Radial neck fractures in children: results when open reduction is indicated

BACKGROUND: Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed. METHODS: Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus. RESULTS: Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P=0.001), reduction of elbow flexion-extension (P=0.001), increase of elbow valgus angle (P=0.002), necrosis of the radial head (P=0.001), premature physeal closure (P=0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P=0.002). DISCUSSION: In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis

Histological changes of semitendinosus autograft after anterior cruciate ligament reconstruction in an immature rabbit model

INTRODUCTION: The anterior cruciate ligament (ACL) injury is one of the most common in the knee. Tendons can be used as alternative grafts for ACL repair, with tendon “ligamentization” often reported in literature. The purpose of this study was to evaluate the morphological and histological changes occurring in a semitendinosus tendon (ST) during ACL reconstruction in growing rabbits. MATERIALS AND METHODS: Twenty-one 8-week-old New Zealand white rabbits, weighing about 1500 g underwent reconstructive surgery on the right knee. In two cases the left knee was used to verify the normal microstructure of the ACL and ST in rabbits. The rabbits were then randomly divided into seven groups and sacrificed at 1, 4, 6, 8, 12, 24 and 48 weeks after surgery. The specimens were evaluated under light microscopy to analyze the changes in the intra-articular tract of the graft. The evidence of necrosis, neovascularization and organization of the collagen fibers were investigated. RESULTS: One month after surgery, numerous disorganized fibroblasts and collagenous fibers were identified. A marked reduction of cellular necrosis was observed in the early phase of the neo-ligament healing process. After 4 weeks, these fusiform-like cells became more rounded. By 8 weeks, the collagen fibers had become aligned in parallel with newly formed capillaries and highly differentiated fibroblasts. At 24 and 48 weeks the transplanted tendon differed histologically from both tendon and ligament. CONCLUSIONS: The data of the present study showed that ligamentization did not occur until at least 24 months post-operatively and, during healing, the grafted tendon assumed a unique micro-architecture that was a middle between a tendon and a ligament. The ACL reconstruction in pediatric age has become more frequent in these past recent years. The use of semitendinosus graft with preservation of its distal attachment should be the gold standard in skeletally immature patients

Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies - SOSORT award 2013 winner.

BACKGROUND: The Juvenile idiopathic scoliosis by age of onset, severity and evolutivity is source of great doubts concerning the purpose and use of conservative treatment. The different clinical experiences leave unsolved the question that arises in applying a conservative treatment when the patients are effectively forward a long growing period, in scoliosis characterized by inevitable evolutivity. The purpose of the present prospective study was to determine the effectiveness of conservative treatment in Juvenile idiopathic scoliosis. METHODS: From 1238 patients treated for idiopathic scoliosis between 1995 and 2012 fulfill the inclusion criteria 163 patients treated with PASB, Lyon brace and Milwaukee. Of these, 113 patients had a definite outcome, 27 have abandoned treatment e 23 are still in treatment. The minimum follow-up was 24 months. Radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning (t1), 6 months after the beginning (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-years minimum follow-up (t5). Three outcomes were distinguished in agreement with SRS criteria: correction, stabilization and progression. RESULTS: The results from our study showed that of the 113 patients with a definite outcome CM mean value was 29.6 ± 7.5 SD at t1 and 16.9 ± 11.1 SD at t5. TA was 13.5 ± 5.4 SD at t1 and 8.5 ± 5.6 at t5. The variations between CM t5-t1 and TA t5-t1 were statistically significantly different. Curve correction was accomplished in 88 patients (77.8%), stabilization was obtained in 18 patients (15.9%). 7 patients (6.19%) have a progression and 4 of these were recommended for surgery. Of 26 patients who abandoned the treatment, at the time of abandonment (12.5 age) have achieved curve correction in 19 cases (70.0%), stabilization in 5 cases (19%) and progression in 3 cases (11%). Of these patients, reviewed at the end of growing, four have been operated on. CONCLUSIONS: Our study confirmed that conservative treatment with brace is highly effective in treating juvenile idiopathic scoliosis, in particular most patients reaching a complete curve correction and only 4.9% of patients need surgery

Conservative treatment in Scheuermann's kyphosis: comparison between lateral curve and variation of the vertebral geometry

Abstract BACKGROUND: Conservative treatment in the Scheuermann's kyphosis obtain, during skeletal growth, remodelling of the deformed vertebras. In a previous paper on Scheuermann's kyphosis, we have studied the geometry variations of all vertebrae included in the curve, before and after the treatment. The purpose of this study was to confirm the effectiveness of conservative treatment in Scheuermann's kyphosis and was to evaluate and compare the variation of the vertebral geometry with the curve trend in Cobb degrees, before and after conservative treatment. METHODS: From a consecutive series of patients, we selected 90 patients with thoracic Scheuermann's kyphosis, treated using anti-gravity brace: 59 male, 31 female. The mean age at the beginning of the treatment was 14 years. Radiographical measurements were performed on radiographs from a lateral projection, at the beginning (t1) and at the end of the treatment (t5). Vertebral geometry modifications at t1 and t5 were analysed according to the following parameters and evaluated by three independent observers: Anterior wedging angle (ALFA) of the apex vertebra and Posterior wall inclination (APOS) of the limiting lower vertebra. The curve was measured in Cobb degrees. RESULTS: The results from our study showed that of the 90 patients with a thoracic curve mean value of Cobb degrees was 57.8\u2009\ub1\u20096.0 SD at t1 and 41.3\u2009\ub1\u20095.6 SD at t5. The differences between t1(angle at baseline) and t5 (end of treatment) were calculated for Cobb, ALFA and APOS angle and were respectively -16.4\u2009\ub1\u20094.5, -6.4\u2009\ub1\u20091.4 and -2.7\u2009\ub1\u20091.2; tested with paired t-test were significative (p\u2009<\u20090.01). The results of the regression analysis to test the relationship between the three measures for the kyphosis (Cobb degree, ALFA and APOS) showed that the best association was between Cobb t5 and ALFA t5 (p\u2009<\u20090.01) and Cobb t1 and APOS t1 (p\u2009<\u20090.01). No significative association was found between the difference between ALFA and APOS. CONCLUSION: We sustain that using new parameters to study vertebral remodelling allows us to reach a better comprehension of Scheuermann spine response to anti-gravity brace treatment. Furthermore, the evaluation of the ALFA angle of the apex vertebra confirms to be more reliable than Cobb's angle because it cannot be affected by the radiological position

Brace technology thematic series: the progressive action short brace (PASB)

<p>Abstract</p> <p>Background</p> <p>The Progressive Action Short Brace (PASB) is a custom-made thoraco-lumbar-sacral orthosis (TLSO), devised in 1976 by Dr. Lorenzo Aulisa (Institute of Orthopedics at the Catholic University of the Sacred Heart, Rome, Italy). The PASB was designed to overcome the limits imposed by the trunk anatomy. Indeed, the particular geometry of the brace is able to generate internal forces that modify the elastic reaction of the spine. The PASB is indicated for the conservative treatment of lumbar and thoraco-lumbar scoliosis. The aim of this article is to explain the biomechanic principles of the PASB and the rationale underlying its design. Recently published studies reporting the results of PASB-based treatment of adolescent scoliotic patients are also discussed.</p> <p>Description and principles</p> <p>On the coronal plane, the upper margin of the PASB, at the side of the curve concavity, prevents the homolateral bending of the scoliotic curve. The opposite upper margin ends just beneath the apical vertebra. The principle underlying such configuration is that the deflection of the inferior tract of a curved elastic structure, fixed at the bottom end, causes straightening of its upper tract. Therefore, whenever the patient bends towards the convexity of the scoliotic curve, the spine is deflected. On the sagittal plane, the inferior margins of the PASB reach the pelvitrochanteric region, in order to stabilize the brace on the pelvis. The transverse section of the brace above the pelvic grip consists of asymmetrical ellipses. This allows the spine to rotate towards the concave side only, leading to the continuous generation of derotating moments. On the sagittal plane, the brace is contoured so as to reduce the lumbar lordosis. The PASB, by allowing only those movements counteracting the progression of the curve, is able to produce corrective forces that are not dissipated. Therefore, the brace is based on the principle that a constrained spine dynamics can achieve the correction of a curve by inverting the abnormal load distribution during skeletal growth.</p> <p>Results</p> <p>Since its introduction in 1976, several studies have been published supporting the validity of the biomechanical principles to which the brace is inspired. In this article, we present the outcome of a case series comprising 110 patients with lumbar and thoraco-lumbar curves treated with PASB brace. Antero-posterior radiographs were used to estimate the curve magnitude (C_M) and the torsion of the apical vertebra (T_A) at 5 time points: beginning of treatment (t₁), one year after the beginning of treatment (t₂), intermediate time between t₁and t₄(t₃), end of weaning (t₄), 2-year minimum follow-up from t₄(t₅). The average C_Mvalue was 29.3°Cobb at t₁and 13.0°Cobb at t₅. T_Awas 15.8° Perdroille at t₁and 5.0° Perdriolle at t₅. These results support the efficacy of the PASB in the management of scoliotic patients with lumbar and thoraco-lumbar curves.</p> <p>Conclusion</p> <p>The results obtained in patients treated with the PASB confirm the validity of our original biomechanical approach. The efficacy of the PASB derives not only from its unique biomechanical features but also from the simplicity of its design, construction and management.</p