Unstable paediatric diaphyseal both-bone forearm fractures requiring fixation have traditionally been treated with rigid internal fixation with plate and screws. Intramedullary stabilisation has grown in popularity over the last 25 years but may be associated with rotational deformity and subsequent loss of pronosupination. This systematic review aims to establish which treatment method provides better functional outcome.A systematic review of the published literature was performed, searching Medline, Embase, Pubmed and the Cochrane Library for English-language studies comparing intramedullary nailing with plate and screws in patients less than 18 years old with both-bone diaphyseal forearm fractures.Seven studies met the inclusion criteria. They were all retrospective comparative studies (level III or IV). One was age- and sex-matched. Three looked specifically at older children. No study reported a significant difference in functional outcome with either treatment.The currently available literature shows no difference in functional outcome between intramedullary nailing and plate and screw fixation, even in older children with less remodelling potential. Intramedullary nailing may therefore be the treatment of choice for simple fracture patterns due to shorter operative time, better cosmesis and ease of removal. Plating may still have a role in more complex injuries.

The clinical features that define congenital talipes equinovarus (CTEV) are the presence of four principal components, equinus, varus, adductus and cavus. Classification systems in CTEV often include a form of assessment of these components and also other concurrent clinical parameters which feature in the condition.Over a 14-year period from 1992 to 2006, 95 consecutive cases of CTEV were prospectively assessed and data recorded in order to investigate the relationships between the clinical parameters in CTEV and to compare these relationships with those that one would expect from our knowledge of the pathological anatomy and mechanics of the condition, relating these findings to the commonly used systems for classification.Ninety-five cases of CTEV had failed conservative treatment and had undergone surgical release. The mean age at surgical release and assessment was 9 months. Cluster analysis demonstrated that there were, broadly, two groups of patients. The first group was those patients with a greater equinus deformity (greater than 31°). This group had a greater adductus deformity and the presence of other parameters indicating increased severity (multiplanar stiffness with the presence of cavus and medial skin crease). The second group was those patients with a smaller equinus deformity (less than 31°) who were more heterogenous with regards to the other parameters.We analysed on a statistical basis the relevant aspects of the deformity in CTEV. We have demonstrated that there are certain parameters, namely, equinus and adductus, whose severity can reasonably predict the severity of other components of the deformity. With regards to hindfoot parameters, increased equinus is related to less sagittal plane reducibility and to stiff hindfoot varus (coronal plane stiffness). In terms of midfoot parameters, the degree of adductus is related to the presence of cavus deformity and the presence of a medial skin crease is associated with less reducibility of the adductus (axial plane stiffness). This is consistent with our current understanding of the pathological anatomy of CTEV and bears implications with regards to treatment and the design of proposed classification systems that are in use.

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.

BACKGROUND:

The recognition of the importance of femoral acetabular impingement (FAI) as a potential cause of hip pain has been stimulated by major efforts to salvage hip joints by reconstruction in order to prevent or delay the need for replacement. The purpose of this review is to define the nature of FAI, the various types, and how to make the diagnosis.

METHODS:

The review describes the characteristics of the hip that cause FAI and emphasizes understanding that the femoral and acetabular components normally function as a unit, complementing each other.

RESULTS

CONCLUSION:

The methods of making the diagnosis of FAI and their limitations are described. If the acetabulum and femur are considered to be independent of each other, conflict may occur, hindering function, and not be apparent. The increasing frequency of making this diagnosis based on abnormal anatomy on one side of the joint, often in face of unclear physical findings, can bring the diagnosis into question. FAI seen in Perthes disease and acetabular dysplasia is explained. Knowing how to analyze the hip, being aware of the limitations of various available clinical and diagnostic studies, and recognizing the continued and ever-changing extensive body of literature is important and challenging. This primer is just the beginning.

The erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count are frequently obtained in the work-up of post-operative fever. However, their diagnostic utility depends upon comparison with normative peri-operative trends which have not yet been described. The purpose of this study is to define a range of erythrocyte sedimentation rates and white blood cell counts following spinal instrumentation and fusion in non-infected patients.Seventy-five patients underwent spinal instrumentation and fusion. The erythrocyte sedimentation rate and white blood cell count were recorded pre-operatively, at 3 and 7 days post-operatively, and at 1 and 3 months post-operatively.Both erythrocyte sedimentation rate and white blood cell count trends demonstrated an early peak, followed by a gradual return to normal. Peak erythrocyte sedimentation rates occurred within the first week post-operatively in 98% of patients. Peak white blood cell counts occurred with the first week in 85% of patients. In the absence of infection, the erythrocyte sedimentation rate was abnormally elevated in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively. The white blood cell count was abnormally elevated in only 6% of patients at 1 month post-operatively. Longer surgical time was associated with elevated white cell count at 1 week post-operatively. The fusion of more vertebral levels had a negative relationship with elevated erythrocyte sedimentation rate at 1 week post-operatively. The anterior surgical approach was associated with significantly lower erythrocyte sedimentation rate at 1 month post-operatively and with lower white cell count at 1 week post-operatively.In non-infected spinal fusion surgeries, erythrocyte sedimentation rates are in the abnormal range in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively, suggesting that the erythrocyte sedimentation rate is of limited diagnostic value in the early post-operative period.

Osteogenesis imperfecta (OI) has been treated with bisphosphonates for many years, with some clear clinical benefits. In adults, there are reports of a new pattern of atraumatic subtrochanteric fractures with bisphosphonate treatment. This study assesses if bisphosphonate treatment leads to an altered pattern of femoral fractures.Retrospective review of imaging for a cohort of 176 bisphosphonate-treated OI patients to identify the locations of femoral fractures over a two-year period, as compared to a historical control group managed pre-bisphosphonates.Sixteen femoral fractures were identified in this time period in the bisphosphonate-treated group. All but two were within the subtrochanteric region. In comparison, the historical group-composed of 26 femoral fractures-had a more widespread fracture pattern, with the most frequent location being the mid-diaphysis. Many of the subtrochanteric fractures in the treatment group occurred with minimal trauma.It appears that concerns over the treatment of the adult osteoporotic population with bisphosphonates are amplified and mirrored in OI. It is possible that the high bending moments in the proximal femur together with altered mechanical properties of cortical bone secondary to the use of this group of drugs increase the risk of this type of injury, which warrants further modification of surgical management of the femur.

Osteogenesis imperfecta (OI) is a genetic disorder characterized by bone fragility and fractures. Patients with OI have clinical features that may range from mild symptoms to severe bone deformities and neonatal lethality. Numerous approaches for the classification of OI have been published. The Sillence classification is the most commonly used. In this study, we aimed at developing a more refined sub-classification by applying a proposed scoring system for the quantitative assessment of clinical severity in different types of OI.This study included 43 patients with OI. Clinical examination and radiological studies were conducted for all patients. Cases were classified according to the Sillence classification into types I-IV. The proposed scoring system included five major criteria of high clinical value: number of fractures per year, motor milestones, long bone deformities, length/height standard deviation score (SDS), and bone mineral density (BMD). Each criterion was assigned a score from 1 to 4, and each patient was marked on a scale from 1 to 20 according to these five criteria.Applying the proposed clinical scoring system showed that all 11 patients with Sillence type I (100%) had a score between 6 and 10, denoting mild affection. The only patient with Sillence type II had a score of 19, denoting severe affection. In Sillence type III, 7 patients (31.8%) were moderately affected and 15 patients (68.2%) were severely affected. Almost all patients with Sillence type IV (88.9%) were moderately affected.Applying the proposed scoring system can quantitatively reflect the degree of clinical severity in OI patients and can be used in complement with the Sillence classification and molecular studies.

Magnetic resonance imaging (MRI) has been successfully used in the determination of the adequacy of the surgical reduction of congenitally dislocated hips in children. We present the results of a prospective series of patients treated conservatively. MRI was performed in all hips after positioning was deemed adequate on radiographs after spica cast application. The goal of this study was to evaluate the usefulness of MRI in this indication.After the study was approved by our local ethics committee, 31 patients for a total of 36 dislocated hips were included. After the traction period, hip testing was performed and a hip spica cast was applied under general anaesthesia. All children had MRI within 1 week of reduction, without the need for contention or general anaesthesia. Hip reduction was assessed on axial and coronal MRI images.The concentric reduction of the hip was confirmed in 30 cases out of 36. In three cases, the dislocation was retrospectively suspected on radiographs and then confirmed. In the three remaining cases, hip dislocation was only diagnosed on MRI.MRI screening of congenitally dislocated hips after reduction procedures is a safe and reliable procedure to assess the concentric reduction of the hip. Even in doubtful cases, MRI detected persistent hip dislocations and was conducive to iterative reduction and satisfactory outcome and result.

Isolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.Twenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.The Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.Ponseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.

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.