intertrochanteric Varus Open Wedge Osteotomy

in Legg-Calve-Perthes Disease Patients Older

than 9 Years Old.

Author: In-Young Ok (Korea, Republic of)

Co-Authors: Seok-Jung Kim (Korea, Republic of)

Purpose: To evaluate the outcome of intertrochanteric varus openwedge osteotomy in LCP for the patients above 9 years old.

Methods: Thirty three patients older than 9 years diagnosed asLCP were treated by intertrochanteric varus open wedge osteot-omy from August, 1989 to August, 2002. The mean age of thepatients was 10.2 years (range 9–14), a mean duration of followup was 7.7 years (range 3.2–14.1 years). According to Harringclassification system, group A patients were 3, B were 21,and Cwere 11. Thirty was male and the others were female. There are 2cases of both sides involvement of LCP in female patients.Radiographic outcome was assessed utilizing Stulberg’s classifi-cation to grade residual deformity.

Results: Stulberg class I and II(spherically congruent) were 10, IIIand IV)(aspherically congruent) were 15,and V(asphericallyincongruent) were 10. Less involvement of the disease and earlystage treatment produced better outcome.

Conclusions: Intertrochanteric varus open wedge osteotomy is areliable treatment inLCPafter the ageof 9, if the disease is evaluatedindividually according to the extent of involvement and stage of it.

Significance: Remodelling after containment treatment could beexpected in advanced age group.

275

The Results of Hip Abduction Brace (Nishio) Treatment

for Legg-Carve-Perthes’ Disease

Author: Yutaka Oketani (Japan)

Co-Authors: Toshio Fujii (Japan), Kazuyuki Takamura (Japan),Haruhisa Yanagida (Japan), Akifusa Wada (Japan), HideakiKubota (Japan), Suin Ryu (Japan), Aiji Matsuura (Japan)

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Purpose: To report the results of the non-weight bearing hipabduction brace (Nishios Brace) for unilateral Legg-Calve-Perthesdisease.

Methods: We studied 97 hips that were treated by Nishio’s bracethat contains the femoral head in the acetabulum at 30 degrees hipabduction and has a pole beneath the sciatic tubercle for the non-weight bearing of the hip. Average age at the time of first visit is6.5 years, and at the last visit was 13.0 years. We evaluated hipswith Catterall classification, lateral pillar classification and Stul-berg classification.

Results: The Catterall classification judged when the period endeddividing (passage of nine months on the average from the firstmedical examination) showed in two hips type 1, 37 in type2, 39 intype 3, and 19 in type 4. The lateral pillar classifications showedeight hips in group A, 54 in group B, 22 in group B/C, and 13 ingroup C. The Stulberg classification when the final passage wasobserved showed 26 hips in type1, 40 in type2, and 20 in type3, ninein type4, and two in type5. Namely, 68.0% (66/97 hips) showedsatisfactory results.

Conclusions: Nishios brace is satisfactorily effective for the treat-ment of unilateral LCPD.

Significance: Nishios brace is satisfactorily effective for the treat-ment of unilateral LCPD.

276

Bone age delay patterns in Legg-Calve-Perthes

disease - an analysis using the TW3 method

Author: Hae-Rong Song (Korea, Republic of)

Co-Authors: Seok-Hyun Lee, Jae-Hyuk Yang, Sandeep Vaidya,Sameer Desai, Gautam Shetty

Purpose: To study the bone age delay patterns in different stagesof Perthes’ disease.

Methods: 140 hand and corresponding hip radiographs in 83 pa-tients were assessed. In the hand radiographs, the RUS (radius,ulna, metacarpals and phalanges) and carpal bone ages werecalculated using the Tanner and Whitehouse 3 (TW3) method andthe Greulich and Pyle (G&P) bone age was assessed using theGreulich and Pyle atlas. From corresponding hip radiographs, themodified Elizabethtown stage was assessed.

Results: RUS and carpal bone age as well as G&P bone age werefound to lag behind the chronological age. The 95% confidenceinterval for difference between RUS and G&P bone ages was 0.19to 0.43 years and between carpal and G&P bone ages was –0.516to –0.14 years indicating a close agreement between the TW3 andG&P methods. RUS bone age delay was maximum in stage Ia(2.00 ± 1.08 years) while carpal delay was maximum in stage IIa(2.15 ± 1.28 years). Bone maturation acceleration was observedin later stages of the disease as bone age tried to catch up withchronological age. Carpal delay was significantly greater thanRUS delay from stage Ib to IIIb (p < 0.05) but no significantdifference was observed between carpal and RUS delays in stageIV (p = 0.21) implying that bone maturation acceleration occursin the radius, ulna, metacarpals and phalanges (RUS) in theearlier stages and carpal bone age tends to catch up with RUSbone age in the healed stage of the disease. RUS and carpal boneage delays in stage I were significantly greater in severe (Catterall’sgroups 3 and 4) disease than in mild (Catterall’s groups 1 and 2)disease.

Conclusions: All patients in whom RUS or carpal bone age delay instage I was greater than 2 years subsequently developed severe dis-

ease indicating a positive correlation between bone age delay in stageI and subsequent extent of involvement of capital femoral epiphysis.

Significance: Regular followup is required in patients showing abone age delay with Perthes disease.

277

Salter Osteotomy in Legg - Calve- Perthes disease (LCPD)

Followed Until Skeletal Maturity.

Author: George H. Thompson (United States)

Co-Authors: Susan Scherl (United States)

Purpose: A prospective study to evaluate the clinical andradiographic results at skeletal maturity of patients with LCPDtreated with a Salter osteotomy. Standardized criteria were usedto make the results comparable to previous and future studieson LCPD.

Methods: Between 1979 and 1996, a Salter osteotomy was per-formed on 52 patients (53 hips) with a clinical age of onset between 6and 10 years of age (5 to 10 years in females) with more than one-half of the capital femoral epiphysis (CFE) involved ( Catterallgroups III and IV, Salter-Thompson Group B, and lateral pillarGroups B and C). They were followed until skeketal maturity andthen evaluated clinically and classified radiographically using theStulberg, et al and Mose circle criteria.

Results: Forty-nine patients and 49 hips (92%) met the criteria forevauation. There were 39 males and 10 females with a mean age atonset of 7.5 years (5.9–10.8 years). Their mean follow-up was9.8 years (5.0–19.1 years). Preoperatively, 44 hips were CatterallIII and 5 Catterall IV; all were Salter-Thompson Group B; and 13hips were Lateral pillar Group B and 36 Group C. At maturity,the clinical results were uniformily good and only 6 patients hadsports related symptoms. Radiographically, 32 hips were Stulberg,et al class II (65%), 14 class III (29%), and 3 class IV (6%). Thus,46 hips(94%) had satisfactory results. The Mose criteria was morerestrictive as there 20 hips (41%) rated good, 14 (28%) fair and 15(31%) poor.

Conclusions: Salter osteotomy is an effective method of surgicalcontainment for patients with LCPD who have a poor prognosis.It alters the natural history. It effects are permanent and appearsto enhance remodeling of the CFE.

Significance: Salter osteotomy is an execellent procedure whensurgical treatment is necessary for LCPD. It requires experience toperform correctly but does not require postoperative immobili-zation. It has numerous advantages (secondary) over a proximalfemoral osteotomy.

6 - Foot and ankle

278

Single Stage Surgical Correction of Congenital Vertical Talus

by Complete Subtalar Release Using Three Incisions.

Author: Mostafa El-Sherbini (Egypt)

Co-Authors:

Purpose: To evaluate the effect of Complete Subtalar ReleasebySingle Stage Surgical Correction in the treatment of CongenitalVertical Talus through three incisions.

Methods: 10 feet of 6 patients with congenital vertical talus whichwere treated by single stage surgical correction by complete sub-

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talar release and peritalar reduction using 3 incisions,posterome-dial,lateral and anterior midleg incision for dorsiflexors length-ening.There were 3 male and 3 female.There ages ranged between9 months and 3 years with average 14.5 months .The follow upranged between 18 months and 51 months with average31.1 months.

Results: There were 8 good and 2 fair results.There was one case ofavascular necrosis of the talus .Radiologically,there was a signif-icant improvement in the anteroposterior and lateral talocalcanealangles, and at follow up,the group averages for each of theseangles were within the normal ranges.

Conclusions: In the treatment of congenital vertical talus,goodclinical and radiological outcomes can obtained with a low inci-dence of complications,using this single-stage surgical correctionwith three incisions.

Significance: To acheve pritalar reduction with low incidenceof complicatiuons.

279

Shortness Of The Fourth Toe

Author: Gamal Ahmed Hosny (Egypt)

Co-Authors:

Purpose: Shortness of the fourth toe is a rare problem.It does notusually produce a functional problem.However,it may produce asignificant cosmetic problem specially in girls.The aim of thisstudy is to evaluate the validity of gradual distraction of thefourth metatarsal to tackle this problem.

Methods: From1993 till 2005,8 cases of congenital shortening of thefourth toe were referred to our center.6 cases were bilateral[total14 feet].All cases were females.Age of patients ranged from 13 to20 years[average: 15.5 y].Shortening ranged from 10 to 70% of theoriginal length.There were no functional problems preopera-tively.Lengthening was performed using minifixator[Pennig Exter-nal fixator} with 2 proximal & 2distal2 mm self tappingscrews.After the application of the srews,the framewas temporarelyremoved and osteotomywas performed in themiddle through 1 cmincision.Then the frame was reapplied.After a waiting period of12 days,distraction started at a rate of 0.75 mm per day.Then therate wasmodified according to regenerate formation and the degreeof developing stiffness in the the metatarsophalangeal joint.Evalu-ation depended upon the achievement of the target length,angula-tion,pain & satisfaction of the patient.

Results: There were 10 excellent & 4 good results after anaverage follow up of of 3 y[range 6 months to 6.5 years]Theaverage healing index was 45 days/cm.Complications includedmild pin tract infection in 11 cases which responded to antibi-otics.Subluxation of the metatarsophalangeal joint developed in2 cases who resolved spontaneousely.Delayed regenerate forma-tion in 2 cases who were treared by repeated compression &distraction.

Conclusions: We recommend cosmetic gradual lengthening of thefourth metatarsal as the treatment of choice for shortness of thefourth toe.We do not recommend soft tissue release or fixation ofthe metatarsophalangeal joint to guard against displacement.

Significance: Cosmetic lengthening is justified in these cases.

280

Mc’Hale’s procedure (open wedge osteotomy of the first

cuneiform and close wedge osteotomy of the cuboid) for club

foot revision surgery.

Author: Raytcho Ivanov Kehayov (Bulgaria)

Co-Authors: Evgenii Mednikarov (Bulgaria), Hristo Georgiev(Bulgaria), Stefan Stefanov (Bulgaria), Borislav Vladimirov(Bulgaria)

Purpose: The authors report 24 cases of revision in recurrent clubfoot deformity. They assessed Mc’Hale’s procedure for treatmentof the residual forefoot adduction. This procedure was generallyassociated with postero-medial, plantar release, and split tibialisanterior tendon transfer.

Methods: 16 children (24 feet), aged 5 to 15 years, underwentmedial open wedge osteotomy of the first cuneiform for correc-tion of 16 feet, closed wedge osteotomy of the cuboid has beenadded to correct the varus deformity of the fore foot, it allowedlateral swing of the forefoot : the bone excised from cuboid isused to stabilized medial osteotomy. This procedure is carriedout when varus of the tarso metatarsal joint is superior to 20degree, it is reduced to its normal value, between 5 and 10degree.

Results: Results have been studied with follow up ranginq between18 months and 5 years. The revision chart comprised 12 clinicaland radiological items. 9 feet were considered as excellent, 10 asgood, 3 as fair, and 2 as poor.

Conclusions: Treatment of the adduction component withMc’Hale’s procedure is focused on the midfoot, and on thecalcaneo-navicular block by postero medial release. This opera-tion is riskless for foot growth, and needs two approaches whichcan be useful for simultaneous procedures as split lateral transferof tibialis anterior tendon.

Significance:Mc’Hale’s procedure associatedwith soft tissues releaseand split anterior tibial transfer, seems to be effective in surgicaltreatment of relapsed clubfeet, but the debate concerning the locationof the adduction component of the deformity remains still open.

281

Distraction lengthening of the long bones of the foot

in children

Author: Alexander Kirienko (Italy)

Co-Authors: Luigi Spreafico (Italy), Massimo de Donato (Italy),Valerio Sansone (Italy)

Purpose: This study investigated metatarsal and phalanx length-ening by distraction osteogenesis for congenital or post-traumaticshortening in 23 metatarsals and 3 phalanx of the hallux, in agroup of 17 patients.

Methods: There were 7 males and 10 female patients, mean age13 years (range from 8 to 17 years). We treated 2 patients withTurner syndrome with bilateral shortening of third and fourthmetatarsal, brachymetatarsia of fourth metatarsal in 9 (threebilateral) and post-traumatic and congenital defect of firstmetatarsal in 3 of them. Three patients had stump of theproximal phalanx of the hallux. We performed lengthening usingsemicircular and Ilizarov’s mini-fixator for fingers. We fixedbones to the external fixators by wires crossed in the transversalplane, performed percutaneous osteotomy and then we starteddistraction five days after the operation. Early weight bearingwas allowed in all cases. The initial rate of lengthening was of0,75 mm per day. After 2 weeks this rate was slowed to 0,5 mmper day.

Results: The average in length was 17,3 mm (range 12–25 mm),with an equivalent increase of 36% (range 25–46%) and a meanhealing index of 61 days/cm. The American Orthopedic Footand Ankle Society (AOFAS) average score for lesser toes was85,3 (range 53–100) and 73 (range 51–93) for hallux. The mostcommon complication was stiffness of metatarsophalangeal

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joint (6), subluxation of this joint (2), angular deviation of thelengthened bone (5), pin track infection in 4 cases, one retard ofconsolidation after lengthening that needed to proceed withdistraction bone transport. We did not need to use bonegrafting in all cases, no neurovascular complications wereencountered.

Conclusions: This technique of gradual distraction gives a suffi-cient precision lengthening for forming physiological arch ofmetatarsals heads. It also permits a contemporarily correction ofdeformities without bone grafting and soft tissue modifications.Subluxation of metatarsophalangeal joint may be prevented bypitting of the toe with longitudinal K-wire. Excellent clinical andfunctional results were obtained with both semicircular and Il-izarov’s mini-fixators.

Significance: This method could be recommended as the way ofchoice for solving the problem of metatarsal and phalanx short-ening. Bone lengthening is effective in patients not only for aes-thetics, but also to relieve pain and callosities on the plantarsurface on the second and third metatarsal heads and preventsecondary deformities of toes nearby.

282

Highly constrained frame in correction

of deformed feet

Author: Hatem Ahmed Kotb (Egypt)

Co-Authors:

Purpose: Ilizarov Method in the correction of complex feet hasproved efficiency. Highly constrained and non constrained dis-traction has been described. The aim of this study is to evaluateout come after Ilizarov highly constrained frame feet correction,and to determine the adequate number of tibial rings needed forcorrection.

Methods: Forty-three feet were operated using a highly con-strained Ilizarov frame from 1996 till 2005. The tibial fixation wastwo rings in five cases and one tibial ring in thirty-seven. Twocases were treated by distraction osteotomies and forty-one bysoft tissue distraction. Nine cases had additional surgical proce-dure. The average age at operation was 10.7 years (range 3–25 years). Average follow up was 5.2 years (range nine years tonine months). The indication for correction were neglected orrelapsed idiopathic congenital talipes equino varus in 22 cases.Eight paralytic feet and six rocker bottom feet. 5 talipes equinovarus feet associated with syndromes. 31 feet had previous oper-ation average 1.8 opration (range 1–4 operations). 6 had previousIlizarov operations. Clinical, functional and radiographic evalu-ation was performed.

Results: the average fixation time was 2.7 months (range from1–5 months). All feet were corrected except one. At final followup 31 had good results, 7 had satisfactory results and 5 hadunsatisfactory results. There has been a marked average in-crease in the function and ankle and subtalar range of motion.There has been 43 minor complication, 3 serious complicationsand no serious complications were related to single tibial ringfixation.

Conclusions: Ilizarov fixator is an effective tool for correction ofdeformed feet, one tibial ring fixation is adequate to achievecorrection. An increase in function and range of motion can beexpected.

Significance: one tibial ring fixation is adequate to achieve cor-rection. An increase in function and range of motion can beexpected.

283

New Modification of John’s Technique to Restore Dorsiflexion

of the Ankle Joint and Normal Development

of the Hallux

Author: Nagy Ahmed Sabet (Egypt)

Purpose: John’s operation is a popular procedure to restoredorsiflexion of the ankle joint in cases of drop foot due toparalysis of the tibialis anterior. The original procedure is com-posed of transfer of the extensor hallucis longus to the neck of thefirst metatarsal bone and arthrodesis of the interphalyngeal jointof the big toe. The previous procedure cannot be done in skeletallyimmature patients because it will stop the development of thehallux and lead to deformity and shortening of it. Modification ofthis technique was tried by doing tenodesis of the interphalyngealjoint using the stump of the extensor hallucis longus muscle toprevent flexion deformity of the joint, but this procedure will failafter few years due to progressive development of the phalanx andnecessitate revision of the tenodesis or arthrodesis of the inter-phalyngeal joint. We tried a new modification by suturing thestump of the extensor hallucis longus to the tendon of the extensorhallucis brevis. This procedure preserves active dorsiflexion andnormal development of the hallux.

Methods: The present procedure was performed to 42 limbs fromJanuary 2000 to December 2004, 2 cases were bilateral.Regardingthe surgical procedure; Tendo-achillis lengthening was performedroutinely to all patients in this study, The extensor halluces longustendon was transferred to the neck of the first metatarsal in (20cases) where there was no varus deformity associated with theequinus, The tendon was transferred laterally to the middlecuniform bone if there was varus deformity (22 cases), andSuturing of the stump of the extensor halluces longus to theextensor halluces brevis was performed in 40 cases out of 42 in-cluded in this study due to normal congenital variant in which theextensor hallucis brevis muscle is congenitally absent. Post oper-ative care; Above knee cast was applied to all cases for one monthfollowed by below knee cast for 2 weeks. Physiotherapy & walk-ing exercises were performed after removal of the cast.

Results: Follow up was ranged from one & half year to six years &6 months. Active dorsiflexion of the ankle was achieved in allcases. Active dorsiflexion of the hallux was also achieved in allcases with different degrees.

Conclusions: Some complications were experienced, 3 casesshowed superficial wound infection and were treated byantibiotics. Failure of the tendon suture due to direct trauma tothe hallux occurred in one case and necessitated revisionof the operation. Congenital absence of the extensor hallucesbrevis was found in three cases and was excluded from the study.

Significance: We concluded that suturing of the stump of theextensor hallucis longus to the extensor hallucis brevis in John’sprocedure is a valuable method to restore dorsiflexion of thehallux and allow normal development of the phalanx.

284

Arthroscopic treatment for osteochondritis dissecans

of the talus in adolescents. a review of 18 cases.

Author: Vidal Imma Vilalta (Spain)

Co-Authors: Font Ullot (Spain), Eva Planes (Spain), CampaCepero (Spain)

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Purpose: It’s not frequent that de pathology of the ankle could betreated with arthroscopy in children and adolescent. This tech-nique is used in our service since 1996, being the osteochondritisdissecans of the talus the most frequent pathology with 18 cases.The first description of the arthroscopic treatment of this injurywas made in 1982.

Methods: We reviewed 18 patients, since 1996 to 2006, ages from10–17 years, who had been treated for an osteochondral defect ofthe talus by arthroscopic drilling. The indication for surgicaltreatment was persistent symptoms after leaving physical activityfor at least six months. There were 9 boys and 9 girls. The lesioninvolved the right ankle in 13 and the left in 5 cases. 70% of thecases were associated with a previous trauma. Arthroscopic dril-ling was performed and the mean follow-up was 7–10 years.

Results: The results were evaluated at least of 1 year by clinicalfindings, X-ray and CT-scan. The outcome was excellent and theparticipation in sport was possible after 9 moths.

Conclusions: We emphasize the role of the arthroscopic of theankle, for surgical processing of the osteochondritis dissecansof the talus. The arthroscopic, allow an adequate viewing ofthe entire joint and avoids the complications of the open surgery.

Significance: The aim of this communication is to confirm that wehave to treat the osteochondritis dissecans of the talus byarthroscopic drilling because of minimally invasive technique withexcellent results and avoids the complication of the open surgery.

Clubfoot

285

Residual forefoot adduction in clubfoot - comparison

of two methods of treatment

Author: Ondrej Adamec (Czech Republic)

Co-Authors: Pavel Dungl (Czech Republic), Jiri Chomiak (CzechRepublic), Monika Frydrychova (Czech Republic)

Purpose: To compare outcomes of temporary transfer tibialisanterior tendon and metatarseal osteotomy to corection ofresidual adduction deformity of the forefoot after the extensivesubtalar release.

Methods: Two surgical methods were used. Compared to originalmethod described by Garceau (1967) in proper technique tibialisanterior tendon pass through subcutaneus tunnel. Result of thepass beneath annular ligament of ankle is mostly loss of function,because of concretion. Metatarseal dome shaped osteotomies wemade from three lenghtwise incisions and fixed every metatarsealbone by one wire. From the group of 460 feet (348 patients)operatet in years 1984 to 2002 by extensive subtalar release wastransfer of tibial anterior tendon used in 78 feet (62 patients) andmetatarseal osteotomy in 56 feet (43 patients). Age of patiensranged between 32 months and 13,5 years. In every cases,deformity demonstrated adduction and supination of forefoot.For functional evaluation was used modified scoring systemaccording to Mc Kay, forefoot rigidity was evaluated according toBlack. X-ray assessment was made by use of talo-I.metatarsal andcalcaneo-V.metatarsal angle changes in dorsoplantar weight-bearing wiew.

Results: In subjective evaluation whith average follow-up4,5 years (2 to 8) was effect of operation percieved at 49 (72 %)feet as excelent, at 15(22 %) as good and et 4 (6 %) as a minimalchange. Deformity became extinct clinicaly and radiologicaly in53 % of cases. Persistance of adductional position of forefootclinicaly and radiologicaly we recorded in 26 % feets in tibialis

anterior transfer group at 6 years of age and more, when theeffect of method was smaller or transient because of presenceforefoot rigidity. In metatarseal osteotomy group we noted 5non-unions represents 1.8% of 280 osteotomized metatarsealbones.

Conclusions: Temporary transfer of tibial anterior tendon byproper modified technique passing tendon in subcutaneous tunnelis safe and reliable method to affect residual forefoot deformity inpatients between 3 to 6 years of age. In patients older than 8 yearsof age and for every rigid deformities (Black II and III) we rec-ommended metatarseal osteotomy as a method of treatment.

Significance: Mean comparisons following analysis of varianceshowed significant differences (all p < 0.0001) between usedmethods and patients age in time of surgery. A significant dif-ference (p = 0.0216) was also noted between the rigid and nonrigid forefoot deformity.

286

Congenital clubfoot. An epidemiological investigation:

1980–2005

Author: Alain Dimeglio (France)

Co-Authors: Federico Canavese (Italy), Frederique Bonnet(France), Tayeb Bentahar (France)

Purpose: This epidemiological investigation was performed toanalyse data on 901 children with clubfoot born in a region ofabout 2.100.000 residents with 25.000 births/years on average.

Methods: 754.532 live births were recorded in the period january1980 - august 2005: 826 children had idiopatic clubfoot (91.7%)and 75 non-idiopatic clubfoot (8.3%). All data were statisticallyanalysed.

Results: The birth prevalence of isolated idiopatic clubfoot (noother birth defects present) was 1/1000 total births and of asso-ciated idiopatic clubfoot (other birth defect present) was 0.12/1000total births. 7.7% of children with idiopatic clubfoot had otherassociated congenital abnormalities: the most common one wasDDH in 2.7% of cases followed by metatarsus adductus (1.6%).Others malformations such as upper limb malformations (0.5%),patella dislocation (0.4%), cardiac malformations (0.4%) wereuncommon. Since 1990 ultrasounds are regularly performed todiagnose DDH. Left metatarsus adductus was frequently associ-ated to right unilateral idiopatic clubfoot (p < 0.001). Non-id-iopatic clubfeet were frequently related to arthrogryposis. Malegender (67.02%) is more likely to have an increased risk of idio-patic clubfoot but there is no significant association betweengender and severity of deformity (p>0.05) and gender and sideaffected (p > 0.05). Unilateral forms make up 55% (31.83% rightand 23.17% left) and bilateral forms are 45%. Prognosis is notinfluenced by the sex (p > 0.1). The mean age of fathers was31.56 years (17.21–68) and of mothers was 28.92 years(14.09–44.04). Family history was positive in 14.14% of cases.3.2% of infants were born preterm and 59.87% had birthweightover 3000 gr. (mean birthweight: 3200 gr.; range: 800–4645 gr.).Analysis failed to identify a monthly or seasonal variation in thispopulation. According to a scale from 0 to 20 5.9% of feet werebenign and completely reductible (score 1–5), 24.56% moderate(score 6–10), 58.55% severe (score 11–15) and 10.99% very severe(score 16–20). After 1997 the lengthening of triceps (Vulpiustechnique) was included in the protocol.

Conclusions: Results are correlated to the Scoring System ; clas-sification is helpful to evaluate the impact of treatment; a signif-icant follow up is necessary to evaluate the effect of treatment;after 1997 the lengthening of triceps (Vulpius technique) was in-

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cluded in the protocol: this mini surgical procedure his helpful toimprove the effects of the conservative treatment.

Significance: Retrospective Study.

287

Treatment of Residual Clubfoot Deformities with the Taylor

Spatial Frame Using a Ponseti Sequence


Co-Authors: Alexander Katzman (Israel), Noam Bor (Israel),Bradley Lamm (United States), John Herzenberg (United States)

Purpose: Correction of residual clubfoot deformities remains agreat surgical challenge, and treatment failure is not uncommon.Open surgical reconstruction often leads to more scarring, risk ofneurovascular injury, and a stiff foot. The Ilizarov external fixatorallows for osseous realignment without open incisions. The Taylorspatial frame (TSF) is a relatively new external fixator that iscapable of simultaneous six-axis deformity correction. Ourmethod applies the Ponseti principles of clubfoot correction to atwo-stage TSF correction (i.e., varus and internal rotation cor-rection and then equinus correction). The Ponseti type 1 frame isprogrammed to correct varus and internal rotation first and thenequinus. The Ponseti type 2 frame follows the same sequence asthe type 1 frame but includes a final phase in which the foot ring iscut on two sides to allow separate correction of forefoot cavus andadductus. We present our initial multicenter experience with thisPonseti-inspired method.

Methods: During a five-year period, seventeen patients (22 feet)were treated for residual clubfoot deformities with the TSF. Ninepatients had idiopathic clubfoot, five had arthrogryposis, one hadmyelomeningocele, one had developmental clubfoot, and one hadclubfoot associated with fibular hemimelia. Eight boys and ninegirls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed innine patients (Ponseti type 1 frame), equinus, internal rotation,and forefoot deformity (adduction and/or cavus) in six patients(Ponseti type 2 frame), and equinus only in two patients. All pa-tients underwent correction with standard two-ring frames using along bone program.

Results: All frames were removed after an average of 3.6 months(range, 3–8 months). One patient had under correction of residualequinus, but all others achieved full correction of deformities.Complications included superficial pin site infection in nine pa-tients, talar subluxation in one patient, and subluxation of the firstmetatarsophalangeal joint in two patients. Infections were suc-cessfully treated with oral antibiotics. The one case of talar sub-luxation was reduced by the residual TSF program. Thesubluxated great toe was pinned in a separate surgery in two cases.

Conclusions: We believe that the Ponseti sequence of correction canbe applied to older children with residual clubfoot deformities evenif they have previously undergone surgery. Our method with theTSF is a safe, accurate (computer-based), and effective treatment.It does not require open surgery, so the potential for scarring isminimized. It also allows for any subsequent treatments as needed.

Significance: The Ponseti-inspired method of residual clubfootdeformity correction with the TSF is accurate and is a viablealternative to repeat open surgical procedures.

288

The Ponseti method for treatment of clubfoot. Review

of a 12 years experience

Author: Edilson Forlin (Brazil)

Co-Authors: Dulce Grimm (Brazil), Luiz Munhoz da Cunha(Brazil), Luis Munhoz da Rocha (Brazil)

Purpose: The Ponseti method for treatment of clubfoot has be-came widely used in the world. Except those from Iowa, most ofthe studies presented has a short follow-up. We start to use themethod in our hospital in 1993. Since then more than 200 patientswere treated. The goal of this study is to present the results,prognosis, problems and difficulties of the first years of the use ofthe method.

Methods: Criteria to be included in this study was idiopathicclubfoot treated from 1993 to 1999, age at the initial casting from0 to three months and a minimal follow-up of 3 years. Eight-onefeet in 49 patients were included. Thirty-one male and 18 female.Thirty-two patients had bilateral involvement. Achilles tenotomywas performed in 79 feet at mean of 10 weeks of casting. Castingpost tenotomy average 8 weeks. Ortosis used was Denis-Brownfor 19 patients, KAFO for 26 patients and none in four patients.Results were classified as: satisfactory (a plantigrade foot, neutralor external rotation alignment at gait, calcaneal aligment in neu-tral or valgus and a dorsal flexion of at least 15 degrees), unsat-isfactory when the foot had residual deformity and failure when aPML release was performed.

Results: The mean follow-up was 48,2 months (36 to 135 months).Final results showed 60 feet as satisfactory, from this group 8needed a limited release (seven transposition of tibialis anteriorand one posterior release), 10 as unsatisfactory and 11 as failure.Unsatisfactory result was related with bilateralism, under correc-tion at the time of the end of casting and with lower degree ofexternal rotation. Length of time using orthosis or its no use wasnot related with unsatisfactory result.

Conclusions: Our results on these initial series were inferior thosereported from Iowa. We believe that some changes of the methodwere related with the result. The position at the end of casting maybe the more important prognostic factor. At that time we hadsome difficult to accept some concepts as the tenotomy, limitedcasting (6 to 10 weeks) and observance to the external rotation. Amore recent series, following Ponsetis recommendation more re-strict, has been studied and presented better outcome.

Significance: As far as we know, our experience with the Ponsetimethod is one of the longest outside Iowa. The patients of thisseries were treated when the Ponsetis method was not so wellknown and accepted widely. This study demonstrated the prog-nostic importance of the position of the foot at the end of casting.To follow with attention the principle of the PonsetiAs method iscrucial for high quality of results.

289

Ultrasound examination of clubfoot in the Ponseti method


Co-Authors: Enrico Talenti (Italy), Sisto Turra (Italy)

Purpose: Critical decision in the Ponseti method is the selection ofthe clubfeet which needs Achilles tenotomy. Purpose of this studywas to determine if ultrasound assessment of clubfoot may behelpful in making surgical decision.

Methods: 98 newborns with 122 congenital clubfeet were treatedby the Ponseti casting technique from mid-2000 to June 2006.According to Manes classification, there were 20 mild, 47moderate and 55 severe clubfeet. After 3 to 8 weeks of casting,clubfeet candidate to surgery underwent sonographic assessmentaccording to the original technique previously published by theauthors. On the sagittal posterior plane the R.O.M. of theankle and subtalar joints was stated both in neutral position

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and under manipulation. No surgery was performed in clubfeetwith normal sonographic dorsiflexion, percutaneous tenotomywas done in clubfeet with mild limited sonographic dorsiflexionand more extensive posterior release (tendon Z-lengthening andposterior cut of ankle and subtalar joint) was performed inclubfeet with most evident sonographic persistent equinus andanterior dislodgment of the talus in the ankle mortise. TheR.O.M. was checked again by ultrasound at the end of treat-ment. According to Ponseti method a Denis Browne bar, withclubfoot 60� externally rotated, was worn full time until thewalking age.

Results: 35 /122 clubfeet (28,6%) were treated conservatively (allthe 20 mild and 15 / 47 of moderate deformities), 87 / 122 (71,4%)surgically (32/47 of moderate deformities and all the 55 severedeformities) . On the basis of the dynamic ultrasound evaluation38 clubfeet underwent simple tenotomy and 49 ones underwentextensive posterior release. At the end of the casting normaldorsiflexion was documented by ultrasound in 72 (82,7%) of theoperated feet.

Conclusions: The need of surgery in the Ponseti casting tech-nique shows a great variability in Literature. These controver-sial data are probably due to the different criteria used inevaluating the correction obtained by casting. Ultrasoundassessment of the deformity gives objective qualitative andquantitative information about the restoration of the physio-logical dorsiflexion and articular biomechanics. On the basis ofthis simple, non invasive and widely available procedure thesurgeon can evaluate the effectiveness of the serial casting andmay be able to establish and graduate the need of correctivesurgery.

Significance: To operate or not to operate the clubfoot at theend of the conservative treatment may be controversial. Thefinal decision is sometime subjective and related to the personalexperience and opinion of the paediatric orthopaedist. Ultra-sound dynamic examination allows to check the physiologicalbiomechanics of dorsiflexion and it was helpful in the selectionof the feet which need surgery to optimise the correctivetreatment.

290

Does the percutaneous Achilles tenotomy in clubfoot treatment

objectively modify the equinus immediately after the procedure ?

Author: Guy Grimard (Canada)

Co-Authors: Benoit Morin (Canada), MA Cantin (Canada),Morris Duhaime (Canada)

Purpose: Achilles tenotomy is generally required in the treatmentcourse of idiopathic clubfeet according to Ponseti technique. Thetenotomy is usually performed around the fifth week after thebeginning of treatment. However, no study has assessed its imme-diate effect on the tibio-calcaneal angle or the equinus. The purposeof this study was to determine the immediate effect of Achillestenotomy on the tibio-calcaneal (TC) tibio-foot (TF) angles.

Methods: This prospective study was carried out at Ste-JustineHospital at the clubfoot clinic between July 2005 and August2006. All patients with a diagnosis of idiopathic clubfoot werepotential candidates. After a minimum of four weeks of manip-ulation and serial casting, patients with a residual equinus or alack of ankle dorsal flexion that was filled to restrain theimprovement of correction received a percutaneous Achilles ten-otomy under local anesthesia. Before and immediately after thetenotomy, a lateral X-ray of the foot with maximal dorsal flexionof the ankle was obtained using a mini C-arm fluoroscope.Afterwards, the foot was placed in a long leg cast for 2 weeks. All

the X-ray images were stored on the PACS and measured by twoobservers. Two measures were assessed, the tibio-calcaneal andthe tibio-foot angles, respectively. A paired-t test was used tocompare the measures pre- and post-tenotomy.

Results: Thirty-four clubfeet (23 patients) were enrolled in thestudy. There were 17 males and 6 females. The right foot was in-volved 17 cases. The mean age at the tenotomy was50.7 ± 16.6 days. The mean pre- and post-tenotomy TC angle was83 ± 10 degrees and 66 ± 9 degrees, respectively (p < 0.001).The mean pre-tenotomy and post-tenotomy TF angle was 77 ± 10degrees and 60 ± 6 degrees, respectively (p < 0.001). No com-plications were associated with the tenotomy.

Conclusions: In conclusion, percutaneous Achilles tenotomy per-formed in the initial stage of the treatment of clubfeet immediatelyimproves the residual equinus in idiopathic clubfeet.

Significance: This study confirms objectively the positive effect ofthe percutaneous Achilles tenotomy early in the course of treat-ment of clubfeet and reinforces the necessity to perform it whenindicated.

291

Idiopathic Congenital Talipes Equino Varus: Predictors

of Outcome when using Ponseti Method

Author: Hatem Ahmed Kotb (Egypt)

Co-Authors:

Purpose: Identifying risk factors for poor outcome in the man-agement of idiopathic congenital talipes equino varus footdeformity using Ponsetti Method.

Methods: 198 feet of idiopathic congenital talipes equino varus footdeformity in 126 children, were treated using the Ponseti technique.They were followed up for a maximum of 36 months. Patient pre-natal, natal and family history were documented. Pre and postintervention morphologic measures were recorded. All cases hadthorough clinical examination to exclude cases other than idio-pathic congenital talipes equino varus, identified syndromes wereexcluded. Serial weekly plaster casting to correct cavus adducts andvarus, followed by heel cord tenotomy if needed. Then footabduction brace was used. Results were graded as fully planti-grade(good), not fully plantigrade (fair) and relapsed (poor).

Results: The mean follow up was 19.9 + 5 months, 14 children 22(11.1%) feet failed to show up at last follow up. Mean age atpresentation was 56 + 143.6 days (1 day to 4 years). 112 childrenwith 176 feet showed up at last follow up. 84 (75%)were males and28 were females 12.5% had a similar condition in the family,positive consanguinity was in 35.7%. 31.2% were delivered byCaesarian section. The average number of casts was 8.2 for eachfoot, 14 (7.9%) had no tenotomy, all feet were corrected. 22(12.5%) relapsed and recasted, 11 (6.2%) feet had retenotomies.In 18 (10.2%) feet (13 children) the parents refused the Ponsetimanagement and under went open surgical releases else were.21.4% of parents were compliant with abduction splint. In thesurgical group 3 feet (16.6%) had a good result, 11 (61.1%) fairand 4 feet (22.2%) poor, 1 (5.5%) foot had residual metatarsusadducts. In the Ponseti managed group of (158 feet), 95 feet(60.1%) were good, 54 feet (34.2%) were fair and 9 feet (5.7%)poor, 21 (13.3%) feet had residual metatarsus adducts. Caesariansection (p = 0.71), consanguinity (p = 0.864), positive familyhistory (p = 0.12), sidedness (p = 0.12) and age at presentation(p = 0.52) had no bearing on results. Equinus angle of 50 or morecarries 20 % relapse angel more than 60 bears a 66.6% chance ofrelapse. The predictive ability of these cut points have a sensitivityof 84.7 and specificity of 100%.

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Conclusions: Parents’ compliance and devotion is a key factor forthe successes of the technique. Significant bad prognostic factorswere found to be; non compliance of parents (p = 0.000), opensurgical release (p = 0.001), maternal illiteracy (p = 0.028), malegender (p = 0.031).

Significance: Significant bad prognostic factors were found to be;non compliance of parents (p = 0.000), open surgical release(p = 0.001), maternal illiteracy (p = 0.028), male gender(p = 0.031).

292

A Prospective study of surgical management

of club foot – Comparision between suturing

vs non-suturing of ‘Z’ plasty tendons

Author: Durga N Kowtharapu (India)

Co-Authors: Rajasekaran S (India), Ajoy P (India)

Purpose: Recurrence is one of the common problems afterclubfoot surgery. It is mainly due to contracture and tetheringof tendons that may be due to suturing tendons tightly at thetime of surgery. We report here a prospective comparativestudy to verify the outcome of two groups, one in which thetendons were sutured and in other tendons were not suturedafter ‘Z’ plasty lengthening.

Methods: 42 children with 65 clubfeet with an average age of6.2 months (range3–10 months) were treated by Modified TurcoPosteromedial soft tissue release & Steindler’s procedure. Theywere divided into Group A (right sided clubfeet n = 37) andGroup B (left sided clubfeet n = 28) and evaluated at an averageof 20 months(range 8–30 months).In Group A tendons werealigned side by side after ‘Z’ plasty, but not sutured. Where as inGroup B they were sutured at appropriate length.

Results: Results in both groups were evaluated preoperatively andpostoperatively by DIMEGLIO 20 point scoring system. Preoper-atively equines (score 2.77,2.79), was the severe deformity followedby adduction (score 2.26,2.25),varus (score2.07,2.08) and calca-neoforefoot rotation (score1.68,1.67) in Group A&B respectively.Average preoperative scores in Group A&B were 10.72 and 10.70.Postoperative scores were 3.8&3.7 respectively. Postoperativelyequinus (Score0.57&0.55) had the best outcome followed byadduction (1.05&1.08), varus (Score1.09&1.11) and calcaneofore-foot rotation (0.91&0.92).There is no significant difference in out-come between the two groups.

Conclusions: This study showed at the end of 20 months there is nosignificant difference in functional and cosmetic outcome by eithersuturing or not suturing the tendons. However, long term follow upis necessary to identify any difference in the recurrence rate.

Significance: There is no significant difference in outcome betweenthe two groups (P < 0.05).

293

Outcome of the Treatment of Relapsed Talipes Equinovarus

Using the Ilizarov External Fixator


Co-Authors: Sally Pollock (United Kingdom), Anthony Caterrall(United Kingdom), Fulvio Franceschi (Italy), Deborah Eastwood(United Kingdom)

Purpose: The Ilizarov external fixator has theoretical advantagesover conventional revision surgery for the treatment of recurrentclubfoot deformity where scarred tissue planes, abnormal anat-omy and impairment of local blood supply are common. This

paper assesses the outcome of treatment of recurrent club-footdeformity using this device.

Methods: The study evaluated Ilizarov external fixator correctionof 40 feet in 31 patients. Deformity was idiopathic in 29 patients,associated with constriction bands in 6 patients and was syndro-mic or associated with a defined neuromuscular disorder in 6patients. Patients were reviewed clinically and completed ques-tionnaires documenting pain, function and satisfaction before andafter treatment at a mean follow-up of 44 months (range 14–131).All patient’s notes and radiographs were examined.

Results: Pain and function scores after treatment improved in67% and 72% of cases respectively. A subjective increase instiffness was noted in 46%. Patient satisfaction with outcome was61%, correlating with improved pain and function scores. Painand function scores were not significantly different in stiff versusnon-stiff feet. The overall recurrence rate was 44%, and washighest in the idiopathic group (59%) compared with the con-striction band group (17%) and the neuromuscular/syndromicgroup (0%). Feet with recurrent deformity had been treated withthe Ilizarov fixator at a younger mean age (7.8 years) than thosefeet which did not recur (mean age 12.6 years). 71% of recur-rences experienced significant pain post treatment, compared withonly 36% of those feet where deformity did not recur. Functionalability was, however, similar in the two groups. Further surgicaltreatment has been necessary in 6 patients, including 4 furtherIlizarov frames. Complications included almost universal minorpin-site infections, flexion contractures of the toes in 5 feet andskin ulceration in 2 feet, 1 requiring a muscle flap.

Conclusions: Treatment of relapsed clubfoot with the Ilizarovfixator can improve the appearance of the foot, correlating withimprovement in pain, function and patient satisfaction. This mustbe balanced however against a high recurrence rate, particularly inyoung idiopathic feet, an increase in stiffness of the ankle, whichhas implications for future surgery, and the risk of complicationsinherent in the technique.

Significance: This paper demonstrates that the Ilizarov device canbe used successfully in the management of severe recurrent talipesequinovarus. There is however a significant rate of recurrenceparticularly if treatment is necessary under ten years of age.

294

Percutaneous section of the calcaneal tendon with a needle

for correction of the residual equinus of clubfoot. Assessment

of the technique and reparative process with ultrasound.


Co-Authors: Daniel Leal (Brazil), Frederico Gatti (Brazil), DanielMaranho (Brazil)

Purpose: To evaluate the technique of division of the calcanealtendon with a needle inserted percutaneously for the treatment ofresidual equinus of clubfoot.

Methods: Sixteen tenotomies were prospectively analyzed in 13patients with clubfoot treated by the Ponseti technique. Thetenotomy was performed percutaneously, under local anesthetic,with a 16 gauge needle and ultrasonographic image wasobtained immediately to assure that a complete section wasachieved and to measure the gap between the two tendonstumps. The following repairing process was followed up withultrasound examinations performed at three weeks and sixmonths after the tenotomy.

Results: The ultrasonography showed that the tenotomy wascomplete in all but two cases which were completed soon after-wards under ultrasound visualization. One case showed bleedingthat was controlled with local pressure. The mean stump gap

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shortly after the tenotomy was 5.2 mm (3.0 – 9.09 mm). Threeweeks later, the gap was filled with hypoecoic tissue andmechanical continuity was observed with muscular movementstransmitted from the calf to the heel. At six months in all but onecase, the ultra-sound appearance of the lengthened part wassimilar to the neighbor normal tendon.

Conclusions: The percutaneous section of the Achilles tendon witha needle proved to be an effective method, with no major compli-cations, but ultrasound examination was important to assure thatthe tenotomy was really completed. There was a complete repair ofthe lengthened tendon with normal tissue within six months.

Significance: Percutaneous tenotomy with a needle, theoretically,decreases morbidity and ultrasound examination assures that acomplete division has been achieved.

295

Use of the longitudinal osteotomy of the talus in treating

the recurrent clubfoot in a developing country.

Author: Kaye Evan Wilkins (United States)

Co-Authors: Idgie Garnier-Kenol (Haiti)

Purpose: In many developing nations clubfeet are still managedprimarily surgically with variations of the standard posteriormedial release. Unfortunately, for a variety of reasons there is ahigh rate of recurrence. In countries with limited medicalresources repeat soft tissue releases can be difficult because of thescar formation from the old surgery. In the past 20 years thesenior author has modified the Veribeli-Ogston procedure to cre-ate a horizontal lateral based closing wedge osteotomy of the talusto obtain a correction of the equinovarus thus avoiding operatingthrough the old medial scar. The purpose of this review is todemonstrate that the longitudinal osteotomy of the talus can begood alternative to correct hind foot varus in children that areolder than 3 years of age in neglected or recurrent clubfoot incountries with limited surgical resources.

Methods: In the past five years 20 patients over 3 years of agewho had this procedure in a nation in the Caribbean werereviewed. Nine had undergone prior soft tissue releases. Eleven hadthe longitudinal osteotomy of the talus as their primary procedurebypassing the usual soft tissue release. Of those with the primaryosteotomy, two had a concurrent soft tissue release. To correct theforefoot adduction,18 underwent had a concurrent anterior cal-caneal osteotomy (Litchblau or Evans). In three patients, a distaltibial osteotomy was needed to complete the correction.

Results: There were 10 males and 10 females. All the cases exceptone who failed to return were seen in follow-up. At follow-up allthe patients had a plantigrade foot. In some of the cases theprimary longitudinal osteotomy provided an incomplete correc-tion. In these cases an adequate correction was achieved witheither a repeat longitudinal osteotomy or decancellation of thetalus. An anterior closing wedge osteotomy of the distal tibialmetaphysis was needed in three cases to correct the residualequinus.

Conclusions: Talus longitudinal osteotomy does correct the varusof a hind foot and is a good alternative for clubfoot children olderthan 3 years old that can’t have a triple arthrodesis.

Significance:

1. The longitudinal osteotomy talus is good procedure to obtain afunctional plantigrade foot following a failed primary soft tissuerelease.

2. In there is a recurrence, the osteotomy of the talus can be re-peated,

3. To prevent any recurrences, it is important that al the muscleforces be balanced.

296

An alternative orthosis to prevent relapse of the Clubfoot

Deformity after correction with the Ponseti Method

Author: Timur Yildirim (Turkey)

Co-Authors: Aysegul Bursali (Turkey), Sukru Gursu (Turkey),Bahattin Aydin (Turkey), Semih Ayanoglu (Turkey)

Purpose: It’s essential to use an abduction orthosis after clubfootcorrection with the Ponseti method. The Dennis-Brown bar is themost commonly used device for this purpose. However in somecases it’s not possible to use this bar. In this study we aimed topresent an alternative device to be used in cases where Dennis-Brown bar is not suitable.

Methods: Among our 167 patients with clubfoot deformity, all ofwhom were treated with the Ponseti method, 14 (8.3%) were notsuitable candidates for using the Dennis-Brown device because ofnon-compliance. 12 of these patients were male, 2 were femalewith a mean age of 4,5 months at presentation (between 11 daysand 14 months). 6 of these patients had bilateral clubfeet and 8had unilateral (20 clubfeet). Mean period of follow up was17 months (6–47 months). 8 patients had previous history oftreatments other then the Ponseti method. The number of thecasts used for the correction of the deformity was in average 5.3.10 of the patients underwent percutaneus achilles tenotomy underlocal anesthesia. The device we used is originally designed forcorrecting metatarsus adductus deformity. It’s made up of 2 piecesand has a calcaneal support, which is our modification, attachedto it. It provides external rotation of the knees and the feet arekept in abduction.

Results: The device is used for 14 patients. 10 patients were giventhis device because they couldn’t tolerate using the Dennis-Brownbar. 2 had very fat feet so that they could not wear shoes. 1 ofthem was very small (11 days old at presentation) and fitting shoescould not be made for his feet. The last child to use this device hada rudimentary left leg and a right clubfoot. Non of the familiesreported non-compliance with this device. Complications such ascontractures, decrease in the range of motion in any jointsdepending on the device were not seen. No patient has recurrentdeformity up to date.

Conclusions: Bracing after correction of clubfoot deformity with thePonseti method is a necessity. But as explained in some cases thismight be a problem because of the non-compliance with theDennis-Brown bar. In such cases this device could be used successfuly.

Significance: Clinical Study.

Trauma - Upper limb

297

The advantages of posterior approach for paediatric

supracondylar humerus fractures: easy reduction, short

operation time

Author: Ismail Demirkale (Turkey)

Co-Authors: Mahmut Ugurlu (Turkey), Osman Tecimel (Turkey),Metin Dogan (Turkey), Tughan Kalkan (Turkey), Murat Bozkurt(Turkey), Nihat Tosun (Turkey)

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Purpose: Nearly 60% of all elbow fractures at the paediatric age issupracondylar humerus fractures. Susceptibility to the traumaincreases because of the decreasing thickness of osseous structureat the anterior-posterior plane between 5–8 years of age. In thisstudy we discussed the importance of posterior approach fort thereduction and fixation of the fractures.

Methods: We assessed the comparison of lateral and posteriorapproaches that were established to 32 extension type Gartlandtype 3 supracondylar humerus fractures between November 2005– August 2006. Posterior and lateral approaches were applied to16 patients per group. After removal of the pins, elbow range ofmotion at the first and second months and the extension strengthat the posterior approach group were examined.

Results: No difference was found between the posterior andlateral group for the extension strength and elbow range ofmotion at the end of second month. Also we evaluated theusage of posterior approach and the operation times. Meanoperation time was shorter and reduction was easier in the pos-terior group.

Conclusions: Posterior approach towards the lateral one used forthe treatment of paediatric age supracondylar humerus fracturesdoesn’t cause secondary loss of neither ROM nor extensionstrength. However this exposure has an advantage of easyreduction and shorter operation time.

Significance: The reduction is easier and more visible by posteriorapproach at paediatric supracondylar humerus fractures.

298

Post-traumatic wrist epiphysiodesis

Author: Alain Dimeglio (France)

Co-Authors: Djamel Louahem (France), Joseph Habanbo(Lebanon)

Purpose: Distal radial growth arrest is related to many factors,including the severity of trauma, degree of displacement, repeatedand delayed manipulation, and repeated drilling.With radialphyseal closure and ulnar overgrowth, a wrist deformity mayappear. The purpose of this study was to evaluate the consequenceof wrist physeal fractures and the results of correction osteoto-mies.

Methods: this is s retrospective study on 10700 fractures betweenthe years 1994 and 2005.the average age was 12.6 years. 610patients had physeal fractures of the distal radius. Eight caseswere complicated by epiphysiodesis (6 closed radial Salter IIfractures, 1 closed Salter III fracture and 1 open Salter I frac-ture). Four patients were treated with open-wedge osteotomy ofthe distal radius associated with ulnar shortening, two patientshad ulnar shortening, one patient had ulnar shortening withepiphysiodesis of the distal end of the ulna, and one epiphysio-desis of the of the distal end of the ulna.The mean follow-up was3.2 years.

Results: Growth arrest of the distal radius occurred only in 1.31%of cases. Diagnosis was made about 1.7 years after injury. Theaverage radio-ulnar index was +10 mm. 50% of results weregood, 37% were excellent and 13% unsatisfactory. The averageR.O.M (palmar flexion and dorsiflexion) was 116�. All of ourpatients had a good cosmetic appearance of the wrist after thesurgical treatment.

Conclusions: Post-traumatic disorders of growth plates can affectthe biomechanics of the wrist. However, the risk of epiphysiodesisis not high, it was 1.31% in our experience. Children with physealfractures of the wrist should be radiographed every 3–6 months

for signs of a bony bridge. CT scan and MRI are helpful to de-scribe the site and the extent of the lesion. Treatment of a growtharrest of the distal radius may require an epiphyseodesis of thedistal ulna if significant malalignement of the distal radial jointsurface has occurred, ulnar shortening may be added if theremaining growth is important.

Significance: this is a retrospective study conducted at our insti-tution.

299

A Novel Innovative Technique of pin passage and construct

in the treatment of Gartland’s extension type 3 Supracondylar

Fracture Humerus in Children

Author: Nanjundappa Somasekhar Harshavardhana (UnitedKingdom)

Co-Authors: Samir Pilankar (India), Anil Karkhanis (India),Nilesh Patil (India), Vaibhav Bagaria (India), Vikram Sapre(India), Manish Lambat (India), Ravi Bharadwaj (India), AjaySahu (India)

Purpose: Elimination of Iatrogenic Ulnar N palsy by our newinnovative method.

Methods: We conducted a prospective study (19 cases) ofGartland’s extension type 3 supracondylar humerus fractures.Good reduction was achieved with closed reduction in 16 whileopen reduction was required in 3 cases. Our new techniqueinvolved passing two 1.6 mm smooth Kirschner wires superiorlyfrom the lateral condyle at an angle of 30 degrees to thehumeral axis across the fracture site to obtain purchase in themedial cortex. A 3rd K wire was passed from the lateral su-pracondylar pillar proximal to the fracture site in a downwarddirection to gain purchase in the subchondral bone of themedial condyle under image intensifier. Care was taken not tobreach the subchondral bone so as to avoid ulnar nerve injury.Reduction and position of the wires was once again confirmedand stability was checked by rotation in real time imaging.Average age of study population was 7.1 years. On an averagesurgery was undertaken within 25 hours of sustaining fracture.The timing of K wire removal was 3 weeks post operatively inclosed pinning and 5 weeks following open reduction. All thepatients were operated under GA in supine. Lateral approachwas employed by the same pin construct in cases which re-quired open reduction. We favor lateral approach as it isthrough intermuscular planes, avoid postoperative stiffness andneed to change the patient position. Above elbow plaster splintwas applied for a period of 3 weeks, at the end of which activeassisted mobilization was started. Post-operatively these patientswere examined on 5th day, 3rd & 6th weeks and at 3 monthsfor assessment of nerve injury, stiffness, deformity, elbow rangeof motion. Wires were removed on the appearance of callusradiologically (3 weeks for closed pinning and 5 weeks for openpinning).

Results: Patients were assessed on the basis of Flynn’s stringentcriteria. Flynn’s criteria takes into consideration both the factorsi.e. loss of carrying angle and range of motion. 16 cases hadexcellent results while 3 patients had good results. None of thecases had fair or poor outcome. Patients were followed for a meanof 11 weeks. None of them had any post-operative nerve palsy,pin tract infection or loss of reduction, cubitus varus or hyper-extension deformity.

Conclusions: Various studies state the risk of ulnar neuropraxia tobe 3% to 5% by medial percutaneous pin passage. To avoid thisiatrogenic ulnar nerve palsy, lateral pin constructs have been usedat the cost of compromising fracture stability. Our new innovative

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technique represents a good option providing the biomechanicaladvantages of cross wiring and eliminating the risk of iatrogeniculnar nerve paresis.

Significance: We recommend our new innovative technique as asound & safe option for the treatment of type 3 displaced su-pracondylar humeral fractures.

300

Fracture Dislocation of the Distal Humeral Physis

in the Newborn Sustained at Delivery

Author: F. Stig Jacobsen (United States)

Co-Authors: Goran Hansson (Sweden), Johan Nathorst-Westfelt(Sweden), Mats Jonsson (Sweden)

Purpose: Fracture dislocation of the distal humeral physis is a rarefracture usually seen after birth trauma or child abuse. The frac-ture is often over-looked. Its treatment is controversial going fromclosed reduction to open reduction and pinning and can causevarus deformity in up to one-third of the cases. The purpose ofthis study is to define the complication and treatment in thefracture sustained after birth injury.

Methods: Six patients presented with severely displaced distalhumeral fractures after difficult deliveries, which is the largestseries published. Only three out of six were referred with thecorrect diagnosis. Further, MRI, ultrasound and arthrogram weredone in five of the six patients. Three patients presented late andwere casted in flexion and pronation while the other three hadclosed reduction and casting without pinning.

Results: At followup (1–10 years) all patients had a normal rangeof motion and five of the six had a normal carrying angle. Onepatient with only one year followup had 10 degrees of varusdeformity.

Conclusions: Closed reduction and casting seem to be sufficienttreatment, even in fractures with significant displacement afterreduction.

Significance: Guidelines for the treatment of displaced distalhumeral physis fracture in the newborn vary in the literature. Wedid not find any indication for open treatment or pinning of thisfracture.

301

Iatrogenic ulnar nerve injuries after supracondylar humeral

fractures treated with closed reduction and percutaneous pinning

Author: Onder Kalenderer (Turkey)

Co-Authors: Levent Surer (Turkey), Ali Reisoglu (Turkey), HalukAgus (Turkey)

Purpose: The purpose of this study was to assess the iatrogeniculnar nerve injuries after supracondylar humeral fractures treatedwith closed reduction and percutaneous pinning in the largestseries published.

Methods: The series consisted of 473 children with supracondylarhumeral fractures. There were 371 patients at Gartland type IIIfractures, the remaining 102 had type II. All patients were treatedclosed reduction and percutaneous pinning. Neurological exami-nation performed immediately after the operation revealed 25ulnar nerve injuries (5.2%) in patients who had completely normalneurological findings in the preoperative period. Electromyo-graphic examinations were performed at 6 and 12 weeks postop-eratively in patient with ulnar nerve lesions. Presence of ulnarnerve palsy did not affect the postoperative regimen at the pins

were removed when the solid union was observed in plain radio-grams, that was 4–6 weeks as in patients without nerve lesions.

Results: All but three of the 25 were followed up. The mean agewas 6 years (4–8). The mean hospitalization time was 2 days andthe mean follow-up time was 30.8 months (17–63). All patientswith electromyogram showed partial denervation and conductionblocks at the elbow in 6 weeks. Regenerative electromyogramfindings were determined in 12 weeks. Sensorial function of allpatients had return average 2 months (1–4) while motor functionhad return average 5.4 months (1–7). All patients had completereturn of nerve function and full motion in their elbows.

Conclusions: We observed ulnar nerve paralysis in 25 of 473 cases,that means a 5.2 % rate of injury and that is comparable withmost of the series in the literature. Ulnar nerve injury followingpercutaneous fixation of supracondylar humeral fractures seemsto be the major complication. But all iatrogenic ulnar nerveinjuries were resolved spontaneously by time and closed reductionand percutaneous fixation is a safe and reliable methods in thesefractures.

Significance: Iatrogenic ulnar nerve injuries is the most importantcomplication in supracondylar humerus fractures treated withclosed reduction and percutaneous pinning and this problem wasresolved spontaneously.

302

Metacarpophalangeal joint dislocation of the thumb in children


Co-Authors: Himanshu Sharma (United Kingdom), RoderickDuncan (United Kingdom)

Purpose: The thumb metacarpophalangeal (MCP) joint disloca-tions in children are uncommon injuries and scarcely reported inthe English literature. The aim of this study was to report thedemographics, clinical course and outcome of a large series oftraumatic dislocations of the thumb MCP joints in children and tocorrelate the radiological pattern with the type of dislocation.

Methods: We retrospectively reviewed a cohort of 37 childrentreated during a fifteen year period. Details were obtained fromdepartmental database, case notes and radiographs. The meanfollow up was 6 weeks.

Results: The mean age at injury was 7.3 years. 33 out of 37underwent closed reduction (a third under a GA ). 4 patientsneeded open reduction. All patients undergoing open reductionhad 1 to 4 unsuccessful closed reduction attempts. 2 of the 4 openreductions revealed soft tissue interposition. All gained a goodresult. There was no infection, recurrent dislocation or grossstiffness.

Conclusions: Thumb MCP dislocations in children are mostlydorsal (97.2%) and majority of them are managed non opera-tively, with excellent outcome. Irreducible dislocations may needopen reduction due to volar plate and other soft tissue interpo-sition. The so called ‘simple complete’ dislocations may presentwith the classical radiological finding of the joint at 90 degreesdorsal angulation but may require open reduction and mayactually be ‘complex complete’ injuries.

Significance: The significance of this study, which is to report thelargest series, to our knowledge, of the metacarpophalangeal jointdislocation of the thumb in children is to understand that theradiological presentation of these injuries does not always followthe traditional classification system and the surgeon must bearthat in mind while reducing these dislocations by closed or opentechniques.

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303

Lateral humeral condyle fractures in children:

a comparative cohort study of screws versus k-wires


Co-Authors: Himanshu Sharma (United Kingdom), Neil Wilson(United Kingdom)

Purpose: There remains little evidence in literature to discernwhether K-wires or screws have different outcomes in the man-agement of lateral condylar mass (LCM) fractures in children. Wepresent a large series of 77 displaced (Jacob types II and III)fractures of the lateral humeral condyle in 77 children in order toinfer the relative benefit of one mode of fixation over another.

Methods: Between 1990 and 2005, we identified 77 children withLateral Condyle fractures in the departmental database whounderwent operative management. Information was collectedfrom theatre-charts, casenotes and radiographs. We analyseddemographic data, fracture features, treatment modalities, com-plications, and clinical and radiographic results. We excluded allcomplex LCM associated with elbow dislocations, olecranonfractures and bi-condylar fractures. The mean follow-up was5.3 months (range, 6 weeks to 3 years).

Results: We reviewed the results of screw osteosynthesis (n = 44)versus K-wire (incl.cross wires or 2 lateral wires, n = 33) at anaverage age of 5.3 years (range, 8 months to 10.9 years). Therewere 49 boys and 28 girls. The average interval between the injuryand the operation was 1.6 days (injury-surgery interval). The meanduration of implant removal was 3.6 weeks for K-wires (removedwithout anaesthesia) and 20.7 weeks for screws (removed undergeneral anaesthesia). There was no non-union in this series.Superficial wound infection (all K-wires) was found in three pa-tients, which completely settled with oral antibiotic therapy. Noinfection was found with screw fixation. There was one delayedunion in each group. One patient had cubitus varus(mild degree) ineach group and an additional cubitus valgus in one(screw), whichrequired a corrective osteotomy. Loss of range of motion of 10–50(mean 22 degrees.) degrees was found in 6 cases (3 in each group).

Conclusions: Based on our observations, we believe that K-wirefixation has comparatively similar final outcome to screw fixation.Screw necessitates a second procedure for removal under Generalanaesthetic, while K-wires are removed in the pin clinic butK-wires have increased risk of superficial infection.

Significance: In our study we have found no significant differencein the final outcome of the screw versus K-wire technique of fix-ation of lateral condyle fractures in children.

304

Neonatal brachial plexus palsy - incidence and risk factor

analysis from United States national databases

Author: Charles Mehlman (United States)

Co-Authors: Susan Foad (United States), Jun Ying (UnitedStates), Linda Michaud (United States)

Purpose: The purpose of this study was to analyze a large nationalpediatric database regarding the incidence of neonatal brachialplexus palsy (NBPP) as well as its potential risk factors.

Methods: The 1997, 2000, and 2003 Health Care UtilizationProject (HCUP) databases were analyzed relative to NBPP (ICD-9 767.6). Weighted estimates and multivariate logistic regressionmodels were used to assess incidence and risk factor relationships.Data were derived and reported via combining all three databases,accounting for discharge data on over 2 ¼ million children.

Results: An overall incidence of 1.5 cases (1.51 +/– 0.02) per 1,000live births was noted. Multivariate analysis revealed that severaldemographic factors to be significantly (p < 0.001) associatedwith an increased risk ofNBPP including race / ethnicity ofAfrican-American or Hispanic, delivery at a teaching hospital, and femalesex. Asian race/ethnicity was found to be significantly (p < 0.001)associated with a lower risk of NBPP. Clinical factors significantly(p < 0.001) associated with an increased risk of NBPP includedassisted delivery (e.g. forceps), shoulder dystocia, macrosomia(> 4.5 g), and neonates with major complications.

Conclusions: T7he incidence of NBPP in the United States is 1.5per 1,000 and reliable pre-delivery predictors of NBPP need to bedeveloped.

Significance: The incidence on NBPP has remained remarkablystable over many decades. Our study reconfirms several wellknown clinical risk factors and introduces some new demographicones (race, sex, hospital type). None of the clinical risk factors canbe reliably identified prior to delivery.

305

Active mobilization programme after flexor tendon repair

in children and adolescents

Author: Aarno Nietosvaara (Finland)

Co-Authors: Nina Lindfors (Finland), Nadja Ristaniemi(Finland), Sanna Rautakorpi (Finland)

Purpose

Hypothesis: active motion programme after multistrand flexortendon repair in children results in good final outcome.

Methods: 25 flexor tendon lacerations involving 17 fingers in 10consecutive children (7–14 years of age) were repaired. Repair wasperformed with pull-out sutures in two zone 1 injuries. In eightzone 2, two zone 3 and eleven zone 5 tendon injuries a four- or six-strand core suture was used. A thermoplastic splint was applied 1–3 days post-operatively for 6 weeks. Active exercises were per-formed four times a day without the splint. An ergo therapistfollowed up all patients at 1, 3, 5 and 7 weeks. Range of motion(ROM) of the wrist and finger joints as well as grip strength wererecorded at a mean 38 months (12–53) after the injury.

Results: There were no infections nor failures of the tendon repairs.Mean ROM of the DIP-joint (60�, range 40�–90�) after zone 2injuries was lower compared to injuries outside zone 2 (82�, range65�–90�). ROM of PIP-, MP- and wrist joints were restored tonormal. Functional outcome was good or excellent in all fingersusing ASSH (5/17 excellent), Buck-Gramcko (13/17 excellent), andrevised Strickland (16/17 excellent) evaluation systems. Mean gripstrength ratio of the injured vs. uninjured hand was 1 (0.9–1.2).

Conclusions: Active mobilization programme is an effective, sim-ple, patient- and therapist friendly technique for mobilizationafter multistrand flexor tendon repair at all levels in children over6 years of age.

Significance: Flexor tendon injuries in school age children can bereliably treated with a simple active mobilization programme withgood functional outcome.

306

Forearm Fascial Strip for Repair of the Annular Ligament

for Late Diagnosis and Failed Closed Reduction of Monteggia

Fractures in Children

Author: Curtis Alexander Robb (United Kingdom)

Co-Authors: Chris Bradish (United Kingdom), Xiao-Dong Wang(China)

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Purpose: To report the use of forearm fascial strip for repairingthe annular ligament in the treatment of late diagnosed and irre-ducible Monteggia fracture.

Methods: Nineteen patients with Monteggia fractures of BadoType I and Type II were treated with a technique using forearmfascia. 1 Approach; we adopted the Boyd’s approach to expose theproximal forearm fascia. 2 The width of the fascial strip is 1.5 cmand length of 6–7 cm, determined precisely following opening thelateral capsule of the joint. 3 The proximal fascia retains itsattachment to the ulna. 4 The radial head is dislocated and thenthe strip is wound around the neck of the radius and the radialhead reduced. Forearm rotation is checked to determine there isno tissue blocking the radioulnar joint. The strip is sutured to theresidual annular ligament in the proximal ulna after correction ofany ulna deformity. Once the ulna is stabilized, the stability of theradial head is assessed using intra-operative fluoroscopy 5. Man-agement of the deformity of the ulna: (not normally required witha fresh fracture) with late diagnosis, ulna lengthening of approx-imately 0.5 cm and stabilization with 4 or 5 hole semitubular AOplate. 6 Six weeks in a posterior long arm splint with the elbowimmobilized in 90� of flexion and full supination for Types I, TypeII are splinted in the same manner in 70� flexion to prevent radialhead subluxation.

Results: Stability of the radial head was achieved in all cases.According to the Anderson classification the final outcome wasExcellent (less than 10� loss of elbow and wrist flexion/extension)in ten cases (fresh fractures: six; late diagnosis: four); Satisfactory(less than 20� loss of elbow or wrist flexion/extension, less than50% loss of forearm rotation) in eight cases (fresh fractures: two;late diagnosis: six); Unsatisfactory (more than 30� loss of elbow orwrist flexion/extension, greater than 50% loss of forearm rotation)in one late diagnosed patient associated radioulnar synostosisafter recovery of compartment syndrome. There were no failures.Two radiocapitellar K-wires broke while in plaster in the initialperiod using this technique, subsequently the use of a K wire wasabandoned.

Conclusions: The length of the incision is less than that requiredfor the Bell Tawse (triceps tendon) technique and permits atourniquet on the upper arm. It is crucial to use an image inten-sifier to verify anatomic fracture reduction and reduction of theradiohumeroulnar joint. Poorer results were achieved with delayin diagnosis beyond 6 months. From our clinical experiencehowever it is still worthwhile reducing the radial head to preventfuture problems with growth.

Significance: We have found this technique to be reliable for sta-bilizing the proximal radioulnar joint but patients must be warnedof potential reduction of forearm rotation.

307

The use of nerve stimulation during percutaneous pinning

of supracondylar fractures in children.

Author: Haim Shtarker (Israel)

Co-Authors: Gershon Volpin (Israel), Oleg Popov (Israel), RiadDakwar (Israel)

Purpose: Injury to the ulnar nerve from the medial pin is the majorconcern during percutaneous pinning for supracondylar fractures.The incidence is estimated to be 2% to 3%. Fixation of suprac-ondylar fractures by 2 lateral pins doesn’t provide enough stabilityand sometime may not prevent secondary displacement of thefracture fragments especially rotation. Soft tissue edema orexcessive mobility of ulnar nerve may be predisposing factors foriatrogenic ulnar nerve injury.

Methods: During last three years 81 children with supracondylarfractures were operated in our department. Before use of nervestimulator, we avoided applying medial pins especially in caseswith swelling around the elbow. In all cases we used nerve stim-ulator permanently connected to pin during all time of wireinsertion. In order to produce permanent monitoring of ulnarnerve during fixation, changes in setting of stimulator were made.There were 67 children with extension type of supracondylarfracture and 14 with flexion type. Average age of the patients was5.3 years (range 3–9 years). Four of 81 fractures were open su-pracondylar fractures. Closed reduction and percutaneous KWfixation by 2 or 3 pins were performed. The pin mounting was: 1medial and 1 lateral pins or 1 medial and 2 lateral pins. In 77 casesof irritation of ulnar nerve, clear muscular contractions wereobserved and place of pin insertion was carefully established. Itwo children irritation of nerve was not found and explorationwas necessary. One child had radial nerve neuropraxy in additionto ulnar palsy. In this case closed reduction with KW fixationwasperformed and during 4 months the neuropraxy recovered with-out additional interventions. In one case brachial artery was dis-rupted. The child underwent open reduction, vascular repair andnerve exploration.

Results: In all cases anatomic reduction was achieved. No cases ofnerve or vascular injury were observed in cases with clear nerveirritation (77/81).No cases of secondary fracture displacement werenoted. All fractures healed in desirable position. In 4 cases mal-alignment due to partial growth arrest was observed in follow up.

Conclusions: Changes in original setting of standard anesthesiol-ogy nerve stimulator may be performed easy in each hospital. Useof this device is very simple, even in cases of emergency.

Significance: The monitoring of ulnar nerve by nerve stimulator isreliable and makes insertion of wires secure.

308

Comparison of intramedullary nailing to plating for forearm

fractures in children ages 10–16 years.

Author: Roger Fanklin Widmann (United States)

Co-Authors: Daniel Green, MD (United States), Keith Reinhardt,BS (United States), David Feldman, MD (United States), DavidScher, MD (United States)

Purpose: To compare radiographic and functional outcomes ofintramedullary nailing versus plating of forearm fractures inchildren between 10 and 16 years of age.

Methods: 31 patients who underwent operative fixation of mid-shaft radius and ulna fractures were divided into nailing andplating groups, and compared retrospectively according to peri-operative data and outcome measures (union at 3 and 6 months,loss of forearm rotation, restoration of radial bow magnitude andlocation, and complications).

Results: The nailing group had 19 patients, mean age 12.5 years(range 10–14.6), and the plating group had 12, mean age 14.5 years(range 11.9–16). Groups were similar for gender, arm injured,fracture location, AO/OTA classification, and number of openfractures. Duration of surgery and tourniquet use were significantlyshorter in the nailing group. No differences were found between thegroups for union at 3 or 6 months. At latest follow-up, radial bowmagnitude was similar for the two groups and restored to normal inboth. Radial bow location in the nailing group was significantlydifferent than reported normal values (p = 0.007). Despite this,there was no difference in forearm rotation between groups.Complication rates were also similar between groups.

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Conclusions: There were no significant differences between groupsfor healing or magnitude of radial bow. There was a difference inlocation of maximal radial bow, with no effect on forearm rota-tion. Based on similar functional and radiographic outcomes withnailing and plating, the operative technique in children 10 to16 years old can be chosen based upon fracture characteristics andsurgeon preference.

Significance: This study suggests that there is no objective evidencesupporting either operative method, when comparing nailing toplating. Decisions regarding operative fixation can be made basedon surgeon preference.

Trauma - Lower limb

309

Shortening after elastic intramedullary nailing of femoral

fractures. Clinical study of a locking system with end caps.

Author: Jean-Michel Clavert (France)

Co-Authors: Theddy Slongo (Switzerland), James Hunter (UnitedKingdom), Richard Reynolds (United States), WolfgangSchlickewei (Germany)

Purpose: Shortening after elastic intramedullary nailing of femo-ral fractures is a rare but recognised complication when treatingunstable fractures. Shortening can be of several centimetres andneeds a change in the technique of osteosynthesis (external fixa-tion). Several methods of locking the elastic nails were biome-chanically studied and finally it was the use of a threaded cap overthe end of the nail that gave a sufficient mechanical stability andthe most convenient implantation technique. End caps avoid alsothe usual conflict between the rough cut nail and the skin.

Methods: After a standard elastic nailing of a femoral shaft frac-ture, nails are implanted as high as possible to have a good cor-tical contact . Nails are cut and the bevelled hollow tamp is used,such that 8 to 10 mm protrude to fit the internal dimensions of theend cap. The diameter of the holes in the distal metaphysis of thefemur is not crucial because the nails make firm contact withthe distal part of the hole and the locking effect is obtained mostlyby the thread of the end cap on this part of the hole. The threadedend cap is implanted over each nail end using a custom driver. Thepurposes of the locking system are to maintain femoral lengthduring healing, to protect the soft tissues, but not to allowimmediate total weight bearing. An international multicentrestudy of the locking system is in progess and we are reporting thefirst twenty five cases.

Results: 25 femoral shaft fractures were treated by elastic intra-medullary nailing and end caps.The stable cases were studied forease of implantation, skin tolerance, healing index, and retrievaland the instable cases also for shortening. All fractures healed in astandard time. The locking end caps prevent compression at thefracture site, but did not lead to a pseudarthrosis or a delayedcallus. We had no shortening and no end cap migration. Anadolescent did not follow the partial bearing recommendationsand walked without crutches from the fourth day without tele-scoping an unstable complex fracture. We recorded no skinproblems. No problem was noticed during implant removal.

Conclusions: The first twenty five clinical cases of using a lockingsystem by end caps for elastic intramedullary nailing of femoralshaft fractures showed no problems with fracture healing, short-ening of unstable fractures and no skin problems.

Significance: End caps for elastic nailing may avoiding shorteningof unstable fractures and skin problems related to the cut ends.

310

Initial Results of the Treatment of Femoral Shaft Fractures

in Children Using the Trigen Trochanteric

Antegrade Nail

Author: Susan Haralabatos (United States)

Co-Authors: Zhanna Sikorski (United States)

Purpose: The Trigen trochanteric antegrade femoral nail has beendesigned for the treatment of femoral shaft fractures in the pedi-atric population. The purpose of this study to to report initialresults of the treatment of pediatric femoral shaft fractures usingthis device.

Methods: Results of twenty femur fractures in nineteen patientstreated with the Trigen trochanteric antegrade nail treated over asix year period were reviewed. All patients had fixation of thefemoral fracture using a locked 8.5 mm Trigen TAN nail. Allpatients were followed clinically and radiographically. The fem-oral nail has been removed in ten of the patients. Length of fol-low-up was from one month to four years 2 months.

Results: Seventeen of the nineteen patients were boys. One patienthad bilateral fractures. The average age at the time of injury was13 years 10 months (9 years 10 months - 17 years 6 months).Mechanism of injury was sports related in six, automobile pas-senger eight, and five patients who collided with a motor vehicle.Nine of the patients sustained other injuries, predominantlyfractures and head injuries. Four of the fractures required openreduction. Patients who went home were discharged an average of3.5 days after surgery (2–6 days). Two patients with other sig-nificant head injury were lost to follow-up after transfer to reha-bilitation centers, and three patients (four fractures) were excludedfrom analysis as their follow-up was less than six months. Patientsdemonstrated full range of motion of the hip and knee four to sixweeks post-operatively, and were able to fully bear weight by eightweeks depending on the fracture pattern and other injuries. Pa-tients were allowed to return to all activities within four months ofsurgery. Ten patients have had removal of the femoral nail anaverage of twelve months after injury (6–22 months). Averagelength of follow up is twenty-two months since injury (5 months– 4 years 2 months). Complications included hypertrophic scar inthree patients and painful distal interlocking screw that requiredremoval in one patient. No patient demonstrated clinically sig-nificant limb length inequality, rotational malalignment, oravascular necrosis of the femoral head.

Conclusions: Static, locked intramedullary nailing using the Trigentrochanteric antegrade nail can be performed in the pre-teens aswell as teenagers. Preliminary results show that this technique iseffective in allowing healing and early return of function withminimal morbidity.

Significance: Early results with the Trigen TAN nail are promis-ing. Continued experience and long-term follow-up will determineif intramedullary fixation of femur fractures becomes the treat-ment of choice in the pediatric age group.

311

Fractures of the base of the fifth metatarsal in children

Author: Jose A Herrera-Soto (United States)

Co-Authors: Michael Scherb (United States), Michael Duffy(United States), Jay Albright (United States)

Purpose: Fractures of the fifth metatarsal are the most commonmetatarsal fractures in children. Their treatment is based on adult

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literature. The purpose of our study was to identify the differenttypes of fifth metatarsal fractures, determine the mean time tohealing and to examine whether current adult recommendationscan be extrapolated to children and adolescents.

Methods: 90 fractures of the 5th metatarsal were identified in 88patients (45 males and 43 females), mean age of 12.7 years.

Results: All 30 apophyseal injuries did well with 3–6 weeks ofshort-leg walking cast. Thirty-three patients presented withnondisplaced intraarticular fractures, most treated with a walkingcast. The healing time for the non-displaced group was 37 days.The average length of treatment for 12 displaced fractures was58 days. This difference in healing time was statistically significant(p = 0.009). Treatment for 15 ‘‘Jones fracture’’ was walking castfor four weeks in eight patients, non-weight bearing cast for sixweeks in five, immediate intramedullary fixation in two. Theaverage length of treatment from the day of injury to the day offracture healing was 12.1 weeks. Three patients of the NWBgroup presented with refractures within 3–10 weeks of cast re-moval. All refractures underwent intramedullary fixation with acannulated lagged screw.

Conclusions: Fractures of the 5th metatarsal in the pediatricpopulation do well clinically after a course of casting, unless thefracture occurs in a specific anatomic area, necessitating non-weight bearing casting or surgery. Displaced intraarticularfractures respond better to non-weight bearing casting. ‘‘Jonesfractures’’ may warrant intramedullary fixation to get patientsback quickly to regular activities, avoid delays in healing andprevent refracture.

Significance: Most of the pediatric injuries to the 5th metatarsalfractures behave similarly to those found in adults. Internal fixa-tion in ‘‘Jones fractures’’ may be warranted.

312

Biomechanical investigations into improving the stability

of elastic nails with screw-in end caps

Author: James Bowman Hunter (United Kingdom)

Co-Authors: Theddy Slongo (Switzerland), Karsten Schwieger(Switzerland), M Windolf (Switzerland), Peter Steiger (Switzer-land), Romano Matthys (Switzerland), B Linke (Switzerland),Jean-Michel Clavert (France), Richard Reynolds (United States)

Purpose: Recent presentations and publications have highlightedthe problem of the stability of elastic nails in unstable fracturesand in older, heavier children and adolescents. Additionally theproblem of skin irritation at insertion sites is well known. Wepresent the results of our biomechanical studies of a design ofendcap designed to address these difficulties.

Methods: Experiment 1. Two sets of paired human femora weretested. Elastic nails were inserted in a retrograde fashion, cut asusual and end caps screwed over the nail end. The proximal portionswere mounted in acrylic cement to prevent proximal migration ofthe elastic nails. A 45 degree, 1.5 cm segment was removed from themid diaphysis of the femora to simulate an unstable fracture. Theprepared femora were mounted in a mechanical testing apparatusthat recorded force and displacement as a steady load, and acquireddata on displacement at 10 Hz. Paired T-test was used for statisticalanalysis. Experiment 2. 15 plastic models of a paediatric femur weresimilarly tested to see if the angle of end cap insertion altered thepush-out force required to dislodge them. End caps were inserted at45, 55 and 65 degrees to the long axis of the femur, and the constructsubmitted to the same loading. The Kruskal-Wallis test was used totest for difference between angulations.

Results: Push out force was increased up to six-fold by the addi-tion of end caps to the cadaveric femora. The force at failure was

between 0 and 250 Newton without end caps, and between 580and 1200 Newton with end caps.(p = 0.007) Push out force wasnot affected by the angle of end cap insertion in model paediatricfemora. The maximum force to failure was between 1500 and 2000Newton for all three angles (p = 0.613).

Conclusions: End caps significantly increase the load to failure ofelastic nails in cadaveric femora. The angle of insertion of the endcaps does not affect the load to failure in themodel paediatric femur.

Significance: The biomechanical data suggest that end caps cansignificantly enhance the stability of elastic nails. A clinical studyhas been started to confirm that these results translate into practice.

313

Paediatric Femoral Shaft Fractures: A Conservative Asian

Perspective.

Author: Arjandas Mahadev (Singapore)

Co-Authors: Y Lee (Singapore), B Lim (Singapore), E Lee(Singapore)

Purpose: This study sets out to ascertain the clinic outcome andcost effectiveness of the treatment of pediatric femoral shaftfractures in a largely Asian population like ours. It also sets out todetermine if there is a need to follow the shift towards moresurgical methods in order to shorten the hospital inpatient stayand cost as well as to avoid the discomfort of wearing the hipspica. Increased complications of the more conservative hip spica,especially in older Caucasian adolescents, is another reason citedfor this shift.

Methods: We retrospectively reviewed case notes and Xrays todetermine the outcomes of femoral shaft fractures managed con-servatively at our Children’s hospital over a fifty-month periodbetween September 1997 and December 2001 inclusive. Our seriescomprised of 63 children between the ages of 1 month and 15 years(mean5.3 years), admittedwith closed fractures of the femoral shaftthat were treated with skin traction and subsequent hip spica.

Results: We found that in our hands, there were no cases ofmalunion, non-union, rotational deformities and significant limblength discrepancy on follow-up. When patients matched for ageand hospital bed costs were compared, we found that treatmentwith flexible intramedullary nailing incurred a cost more than oneand a half times that of conservative treatment with traction andhip spica. This increased cost is largely due to implant costs,operating room costs and surgeon’s fees.

Conclusions: In view of the fact that complications still do occur withsurgical treatment and, in our case, can cost more, we advocate thatskin traction followed by a hip spica in the treatment of closed fem-oral shaft fractures in our children, even in their adolescence, is safe,cost-effective and associated with a low complication rate.

Significance: In our largely Asian population, conservative man-agement remains the most cost effective way to treat paediatricfractures even in adolescents with no significant complications.This further confirms the lag in bony and cartilage maturity inAsian children previously studied.

314

Knee articular fractures in teenagers (revision of 45 cases)

Author: Antonia Matamalas Adrover (Spain)

Co-Authors: Rosendo Ullot (Spain), L Gonzalez-Canas (Spain),Santiago Cepero (Spain), A Avila (Spain)

Purpose: Studies dealing with articular knee fractures in adoles-cent are absent in the literature and their magnitude remains

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unknown. Through a longitudinal descriptive study, their inci-dence in a children’s hospital will be unveiled.

Methods: All 3,670 medical histories from people with fracturesadmitted in our centre between 1999 and 2005 were reviewed. Jointknee fractures were identified and sex, age, type of fracture, associ-ated injuries and treatment was gathered in each case.

Results: Forty-five articular knee fractures (1.2%) were identified,of them 29 were men (70.3%) and the average age was14.8 years. The most frequent place of fracture was the proximaltibia (55.5%), followed by patella (28.8%) and distal femur(15.5%). Among the ones occurring in the proximal tibia, tibialplateau was the most frequent location (13), 7 followed by tibialspine (7), type III epiphysiolisis of the tibial tuberosity (4) andopened complex fracture (1). In the patella: 6 cross-sectionalfractures, 1 longitudinal, 4 conminutes and 2 osteochondral. Inthe femur: 1 type III epiphysiolisis, 2 type IV epiphysiolisis, 1fracture of condyle and 3 opened complex fractures. In 13(31,7%) patients fractures healed with nonoperative treatmentand 28 (68.3%) were fixed intraoperatively. The time average ofimmobilization of the knee in nonoperative treatment was6.3 weeks. 22 associated injuries were detected : 11 intra-articular(1 external meniscus injury and 9 ligamentous injuries: 6 dis-ruptions of the anterior cruciate, 1 of the posterior cruciate, 2 ofthe lateral external ligament and 1 of the lateral internal one);and 11 extra-articular (6 diaphyseal femur, 3 fibula and 1 tibialdiaphysis fractures). In 15 (33,3%) some type of complicationappeared: 11 knee stiffness (7 recovered completely with reha-bilitation, 3 needed surgery and 1 mobilization under anesthesiaand rehabilitation). 2 patients had a dismetry without clinicalrepercussion. Growth was not affected in any case. Paresis withcomplete recovery was found in 1 case. Formation of medialtibial exostosis appeared in 1 case.

Conclusions: The knee intra-articular fractures in teenagers wereunfrequent and were more frequent in men. The main mechanismwas through traffic accidents. More than a half required surgicaltreatment and themost common regionwasproximal tibia.Themostfrequent associated articular injury was disruption of anterior cru-ciate ligament and articular stiffness was the principal complication.

Significance: Our study provided the first incidence of articularknee fractures in children. The rate, as well as the most commongender and mechanism were the spected ones.

315

Treatment of femoral shaft fractures in children: Comparison

between intramedullary flexible nails and traction followed by

spica cast.

Author: Fabiano Prata Nascimento (Brazil)

Co-Authors: Claudio Santili (Brazil), Miguel Akkari (Brazil),Gilberto Waisberg (Brazil), Susana Braga (Brazil)

Purpose: This study compares the results of the use of intrame-dullary nails to traction followed by spica cast.

Methods: 57 children were evaluated with ages varyingbetween five and thirteen years old, 29 treated with tractionfollowed by spica cast and 28 with titanium flexible intrame-dullary nails.

Results: The time of hospitalization was an average of nine daysfor nail group and twenty for the spica group. The average timefor healing was 7.6 weeks for the patients treated with the nailsand 9.3 weeks for the ones treated with cast. A proportion ofovergrowth with the use of nails was 64.3% e 13.8% for the castgroup. Partial weight bearing was tolerated with 3.4 weeks for thenail s group and 9.6 weeks for the spica cast group. The propor-tion of new hospitalization for the spica group was 64.3% for the

group that used nails and 17.2% for the group treated with cast.The period of traction and hospitalization were less in the nailgroup.

Conclusions: The patients treated with cast presented a highernumber of complications related to loss of reduction and asym-metry. The method of intramedulary nail had good results,especially about alignament and early rehabilitation.

Significance: Level III.

316

Complications, problems and femoral length after

intramedullary stabilisation of femoral shaft fractures

Author: Klaus Dieter Parsch (Germany)

Co-Authors: Martin Schilz (Germany)

Purpose: Controversial publications about problems, the rate ofcomplications, as well as femoral overgrowth after intramedullaryfracture stabilisation.

Methods: Retrospective evaluation of 110 femoral shaft fracturestreated from 1990 to 1998 by intramedullary fixation. Problemsor complications were judged from clinical notes and radio-graphic files. 64 children were seen in a follow-up clinic, andaverage of 61,5 months after surgery. Clinical and radiologicaloutcome of the treatment and possible leg length discrepancywas evaluated.

Results: Initially thick K-wires, later Nancy titanium nails of thefirst and finally of the second generation were used. Mid-shaft andproximal fractures were treated by retrograde insertion of 2 elasticnails, distal fractures by 2 antegrade nails. Additional spica castswere applied during the first 2 years. Hard-ware removal wasdone an average of 7,5 months after insertion. Major complica-tion like osteomyelitis, AVN or malposition were not seen in thisseries. 9,1 % showed nail migration, mostly in combination withsoft tissue irritation around the knee, mainly in cases with uni-cameral bone cysts or fibrous dysplasia. An average plus of0,50 cm was measured in femurs after intramedullary fixation ofthe fracture . Several children with a persistent plus of more then1 cm underwent epiphyseodesis during prepuberty. The problemof a super-obese child with > 100 kg was not encountered.

Conclusions: Intramedullary titanium nails for femoral shaftfractures in children showed no serious complication in this one-unit series. There was a learning curve to avoid problems con-cerning soft tissue irritations around the knee joint, correct naildiameter, retrograde or antegrade pinning and the use of anadditional spica cast.

Significance: No significant relationship between age of child whensustaining a fracture, type of fracture and posttraumatic femorallength was seen.

317

Intraepiphyseal malleolar fracture of the fibula or tibia Ogden

type 7A or an accessory ossification centre? The ultrasound

diagnosis.

Author: Tomas Pesl (Czech Republic)

Co-Authors: Hana Melinova (Czech Republic), Petr Havranek(Czech Republic), Karel Cermak (Czech Republic)

Purpose: Diferentiation between the distal fibular or tibialepiphyseal fracture Ogden type 7A and the os subfibulare orsubtibiale (subfibular or subtibial ossification centre) in case ofacute injury is necessary because of the consecutive way of

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treatment. The authors try to use the ultrasound (USG) to solvethis problem.

Methods: Two hundred and thirty-six children with an acute in-jury of the ankle joint were treated in our department during theone-year period (2005). In all the plain radiographs in two stan-dard planes were performed. In twenty-two of them the apicallesion of the distal fibular or tibial epiphysis was diagnosed. TheUSG was performed to diferentiate the acute skeletal injury andthe accessory ossification.

Results: In eight of the twenty-two injured children was verified bymeans of USG, that the continuity of the distal fibular or tibialepiphysis was not interrupted. It indicated the diagnosis of anaccessory osification and a plain ankle joint sprain. In the restfourteen cases the continuity of the fibular or tibial malleoli wasbroken off. It indicated the diagnosis of the intraepiphyseal mal-leolar apex fracture Ogden type 7A of the tibia or fibula. Thesefingings were verified by follow up radiographs.

Conclusions: The USG is safe, effective and useful method fordiagnosis of the acute skeletal injury of the distal fibular or tibialepiphyseal apex and/or for verifiing the os subfibulare or subtibiale.

Significance: Diferential diagnosis of the accessory ossificationversus the intraepiphyseal malleolar apex fracture Odgen type7A of the tibia or fibula represents an important clinicalproblem because of the dicrepancy of the plaster cast immo-bilisation in case of ankle joint sprain and the intraepiphysealmalleolar fracture Ogden type 7A. In children the ankle jointsprain requires only a short time plaster cast imobilisation ofthe ankle joint, if any because the ligaments are not affect. Onthe contrary the intraepiphyseal apical fracture of the distalfibula or tibia Ogden type 7A should be immobilised for four tofive weeks.

318

Fixation of Femoral Shaft Fractures in Children

with a New Flexible Interlocking Intramedullary Nail

Author: Jonathan Huw Phillips (United States)

Co-Authors: Lubica Jencikova-Celerin (Canada), Werk Lloyd(United States), Stacey Wiltrout (United States)

Purpose: This study examined whether fixation of femoral shaftfractures in children with a new flexible interlocking intramedul-lary nail (FIIN) would result in fewer complications, faster weightbearing, and quicker healing than standard surgical techniques(SST).

Methods: Hospital, outpatient medical records and radiographswere reviewed in a retrospective cohort study among children 7 to18 years old with femoral shaft fracture requiring open treatment.One hundred thirty-seven children met selection criteria including59 subjects enrolled in the FIIN group and 78 among those in theSST group. There was no difference among groups based on age,gender, and fracture characteristics.

Results: The most common fracture patterns recorded weretransverse and comminuted with a location commonly in thesecond or third quarter of the femoral shaft. Average age was11.5 years. Complications were found in 20.3 percent subjects inthe FIIN group and 30.8 percent in the SST group. Trochantericheterotopic ossification was the most common complication 13.6percent in the FIIN group and superficial infection 12.8 percent inthe SST group. Major complications including avascular necrosis,malunion, deep infection, and refracture were found in 1.7 percentof the FIIN and 11.5 percent of SST patients (p equals 0.043).Patients in the FIIN group achieved full weight bearing 34 days

sooner (p equals 0.001) and healed radiographically 37.4 dayssooner (p equals 0.043) than those in SST group.

Conclusions: Patients treated with a flexible interlocking intra-medullary nail demonstrated better treatment outcomes thanstandard surgical techniques.

Significance: This new implant shows early promise in treatmentof children’s femoral fractures.

319

Isolated Femur Fractures in Adolescents: Comparison

of 4 Operative Methods

Author: Leonhard Erich Ramseier (Switzerland)

Co-Authors: Unni Narayanan (Canada)

Purpose: To compare the results and complications of fourmethods of fixation of isolated femur fractures in adolescents.

Methods: This is a retrospective cohort study of isolated traumaticdiaphyseal femur fractures in children, 11 to 18 yrs, treated from1995–2005 at a level 1 paediatric trauma centre. Patients werecharacterized by age, weight, mechanism and energy of injury,fracture level, pattern, % comminution, and method of fixation:elastic stable intramedullary nail(78), external fixator(17), rigidIM nail(25) and plate osteosynthesis(12). We compared length ofhospital stay, time to union and full range of motion, and com-plication rates: loss of reduction requiring reoperation, malunion(‡10� coronal &/or ‡20� sagittal), nonunion, refracture, infections,need for reoperation other than routine.

Results: Mean age was 13.25 yrs(11–17.6). IM nail group wasslightly older(14.5 yr). Mean weight was 48.5 kg(25 –80), similaracross groups. ESIN group were mostly tranverse/obliquefractures of the middle & proximal femur with < 25% com-minution; ExFix were comminuted spiral fractures of theproximal & middle femur; IM nails were proximal & midfemoral high energy fractures in older children; plates mostlydistal fractures with <25% comminution. Mean length of staywas 5 days for all groups. Mean follow-up was 12.7 months. Allfractures healed, with radiographic union occurring at9.5(ESIN), 12(ExFix), 9(IM), and 11(Plate) weeks respectively.Functional knee range of motion was recorded by 11 weeks inall groups but 24 weeks for ExFix group. Loss of reductionrequiring a reoperation occurred in 2/78 ESIN and 4/17 ExFix.At final follow-up minor malunion was noted in 4/75(ESIN), 2/16(ExFix), 1/25(IM) respectively, none of which were treated. 1patient in the IM group had 2.5 cm shortening. 6 patientsunderwent reoperation in the ESIN group(1 non-union at8 months, 1 late refracture due to reinjury, 2 prominent nailsneeding trimming/advancement, and 2 for reduction loss). 5ExFix patients required 7 reoperations(5 for loss of reduction, 1for replacement of an infected pin, and 1 debridement for deepinfection). 1 prominent distal interlocking screw was removed.23/75 ESIN were removed(21/23 for symptoms at nail insertionsite), 3 rigid IM nails, and 2 plates(for pain) were removed.

Conclusions: Treatment choice is influenced by age, fracture level,pattern and comminution. Adjusting for baseline differences, all 4treatments had satisfactory outcomes, but are associated withspecific complications. ESIN performs at least as well as othermethods and most of tits complications are preventable.

Significance: No single technique is universally applicable to alladolescent femur fractures. Until evidence to the contrary isavailable, surgeons should be familiar with multiple techniques,the choice of which is likely to be influenced by patient andfracture characteristics and patient/family preferences.

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320

Surgical treatment of nineteen anterior tibial tuberosity fracture

in children.

Author: Francisco Soldado Carrera (Spain)

Co-Authors: Oscar Ares-Rodriguez (Spain), Roberto Seijas(Spain), Pedro Alvarez (Spain), Cesar Garcia Fontecha (Spain),Gilbert Steinbacher (Spain), Marius Aguirre Canyadell (Spain),Ramon Cugat (Spain)

Purpose: The anterior tibial tuberosity is a very few frequentfracture (1 each 4 years). This fracture represents the 3% of thetibial fractures and 1% of the physeal fractures. It affects a ath-letics boys whose are between 14 and 17 years old. We show ourexperience in this kind of fractures. We use a technique withparallel screws to the proximal tibial physis.

Methods: Retrospective study of the anterior tibial tuberosityavulsion-fractures in the last 10 years in Vall d’Hebron Hospitaland the last 3 years in a football clinic. When the patient needsurgery, we use screws or K-wire situated parallel to the tibialphysis to avoid the fusion at this point.

Results: You collect nineteen fractures, all of them male withmean age of 14,72 years (10–18). In 14 patients (73.7%) was af-fected the left side. All the fractures were closed ones. The dis-tribution of the fractures according as Ogden classification is: 2IA; 2 IB, 2 IIA, 1 IIB; 6 IIIA, 6 IIIB. Three patient were treatedwith cast immobilization and 16 received surgery. We used screwsin 80% of the patients and K-wires in 20 % of the cases. We use acast immobilization for five weeks. Only in one case we practiced afasciotomy. Only two patients didn’t need rehabilitation program.The ROM was full in all the cases. They began daily activitiesincluding sports after a mean of 13.71 weeks We have no comp-liations as infection or compartmental syndrome. During thefollow-up, we did not have any case with early physeal closure andno case with genu recurvatum. 50 % of the patients need a secondsurgery to remove the internal fixation.

Conclusions: The surgery treatment is safe. The treatment has toachive four objectives, as an anatomical reduction of the articularfracture, no alteration of the physeal development, keeping thepatella height and stable osteosynthesis. Our technique withparallel osteosynthesis give us an anatomical reduction, non ep-ifisiodesis full ROM. It is not necessary to remeove the material inall the cases.

Significance: III.

321

Complications in fractures of the proximal tibial metaphysis

in children

Author: George Tagaris (Greece)

Co-Authors: George Christodoulou (Greece), George Sdougkos(Greece), Apostolos Vlachos (Greece), Alexander Vris (Greece)

Purpose: This study examines the proximal tibial metaphysealfractures in children and specifically the valgus deformity and legovergrowth of the tibia.

Methods: We examined 27 children with proximal tibial meta-physeal fractures. Among them, 11 presented with greenstickfractures, 6 with complete, 5 with hairline, 3 with torus and 2 withstress fractures. The mean age was 7 years old (1–14). The averagefollow up period was 9.5 years. Fifteen children were below theage of 7 while 12 were between 8–14 years old. Twenty fivepatients were treated conservatively and 2 surgically.

Results: Valgus deformity occurred during the follow up period in73% of the children aged below 7 y.o. and 17% of the olderchildren. The higher values of valgus deformity ranged between8–18 degrees and were observed at 10–18 months post-traumati-cally, especially in younger ages and after inadequate reductions.At the time of the final follow up examination, satisfactoryspontaneous correction of the deformity, inversely proportional toage was observed in all cases. The degree of final valgus deformityranged between 1–9 degrees. Overgrowth of the affected extremitywas observed in 74% of the cases and ranged between 0, 4 and 1,5 cm. Tibial overgrowth is not dependent to skeletal age. None oftorus and stress fractures developed valgus deformity or longitu-dinal overgrowth. Compartment syndrome occurred in one case.

Conclusions: A high tendency to valgus deformity, especially inyounger ages, was observed in proximal tibial metaphysealfractures, even among undisplaced or surgically treated ones.Approximately two years post-traumatically, the beginning of aprogressive spontaneous satisfactory correction of the deformity –inversely proportional to age – was noticed. It is worth men-tioning that valgus deformity up to 10 degrees and tibialovergrowth up to 1, 5 cm cause no functional or cosmetic prob-lems.

Significance: The above observations prevent us from unnecessarysurgical correction. Conservative treatment is preferred for theproximal tibial metaphyseal fractures. Operative treatment isindicated after inadequate reduction, especially in older childrenand after open fractures.

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Long term results of the surgically treated displaced

supracondylar humerus fractures

Author: Mehmet Can Unlu (Turkey)

Co-Authors: Tuncay Centel (Turkey), Hayrettin Kesmezacar(Turkey), Egemen Ayhan (Turkey)

Purpose: The primary purpose of this retrospective study was toevaluate long-term results of the completely displaced supracondylarhumerus fractures that had been treated by open reduction and wirefixation. Our secondary purpose was to assess the relation betweenthe early postoperative reduction of the fracture and the radiologicaloutcome at follow-up.

Methods: The study included 49 children with displaced exten-sion-type supracondylar fractures of humerus, all having unilat-eral extension-type Gartland type III fractures. Open reductionand crosswire fixation with K-wires were performed in all pa-tients. Two separate incisions (medial and lateral) were used forall the cases. Mean follow up was 18 years and 3.3 months. Theywere assessed using the criteria of Flynn. Baumann’s, hume-roulnar and lateral angles were measured on the x-rays. Hume-roulnar and lateral angles were also recorded on the radiographsmade at follow-up. The lateral angle was determined by mea-suring the arc between the long axis of the distal humeral shaftand epicondylar ridges. Humeroulnar angle was found by mea-suring the angle between the lines of distal humerus and proximalulna that intersect at the center of throchlear joint line. Forstatistical analysis, comparison of the radiological angles mea-sured at early postoperative period and at the time of healing ofthe fracture was performed to determine any early loss of cor-rection. Furthermore humeroulnar and lateral angles that werefound soon after the surgery and at follow-up was compared ifany change occurred during time. Finally radiological and clinicalcriteria of the injured elbows were evaluated in reference to thecontralateral side.

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Results: Measurement of the Baumann’s, humeroulnar and lat-eral angles at the time of fracture healing showed that there wasno significant loss of reduction comparing soon after the sur-gery. Follow-up examination revealed good or excellent func-tional results in 35 cases (71,4%). The humeroulnar anglemeasured after reduction was found to correlate well with thefinal carrying angle. The Baumann’s angle was not found tocorrelate well with the final carrying angle. In all of the frac-tures that were primarily reduced in flexion in the sagittalplane, spontaneous correction occurred. Spontaneous correctioncould not be shown in reduction in extension. Growth distur-

bance was discovered in 36,7% of the patients in the frontalplane. No growth disturbance was demonstrated in the sagittalplane. Spontaneous correction in the frontal plane could not beshown.

Conclusions: Open reduction and crosswire fixation with K-wiresis a safe and efficient treatment for displaced humerus surprac-ondylar fractures in children. The humeroulnar angle afterreduction can be reliably used to predict accurately the finalcarrying angle.

Significance: Defining the humeroulnar angle as the indicator ofthe final carrying angle contributes also to final outcome.

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Author Index

The numbers refer to the abstract(s) numbers(s)

Aarnes G 179Abid A 71Abraham A 44Abudu A 9Acaroglu E 64Accadbled F 208, 209Adamec O 173, 285Agorastidis N 176, 177Agus H 226, 301Ahmet A 64Aiona M 133, 153Ajoy P 292Akazawa H 126Akkari M 95, 315Akman Y 31Aksahin E 12Albaugh J 194Albisetti W 87Albright J 311Alexander K 4Alka J 41Almaiyah M 258Almeida M 95Alvarez P 320Alvin H 46Anastasopoulos J 170Anelati G 192Aoki K 126Aoun N 272Apel P 198Apostolopoulos A 217Ares-Rodriguez O 320Aretaki A 170Arkader A 8, 51Armstrong D 212Armstrong DA 78Aronsson D 66Assumpcao R 135Athanasian E 8Audige L 232Auner C 131Avila A 314Axelrod F 77, 249Ayanoglu S 296Aydin B 296Ayhan E 322

Badelon O 171, 243Badras L 136, 137, 161Badve S 72Bae KJ 105Bae K-C 240Bagaria V 299Bajelidze G 121Balsano M 201Balvin M 211Bapat M 72Baradhi A 158Barakat M 117Barrios C 254Barroso JL 216

Bartels L 205Bass A 40, 151Baunin C 2Bayrakci K 47Beguiristain JL 216Behensky H 18Belangero W 113Bell M 167Belthur M 76, 80, 106,121, 206

Belza B 132Belzer J 197Bennet G 222Benoit B 247Benson M 61Bentahar T 286Berard J 85, 244Berden N 23Bergeson A 211Berker N 154Berton C 27Besselaar A 127Besselaar P 94Betz R 81, 214Bevan W 32, 221Bharadwaj R 299Bialik V 133, 174, 248Bicimoglu A 12Biedermann R 18Bjornson K 7, 130, 132Blakemore L 212Boatright K 221Boero S 245Boland P 8Bollini G 73, 110, 208Bonnel F 65Bonnet F 286Booker W 70Bor N 287Boran S 193, 202Borgo A 219Borkhuu B 80Borowski A 246Bozkurt M 297Bradish C 178, 306Braga L 234Braga S 95, 315Brecelj J 155Bruce C 6, 40Brunet O 244Brunner R 119, 225Buckon C 153Bueno J 90Burghardt R 104, 187Burnei G 26Burns J 221Bursali A 296Bye M 70

Cabukoglu C 154Cequier SL 36

Cahuzac J 71, 208, 209Callender O 193, 229, 230Campbell R 67, 81, 214Canavese B 65Canavese F 65, 286Cantin MA 290Canyadell AM 320Carbone M 74Carrera SF 320Carter S 9Cassidy N 199Castelein R 127, 205Caterrall A 293Cavalli F 65Celebi L 12Centel T 322Cepero C 284Cepero S 188, 236, 314Cequier SL 36Cermak K 317Cerna C 24Chagas Jr M 269Chaloupka R 79Chang C 128Chen J 211Chen Y 128Chiaramonte N 219Cho C-H 240Cho D-Y 233Cho HS 264Cho T-J 58, 105, 112, 116, 172,255, 264, 270

Choi IH 58, 105, 112, 116,172, 255, 264, 270

Chomiak J 173, 285Chotel F 9, 85, 244Chousta A 85Christodoulou G 25, 321Chung CY 58, 105, 112, 116,172, 255, 264, 270

Cigala F 163Clark K 66Claudon M 111Clavert J-M 232, 309, 312Cole W 156Comelli C 223Comisso M 201Conrad EC 7Conroy E 15Cosma D 26, 262Costici F 141Cournot M 209Coutie A 208Couto J 43Cristini E 223Cruz M 268Csepan R 138Cucchiaro G 195Cugat R 320Cumlivski R 139Cunin V 244

Cunha ML 17Czubak J 145

Dabney K 121, 122, 150da Cunha ML 288Dagher F 102, 158, 272Daglar B 47Daglioglu K 64Dakwar R 157, 307Dan D 26Danielsson A 82Dannecker G 22da Paz Jr CA 234da Rocha ML 288Das S 45Daures J-P 65Davies AG 97Davis N 228De Bartolomeo O 87de Donato M 281de Gauzy SJ 2, 71, 208, 209de la Iglesia GD 36De Maupeou F 2De Pellegrin M 14de Sanctis N 166Delhaas T 205Delialioglu O 47Dellenbaugh S 37Demirkale I 297Desai S 89, 189, 190,233, 276

Deshmane P 72Desloovere K 134Devito R 162Dheenadhayalan J 181Di Lazzaro A 152Di Sicco J 271Dias L 42Dillon E 130Dimeglio A 65, 286, 298Dimitriou J 265Dimitriou R 265Dobashi E 271Doblare M 254Dogan A 31Dogan M 297Dohin B 21, 129Donnan L 18Dowling F 193, 202Drassler J 221Dreher T 119Duffy M 311Duhaime M 247, 290Duncan R 302Dungl P 173, 285

Eastwood D 94, 165, 293Eckhoff J 182, 183Effman E 67Eidelman M 174, 248, 287El Hage S 158

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El Tayeby H 33Elalfy B 91El-Batouty M 29Elmowafi H 91El-Sherbini M 278Emara K 133Emerson D 211Endo H 126Etienne J 21Ey Batlle A 36Ezra E 62, 200, 273

Fabry K 134Fadel M 160Falappa P 162Fallatah S 69Fassari F 162Fassier A 39Fazioli F 163Fedarko N 41Feldman D 77, 203, 249,250, 308

Fernandes J 167Fernandez-Palazzi F 30, 251Fernando H 185Ferretti A 75Filo O 83Fiore F 163Fishkin M 62, 83, 200Florentino-Pineda I 78Floret D 21Flynn J 195Foad S 304Fogarty E 193, 202, 229, 230Fontecha GC 320Forlin E 17, 288Fragaki M 217Frances J 8Franceschi F 293Fraponi A 223Freeman R 61Frick S 232Friedman J 51Frigo C 119Frydrychova M 173, 285Fu Y-C 242Fucs P 135Fujii M 20Fujii T 20, 235, 261, 263, 275

Gabos P 80Gabriel A 18Ganger R 109Ganley T 194, 195Gantelius S 146Garcıa-Aznar J 254Garcia-Llaver G 88, 175Garg N 6Gargan M 117Gargantilla A 188, 236Garin C 129Garnier-Kenol I 295Gasco J 254Gatti F 294Gavriliu S 26

Gelman A 204Genovese E 162George H 40Georgescu I 26Georgiev H 280Gereis V 176, 177Ghanem I 102, 158Ghorayeb J 100Giannakopoulos H 137, 161Gigante C 27, 253, 289Giglio C 215Gilberto S 74Girsch W 237Glutting J 122Glynn A 199Goldberg C 202Goldberg M 204Gomez J 70Gomez-Benito MJ 254Gonzalez-Canas L 314Goto S 126Grabowski B 145Gradinger R 183Grainger J 164Grant A 93Green D 308Greiwe M 46Grill F 98, 109Grimard G 247, 290Grimer R 9Grimm D 17, 288Grissom L 206, 246, 256Gross R 207Grottkau B 50Gryfakis N 42Grzegorzewski A 159Guida P 166Guillaume J 208Gulcek S 12Gunal T 12Gunel U 47Gungor E 47Gurcu T 226Gursu S 296Guzman M 30

Habanbo J 298Habermann C 56Hadavi F 180Haddad E 272Haddad-Zebouni S 272Halbertsma J 142Hamada Y 19Hansson G 300Hara H 140Haralabatos S 310Harper J 165Harshavardhana N 72, 299Harty J 15Harvey B 35Hasler C 225Hasserius R 82Haumont T 111Haverkamp A 127Havranek P 317

Hayek S 273Healey J 8Heimkes B 124Hemo Y 62Henderson E 77, 203, 250Herrera-Soto J 311Herring J 54Herzenberg J 92, 104, 187,204, 287

Higgins G 178Hochmuth K 182, 183Hoeglinger M 109Hoey S 165Homaechevarria A 197Hopgood P 164Horak M 173Horiuchi T 19Horky D 79Horn J 179Hosny G 160, 279Hospach T 22Huang P-J 242Huguet R 188, 236Hunter J 232, 309Huntley J 169Hurschler C 13Hutt N 198Hyman J 70, 213Hyun S 190

Iaccarino V 163Iacono V 163Ibieta A 24Ide T 19Imai Y 96Inan M 256Ingram D 131Inscore S 67Ishida A 271Ito Y 140Iwamoto Y 20

Jacobsen F 300Jacopin S 110Jacquemier M 110Jae Y 89, 189, 210, 276Jaffe K 130Jager M 59Jalaludhin J 252James L 6Jang HP 220Janicki J 35Jarman R 196Javid M 180, 224Jawish R 100Jencikova-Celerin L 318Jensen C 196Jeys L 9Jiminez N 211Jingushi S 20John E 214Johnston C 68Jones K 195Jonsson M 300Joo SY 60, 107

Joshi Y 6Journeau P 111Jouve J 208Jouve J-L 73, 110Juenemann S 225Jung H-J 255Jung S-C 233

Kahwaji A 100Kalenderer O 226, 301Kalkan T 297Kallio P 52Kamegaya M 63Kandil Y 61Kanellopoulos A 136, 137, 161Kang C-H 240Kangesu L 165Kanti U 45Karanikas E 170Karkhanis A 299Karol L 68Karpas K 3Kartin D 132Katzman A 174, 248, 287Kawabata H 241Kazarian T 41Kehayov R 280Kenet G 273Kenmoku T 63Kesmezacar H 322Khalife R 100Khan T 44Kharrat K 102, 158, 272Kim HW 60, 107, 143, 144Kim JA 112Kim S-J 274Kimori K 19Kirienko A 281Kiss S 84, 191Kitano T 96Klassen R 53Knahr K 98Knaus A 118Knilsson K 198Knorr J 71Kobayashi D 267Kohler R 21, 129Kolovos S 170Kotb H 282, 291Koukos S 25Koureas G 39Kouwenhoven J-W 205Kovacs G 168Kowalczyk B 184Kowtharapu D 181, 292Krajbich JI 4Kranzl A 109Krauspe R 59Krbec M 79Krebs A 138, 139Krismer M 18Kristiansen L 179Kubota H 140, 261, 275Kuroda T 96Kyrikou H 217

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S129

La Rosa G 141, 162Labianca L 75Laflamme Y 247Laheri V 72Laine T 227Lambat M 299Lambiase A 163Lamm B 287Lamminen A 238Lamprou D 136Langendoerfer M 22Langendorfer M 1Lapie N 209Lascombes P 111Lauen J 182, 183Launay F 73, 110, 208Lauschova I 79Leal D 294Lee DY 58, 112, 270Lee E 49, 313Lee KS 58, 172Lee SM 172Lee S 89, 276Lee Y 313Lee Z 128Leet A 23, 149Lefevre Y 73Lejman T 184Lenehan B 193, 202Lettera M 163Liantsis A 120Lieber R 146Lim B 49, 313Lim K 227Lindfors N 305Linke B 312Littleton A 76, 80, 106, 246Lloyd W 318Logsdon R 132Louahem D 298Lousteau O 2Ludvigsen P 179Lutz N 232

Maathuis K 142Maathuis P 38, 142Mackenzie W 76, 106, 206,246, 256

Macri R 124Madan S 101Maddaluno L 163Mahadev A 49, 313Mahajan R 190Maheshwari R 101, 302, 303Mahnken A 257Mainard L 111Malizos K 120Mallat S 158Mandarano FL 269Mandry D 111Mangiola F 75Manner H 109Mannoji C 63Maranho D 294Marawar S 72

Martinez G 88, 175Martini G 27Masek M 173Mason D 80Matamalas AA 314Matıas S 90Matsinos G 170Matsumoto H 37, 70, 213,214

Matsuura A 140, 275Matta H 89, 190Matthys R 312Mawatari T 20Max S 13Mazza O 141McCann H 207McCarthy E 41McCool D 197McCormack D 199, 266McLaughlin J 132McManus A 228McManus F 15, 266Meadows T 164Mednikarov E 280Mehlman C 46, 304Meiss L 56Melinova H 317Memeo A 87, 192, 223Messina S 75Micaglio A 219Michaud L 304Michelis MB 245Michelis M 74Milani C 271Miller F 106, 115, 121, 122,148, 150

Min B-W 240Miscione H 185Mitani S 126Mladenov K 68Moen T 42Moharamzadeh D 14Mohil R 164Molenaers G 134Møller-Madsen B 125Monasterio JL 216Monsell F 117, 165, 293Montanaro A 75Montgomery R 258Moore D 193, 202Morcuende J 37Morgan A 167Morin B 247, 290Morita M 96Moriya H 63Morocz I 168Morris A 114Morris C 8Mosca V 32Moscovitch G 2Mourani C 158Mumcuoglu I 31Muratli H 12Murphy M 266Murray A 222

Nachemson A 82Nadarajah R 131Nagai M 150, 256Nakagawa K 96Nakamura J 63Nakashima Y 20Narayanan U 35, 114, 227,319

Nascimento F 315Nasu T 126Nathorst-Westfelt J 300Neves CM 218, 259Nietosvaara A 52, 238, 305Nikolic Z 8Nilsson K 197Nilsson W 221Nisar A 97Noguchi Y 20Nott EV 48

Oda K 126Oh C-W 186Oh KS 143, 144O’Hare B 229, 230Ohlin A 82Ok I-Y 274Oketani Y 140, 275Oner C 64Ostadal M 173O’Toole P 229, 230Ouhayoun E 2Ovadia D 83Ovesen J 125

Paley D 92, 104, 187, 204Palmu S 52Pap K 84, 191Papandreou N 176, 177Paris A 197Park B-C 186Park HW 60, 107, 143, 144Park J-W 233Park KB 143, 144Park M 116Parot R 244Parrot R 85Parsch K 28, 316Pascarella A 166Paseta O 254Pasparakis D 176Pasparakis D 177Paterson M 131Patil N 299Patni H 72Pavone V 231Pedreira J 268Pekmezc_ı M 64Peltonen J 238Peluso CPena L 216Peretti G 87, 192, 223Perez M 236Perez MC 188Perrone G 188, 236Pesl T 317

Petermann A 59Peterson H 53Pettas N 217Pfeiffer R 198Phelps D 197Phillips J 318Pietrzak S 145Pilankar S 299Pineda D 24Pistevos G 176, 177Pitcher Jr JD 5Pittioni E 65Planes E 284Plitz W 124Poe-Kochert C 78, 212Pogonowicz E 159Pollock S 293Pomero V 110Ponten E 146Popov O 307Porter D 10, 169Pospischill M 98Poul J 147Poyhia T 238Pressel T 13Privitera D 213Protopapadakis G 25Pruijs H 127Puskar Z 84Pydisetty R 252Pyman J 117

Radler C 98, 109Railhac J 2Raja S 181, 292Rajasekaran S 181Ram SK 48Ramirez-Lluch N 81Ramseier L 319Ranade A 187Randal B 81, 214Ranjan A 45Rautakorpi S 305Rebello G 50Redding G 67Redekop S 114Refai M 91Regondi E 192Reid R 10, 169Reinhardt BSK 308Reisoglu A 226, 301Repko M 79Reynolds R 309, 312Rhee K-J 86Riad J 115, 148Rich M 55Rigamonti W 253Rigopoulos N 120Ristaniemi N 305Rizzo N 166Robb C 306Rocha ML 17Roemhildt M 66Roposch A 99Rosenberg N 273

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Rosenberg Z 250Rosenfeld S 54Roth S 34Rouleau D 247Rowland D 167Roy A 35Roy D 103, 260Roye D 70, 213, 214Rubie H 2Ruchelsman D 249Ruggieri M 231Rumyantsev N 108Russman B 153Ryu S 140, 275

Sabet N 283Sadile F 163Saghieh S 92Sahu A 299Sailhan F 85, 244Saisu T 63Sakkers R 127Sala D 250Salama A 97Salter R 11Samara E 43Sampath J 151, 252Sandhu S 196Sansone V 281Sant’Anna F 218, 259Santili C 95, 315Santner T 152Sapre V 299Sasaki K 96Satsuma S 267Schara K 23, 149Schaufele P 24Scher D 308Scherb M 311Scherl S 277Schiavon R 219Schiering J 28Schilz M 316Schlickewei W 309Schoenecker P 55Schreiner A 57Schweitzer M 77, 249Schwieger K 312Sciarra F 75Scorsone-Pagny S 110Scully S 5Sdougkos G 25, 321Sebire N 165Segal E 43Segev E 62Seijas R 320Sembrano J 133Senaran H 122, 150Seo JB 112Sepulveda D 90Seringe R 39Shah R 45Shah S 80, 122Shahcheraghi G 180, 224Shapiro J 41

Shariff R 151Sharma H 302, 303Shaughnessy W 53Shea K 197, 198Shechtman A 83Sheehan E 199Sheiko M 7Shetty G 89, 189, 190, 210,233, 276

Shim JS 220, 239Shin HD 86Shin H-D 186Shisha T 84, 191Shivarathre D 40, 151Shtarker H 157, 307Shualy M 204Sienko TS 153Sikorski Z 310Silicorni A 223Silva F 218Simis S 135Simon S 152Simpson H 191Singerhoff S 56Skaggs D 214Skarpas G 217Slimp J 211Slongo T 232, 309, 312Smith J 81, 214Sohodolcan L 155Sokhi K 169Song B 92Song H 89Song H-R 186, 189, 190, 210,233, 276

Song H-S 86Song K 7, 67, 130, 211, 214,221

Song K 240Son-Hing J 212Sousa RM 218, 259Specht S 187Spencer D 249Spoletini M 75Sponer P 3Spreafico L 281Standard S 104Stans A 53Stebbins J 123Stebel M 65Steen H 179Stefano E 88, 175Stefanov S 280Steiger P 312Steinbacher G 320Steinberg D 273Stella M 245Stephens M 199Stokes I 66Straight J 249Strobl W 138, 139Strom M 221Suda R 98Suenaga E 20Sugiyama H 19

Sul EJ 220Sul E 239Surer L 301Sussman M 133, 153Svartman C 135Synder M 159Szepesi K 168Szoke G 84Szoke G 191Szucs G 168

Tagaris G 25, 321Takagi R 241Takamura K 235, 261, 263,275

Takaoka K 96Talenti E 289Tamura D 241Tasbas B 47Tavares D 218, 259Tecimel O 297Temple HT 5Ten Berge S 142Teoh K 10, 169Terjesen T 16, 118Thacker M 5, 76, 106, 206,246

Theologis T 61, 123Tho H 131Thomas S 11Thompson G 78, 212, 277Thompson N 123Thomsen JS 125Tien Y-C 242Tierno G 268Tillman R 9Timlin M 15Tosun N 297Turra S 27, 253, 289Turturro F 75

Ugurlu M 297Ullot F 284Ullot R 188, 236, 314Unlu M 322Urano N 235, 261, 263Urban K 3Urbanova E 3Ursei M 71

Vaidya S 189, 276Vallejos-meana N 88, 175Vallongo C 27Vallverdu PM 36van Bosse H 250Van Gelder H 38Vancampenhout A 134Vasilescu D 262Vasilescu D 26, 262Venkatramani H 181Verbout A 205Verdoni F 87, 192Verheij N 142Viehweger E 72, 110Viergever M 205

Viguier E 85Vilalta V 284Villaminar A 201Vincken K 205Violas P 208Vioreanu M 199Visser J 38Vitale M 37, 70, 213, 214Vittoria F 245Vlachos A 321Vlad C 26Vladimirov B 280Volpatti D 65Volpin G 157, 307Volpon J 215, 269, 294von Liebe A 124Voutsas N 217Vrettos S 137Vris A 321

Wachter R 18Wada A 235, 261, 263,275

Wada M 241Wainwright A 61, 123Waisberg G 95, 315Waldman D 273Wall E 46Walsh S 229, 230Wang T-L 242Wang X-D 306Warner W 51Waters L 213Watts A 10Webb J 258Wedge J 11, 99Weinzapfel B 212Weir S 114Wells L 51, 195Westhoff B 59While T 117White K 211Wicart P 39Widmann R 308Wientroub S 62, 83,200, 273

Wilkins K 48, 295Willems W 50Wilson D 152Wilson N 222, 303Wiltrout S 318Windhagen H 13Windolf M 312Winkler P 1, 22Wirth T 1, 22Witbreuk M 94Woo S 210Wraith ED 164Wright J 35Wynn R 164

Yalcin S 154Yamamoto T 20Yamane P 271

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Yanagida H 235, 261,263, 275

Yang J 89, 189, 210, 276Yang JH 233Yaniv M 62, 200

Yazici M 64Yebra IJ 36Yildirim T 296Yilmaz G 64Ying J 304

Yoo WJ 58, 105, 112, 116,172, 255, 264, 270

Yoon H-R 233Young M 92Yuksel HY 12

Zanferari M 17Zorer G 31Zulian F 27

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EPOS/IFPOS Combined Meeting EPOS - 26th Annual Meeting

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Transcript of EPOS/IFPOS Combined Meeting EPOS - 26th Annual Meeting