The role of Taylor spatial frame in the treatment of Blount disease

BACKGROUND: Alteration of the posteromedial part of the proximal tibia is the main characteristic of Blount's disease and if left untreated, leg alignment and normal development of the lower limbs may be compromised.AIM: To report treatment outcomes in children with Blount's disease using the Taylor Spatial Frame (TSF).MATERIALS AND METHODS: From January 2007 to December 2014, 16 young children (24 tibia) with a mean age of 7.5 years (range of 3-14 yrs) and severe Blount's disease were treated using TSF. Preoperative long standing radiographs were performed and anatomic medial proximal tibial angle (MPTA), diaphyseal-metaphyseal tibial angle (Drennan), femoro-tibial angle and leg length discrepancy (LLD) were measured.RESULTS: Post-operative improvement of all measurements was observed. MPTA increased from a mean of 71.8\ub0 (58\ub0 - 79\ub0) to 92.5\ub0 (90\ub0 - 95\ub0), the Drennan decreased from 16.6\ub0 (14\ub0 - 18\ub0) to 3.6\ub0 (0\ub0 - 6\ub0), the F-T angle changed from 15.4\ub0 (10\ub0 - 25\ub0) of varus to 5.9\ub0 (2\ub0 - 10\ub0) of valgus and the LLD decreased from 208 mm (150-320) to 69 mm (0- +120). Mean follow-up was 45.6 months. According to Paley's criteria pin track infection was present in 6 tibiae, while in 5 patients software changes were necessary. Recurrence was observed in 3 patients (triplets). Complete restoration of the mechanical axis was obtained at the end of the treatment.CONCLUSIONS: In the last decades, different surgical treatments have been proposed for Blount's disease (tension band plate, staples, osteotomies using external or internal fixation). External fixation using the TSF allows gradual safe correction of multiplanar deformities and is a well-tolerated technique by patients with Blount's disease

Spondyloepiphyseal dysplasia in three generations

Spondyloepiphyseal dysplasia is a heterogeneous group of disorders characterized by growth abnormalities in the epiphyses and spine. The purpose of this study is to present a rare case of three patients with a congenital type of spondyloepiphyseal dysplasia, all members of a single family spanning three generations. Interestingly, each one presented with variable radiographic severity and clinical picture. Spondyloepiphyseal dysplasia is a disorder that should always be taken into consideration during investigations of short stature. The relevant literature is presented and discussed. © Springer-Verlag 2004

Outcome models in peripheral nerve repair: Time for a reappraisal or for a novel?

Peripheral nerve injuries are still underestimated. The complexity of assessment of outcome after nerve injury and repair has been described by many authors. Furthermore, the outcome is influenced by several factors that depend on mechanisms in the peripheral as well as the central nervous system. Appropriate formulation of a global accepted postoperative clinical protocol for peripheral nerve repair in the upper extremity remains a subject of debate. The purpose of this review is to detail the current concepts of methods of evaluation after peripheral nerves repair. Finally, we discuss the most crucial factors that determine the final hand function and we consider the challenges that need to be addressed to create a realistic clinical protocol that reflects a prognostic importance. © 2011 Wiley Periodicals, Inc

The biomechanical capacity of the periosteum in intact long bones

Introduction: The biological function of the periosteum is profusely described but its contribution to the biomechanical properties of the bone has been considered negligible. The purpose of this study was to examine the biomechanical properties of periosteum-preserved long bones. Materials and methods: The biomechanical properties of both femora and tibiae of 30 male, 4-month-old Wistar rats were evaluated using a destructive three-point-bending testing protocol. In both bones from one side the periosteum was preserved, while in the contralateral bones the periosteum was stripped off. Ultimate strength, stiffness, energy absorption and deflection were derived automatically from the load-deformation curve recorded for each bone. Results: As regards the femur, the periosteum-covered bones displayed statistically significant higher values for all parameters measured compared to the periosteum-stripped bones. Ultimate strength, stiffness, absorbed energy and deflection of stripped and periosteum-covered femora were, respectively, 146.76 ± 44.71 and 196.01 ± 41.47 N, 44.25 ± 17.35 and 61.62 ± 15.07 N/mm, 0.00054 ± 0.00274 and 0.00011 ± 0.00354 Nmm, 0.67 ± 0.25 and 1.07 ± 0.28 mm. In the tibia, only energy absorption (0.00353 ± 0.00199 and 0.0010 ± 0.00339 Nmm) and deflection (1.71 ± 0.56 and 0.86 ± 0.36 mm) were significantly higher in the periosteum-covered bones. The pattern of bone failure was also different in the two groups. In periosteum-covered bones the two bone parts remained in close apposition stabilized by the periosteal membrane, while in a few cases the periosteum was stretched or torn opposite the loading site. Conclusion: The periosteum not only has significant biological function but also provides mechanical support to the bone and amplifies the biomechanical capacity of intact rat long bones in bending, probably taking advantage of its fibrous and elastic properties. © Springer-Verlag 2007

The orthopaedic aspect of spastic cerebral palsy

Spastic Cerebral Palsy (CP) is the most common form of CP, comprising of 80% of all cases. Spasticity is a type of hypertonia that clinically manifests as dynamic contractures. The dynamic contracture along with the reduced level of physical activity in a child with CP leads to secondary structural and morphological changes in spastic muscle, causing real musculotendinous shortening, known as fixed contractures. When fixed muscle contractures are not treated early, progressive musculoskeletal deformities develop. As a consequence, spastic CP from a static neurological pathology becomes a progressive orthopaedic pathology which needs to be managed surgically. Orthopaedic surgical management of CP has evolved from previous “multi-event single level” procedures to a “single event multilevel” procedures, with changes in selection and execution of treatment modalities. There is increasing evidence that multilevel surgery is an integral and essential part of therapeutic management of spastic CP, but more research is needed to ensure effectiveness of this intervention on all domains of physical disability in CP. © 202

Distal Intramedullary Nail Interlocking: The Flag and Grid Technique

Distal interlocking in intramedullary nailing of long bone fractures accounts for a significant proportion of the total fluoroscopy and operative time. We describe a modification of the “perfect circles” freehand technique employing a metallic grid temporarily attached to the skin of the lateral surface of the femur or to the medial surface of the tibia that acts as a fixed “navigational” aid. The position of the distal nail holes in relation to the grid is fluoroscopically ascertained. Subsequently, under fluoroscopic control, a modified Steinmann pin with a metallic handle attached to its blunt end (“flag”) is used to accomplish targeting and to create the screw holes, affording improved visualization. This technique was compared with the traditional freehand technique in 2 groups of patients. Use of the modified technique led to reduction of radiation exposure and total distal interlocking time, and there were no significant complications related to the technique. © 2005 Lippincott Williams & Wilkins, Inc

Results of extra-articular subtalar arthrodesis in children with cerebral palsy

Background: Grice-Green extra-articular subtalar arthrodesis is considered to be a valid surgical method which improves foot alignment in patients with spastic pes planovalgus deformity. The purpose of the present study was to examine the longterm results of Grice-Green procedure and whether it can achieve significant correction of each of the components of pes planovalgus deformity. Methods: Eleven children (16 feet) with cerebral palsy who underwent Grice extra-articular subtalar arthrodesis were reviewed retrospectively. The mean age of patients at the time of surgery was 9 years and 8 months (range, 6 years 5 months to 12 years 4 months). The mean followup was 3 years and 7 months (range, 2 years 1 month to 8 years 3 months). Seven radiographic parameters of each patient before surgery, after surgery and at the latest followup were used. In addition, position of the graft relative to the weightbearing axis of the tibia was evaluated. Results: Most of the examined parameters showed statistically significant correction which was maintained in the long run. Moreover, the placement of the graft along the mechanical axis seemed to play an important role for stability and preservation of correction of the planovalgus deformity. On the other hand, there were three cases where the osseous graft was absorbed and two cases where triple arthrodesis was necessary due to recurrence of the deformity. Conclusion: Grice-Green extra-articular subtalar arthrodesis improves foot alignment in patients with spastic pes planovalgus deformity and can achieve significant correction, postoperatively as well as on a long-term basis, of each of the components of pes planovalgus deformity. Copyright © 2012 by the American Orthopaedic Foot & Ankle Society

Intrinsic passive stiffness of 2 constructs of varus proximal femoral osteotomy: External fixator or blade plate

Background: Despite the published clinical evidence of the implementation of external fixation of proximal femoral osteotomies, there is lack of specific laboratory justification. Methods: Two groups of 5 adult composite femur constructs of varus proximal femoral osteotomy were tested under incremental and cyclical loading of up to 600N along the mechanical axis. Five were fixed with a blade plate and another 5 with a monolateral external fixator. Load versus displacement curves were produced, and passive stiffness of all constructs was calculated. The described loading regime aimed to simulate the initial postoperative state and provide data for the assessment of vertical intrinsic passive stiffness in partial weight-bearing conditions. Results: Although the blade plate constructs showed higher average stiffness, this was not statistically significant [F(1,8) = 1.712, P = 0.23]. No construct failed. No failure or plastic deformation was observed under the described loading regime. Conclusions: Vertical intrinsic passive stiffness in partial weight- bearing conditions during the initial postoperative period can be considered satisfactory subsequent to unilateral external fixation of a varus intertrochanteric osteotomy. Clinical Relevance: The results support the hypothesis that external fixation is a biomechanically sound alternative to internal fixation of varus intertrochanteric osteotomies, in selected patients. Copyright © 2010 by Lippincott Williams & Wilkins