Journal of Children s Orthopaedics

Publisher: Springer Verlag


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Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: TITLE Congenital Volkmann's ischemic contracture, a rare and challenging condition. KEYWORDS Volkmann; Ischemic contracture; PURPOSE Congenital Volkmann’s ischemic contracture is a very uncommon situation. Only around fifty cases have been described in literature. In order to minimize the devastating consequences of this condition, a therapeutic approach may be systematized. MATERIAL AND METHODS Five patients have been evaluated from 1998 to 2013. In all cases, unilateral hand and forearm were affected. The management and evolution of these cases is described, and a review of literature is made. The pathological findings during pregnancy were: one gestational diabetes with regular insulin treatment, one preeclampsia and three unspecific oligoamnios. The association of skin lesions (necrotic bedsore with a central pallor, ulcers, bullae), diffuse oedema, contractures and neuromuscular affectation(flaccid paralysis) in a newborn’s upper limb leads to the diagnosis of congenital Volkmann's ischemic contracture. This presentation may not be confused with aplasia cutis congenital, septic necrotizing fasciitis, amniotic band syndrome, epidermiolysis bullosa, neonatal gangrene, congenital varicella or vascular affectation. Radiological findings such as demineralization, metaphysis rarefaction, epiphysis affectation or even more extensive diaphysis bone affectation may be found. RESULTS An urgent approach was proposed, based on the common surgical procedures for any Volkmann’s contracture: fasciotomy, wide skin and deep tissue’s debridement, neurolysis, scar release and skin graft. In two cases, we included the use of a regional anesthetic axillary block with ropivacaine. The regional anesthetic caused a sympathetic block which generated a vasolidatating response. Later, we recommended hand therapy and splinting. Also some deferred surgical procedures were needed, such as contracture liberations, tendinous transfers, angular deformities bone corrections and neurotizations. In one patient, a digit amputation was mandatory. We evaluated wrist, metacarpophalangeal and interphalangeal mobility, as well as the thumb function with good functional results in three patients. One patient presented a deep mobility affectation. Another patient was lost during the follow-up. CONCLUSIONS There is a clear connection between some extrinsic intrauterine and intrinsic fetal factors during the last trimester of pregnancy and an increased intracompartmental pressure in these affected upper limbs. These patients require an urgent treatment, which may minimize late consequences such as disrupted upper limb functionality and, in some cases, even amputations. The use of a regional anesthetic block, which causes a sympathetic block and with that, a vasodilatation, seems to improvesubstantially the final functional results. SIGNIFICANCE Efforts among the community of pediatric hand surgeons may be joined, in order to share knowledge and to provide new ideas. The origin and the possible treatments for this devastating condition may be more studied and detailed.
    Journal of Children s Orthopaedics 04/2014; 2014 (Suppl 1):S64-S65.
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    ABSTRACT: Introduction: The goal of an orthotic treatment in cerebral palsy (CP) is to come closer at best to a physiological gait. According to the Amsterdam Gait Classification, the pathological gait patterns of CP patients are divided into five gait types. This classification must be considered for an optimal care. During swing phase an ankle foot orthosis (AFO) prepares the foot for initial contact (IC). It also enables a better stability and supports the ankle's push off during stance phase. Besides, an AFO should have a positive effect on therapy and must not lock residual physiological motion. A detailed consideration of existing orthosis types should indicate whether the requirements for all gait types can be met. Materials and Methods: The effect of already existing AFO is evaluated. Considering the criteria of adjustable alignment, pivot point, range of motion and spring force, supramalleolar orthoses, solid AFO (SAFO), dynamic AFO (DAFO), floor reaction AFO (FRAFO), posterior leaf spring AFO (PLS AFO) and hinged AFO (HAFO) are compared with each other. Results: The alignment of most of the compared orthoses cannot be subsequently adjusted. In HAFO this is only possible to a limited extent depending on the joint type used. In PLS AFO, FRAFO and DAFO a defined pivot point is missing, while in HAFO it can be placed on the anatomical pivot point. Nevertheless, all orthoses lock the plantar flexion or just allow it through active muscle work. The range of motion is not possible, except for certain joint types (HAFO). In PLS AFO, FRAFO and DAFO the spring force can only be regulated by the material and its thickness used during producing. Elastomer spring or coil spring joints that are mounted in a HAFO have too low spring forces. Discussion: Due to an appropriate orthosis, coming closer to a physiological gait and improving the energy consumption of CP patients are possible. Depending on the gait type, different AFO are used for the treatment. Already existing AFO do not fulfil all necessary requirements because basic adjustment possibilities are missing. The spring force needed to be applied to the ankle by an AFO depends on the gait type as well as on the anthropometric data of the patient. The correct alignment of the orthosis using biomechanical principles is essential for a successful orthotic treatment. The remaining function of the muscles involved is used to provide the nervous system with proprioceptive input. This process is known as neuroplasticity and takes place especially during plantar flexion in IC. Therefore, the resulting demand is: Both dynamic and static AFO should be produced with an adjustable ankle joint. The optimal ankle joint for a HAFO should dispose of three adjustments that can be changed separately and do not influence each other: 1. spring force, 2. alignment of the orthosis and 3. range of motion.
    Journal of Children s Orthopaedics 10/2013; 7(4):329.
  • Journal of Children s Orthopaedics 12/2012;
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    ABSTRACT: Aim. Septic arthritis of the hip in childhood is a therapeutic emergency and can result in severe long-term sequelae in terms of loss of movement, pathologic hip dislocation, growth disturbance and leg-length discrepancy. The aim of this study was to compare results of open arthrotomy of the hip versus repeated ultrasound-guided aspirations. Methods. This study was carried out during the period between October 1999 and December 2006 at Prishtina University Hospital, Kosovo. During that period 28 children with acute septic arthritis of the hip were treated in our hospital. 14 of them were treated with repeated aspiration and irrigation with normal saline solution via an anterior approach under local anesthesia using ultrasound guidance. The other fourteen children underwent open anterior hip arthrotomy as an emergency procedure immediately after ultrasound-guided needle aspiration. Parentheral antimicrobial therapy was used for a total period of 20 days. Postoperatively the patients were given simply rest with skin traction for two weeks and non-weight bearing on the affected hip for four weeks followed by partial weight bearing for another three weeks. Results. Apyrexia was obtained after a mean period of 4 days. The mean number of aspiration was 5.6 (range 5-8), and 70% of the patients resumed walking after 72 hours. The mean follow-up time was 7.4 years (range 4-12). On the last follow-up visit all patients expect one in open anterior hip arthrotomy group were totally painless and had no limitation of physical activity. US-guided aspiration allowed selection of only those with septic arthritis for operative drainage or repeated ultrasound guided aspirations. Conclusion. Ultrasound-guided percutaneous aspiration irrigation drainage gave very good results in this study populations, earlier return to normal activity with rapid clinical and biological improvement and absence of long-term sequelae.
    EPOS 2012, Helsinki; 04/2012
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    ABSTRACT: Persistent tibial torsion in the older child can be treated with a derotation osteotomy. Distal tibial osteotomy has been recommended due to concerns of peroneal nerve palsy, vascular injury, and compartment syndrome with a proximal tibial osteotomy. However, an osteotomy in the proximal tibia may achieve union more rapidly and skin issues, as described for distal tibial osteotomies, are less likely. This study investigates the safety and efficacy of proximal tibial derotation osteotomies. We retrospectively reviewed 43 tibiae in 25 consecutive children with persistent tibial torsion treated with a proximal tibial derotation osteotomy between 1991 and 2006. Patients with concomitant varus or valgus osteotomies were excluded. Diaphyseal fibular osteotomies were performed in five patients, while all patients had a prophylactic anterior compartment fasciotomy. The mean age at surgery was 10.4 ± 4.0 years and the mean follow-up was 3.2 ± 3.5 years. Patients with internal tibial torsion had a mean preoperative thigh-foot angle (TFA) of -14° ± 6° and a mean postoperative TFA of 8° ± 4°. Patients with external tibial torsion had a mean preoperative TFA of 38° ± 9° and a mean postoperative TFA of 7° ± 5°. The overall mean correction was 26° ± 9°. Major postoperative complications occurred in 4 patients (9%), including one peroneal nerve palsy which resolved, one delayed union requiring revision surgery, and two patients with mild postoperative valgus deformities. Proximal tibial derotation osteotomy with an anterior compartment fasciotomy is a reliable method for treating tibial torsion with an acceptable complication rate. Given the larger bony surface area and improved soft tissue envelope, proximal tibial derotation osteotomy can be considered as an alternative to a distal tibial derotation osteotomy.
    Journal of Children s Orthopaedics 03/2012; 6(1):81-5.
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    ABSTRACT: Pamidronate, used for the treatment of paediatric osteoporosis, reduces the fracture rate and improves ambulatory status. Intravenous pamidronate therapy has known complications which have not been stratified based on its dose and distribution. This study aims to assess the early minor and major medical and late surgical complications and the effect of the dose and regimen of infusion on these events in paediatric osteoporosis. Retrospective cohort. Three regimens for pamidronate infusion were followed in sequential periods in 10 years. Regimen A delivered 1.5 mg/kg/day as a single dose once in 3 months. Regimen B delivered 2 mg/kg/day for 3 days twice a year, while regimen C delivered 1 mg/kg/day for 3 days every 3-4 months. Adverse events were classified as early (major and minor) or late (surgical). Forty-eight children received 158 infusions using one of the three regimens. Twenty-nine complications occurred in 24 children. A significant difference in the complication rate was present among the three regimens ( = 0.005). Nineteen children had minor complications, mainly febrile reaction or asymptomatic hypocalcaemia. Four major complications consisting of one seizure, one respiratory distress and two hypocalcaemic tetany were encountered, all with regimen B. Intraoperative complication faced was loss of position due to splintering of the cortex while rush rodding. This was seen in 20% of the long bone segments operated in those who received pamidronate as compared to 4.4% of the segments which were operated prior to the initiation of pamidronate therapy; the odds of splintering were 5.4 times higher for those patients who were bone segment rodded after pamidronate therapy. Intravenous pamidronate is associated with complications in 50% of children with paediatric osteoporosis, with a dose-dependent significant difference. Major complications are not uncommon with higher doses and can be avoided by increasing the number of doses per year and decreasing the dose per cycle. Surgical difficulty, when possible, can be avoided by correcting any major deformities at presentation prior to the induction of pamidronate therapy.
    Journal of Children s Orthopaedics 03/2012; 6(1):37-43.
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    ABSTRACT: Both congenital and acquired orthopaedic deformities are common in patients with spina bifida. Examples of congenital deformities, which are present at birth, include clubfoot and vertical talus. Acquired developmental deformities are related to the level of neurologic involvement and include calcaneus and cavovarus. Orthopaedic deformities may also result from postoperative tethered cord syndrome. The previously published Part I reviewed the overall orthopaedic care of a patient with spina bifida, with a focused review of hip, knee, and rotational deformities. This paper will cover foot and ankle deformities associated with spina bifida, including clubfoot, equinus, vertical talus, calcaneus and calcaneovalgus, ankle and hindfoot valgus, and cavovarus. In addition, this paper will address the issues surrounding skin breakdown in patients with spina bifida.
    Journal of Children s Orthopaedics 12/2011; 5(6):403-14.