Abdul Razak Sulaiman

Long-term effect on foot and ankle donor site following vascularized fibular graft resection in children.

This study was carried out to evaluate the long-term effect on the donor side of the foot and ankle following vascularized fibular graft resection in children. Eight patients underwent resection of the fibula for the purpose of a vascularized fibular graft by a surgical team who practiced leaving at least 6 cm residual distal fibula. The age of these children at the time of surgery was between 3 and 12 years. They were reviewed between 3 and 12 years after surgery. Two patients who underwent resection of the middle shaft of the fibula at 3 and 5 years of age developed abnormal growth of the distal tibia, leading to ankle valgus. They were treated with growth modulation of the distal tibial physis and supramalleolar osteotomy with tibiofibular synostosis. Another patient who underwent the entire proximal fibula resection at the age of 6 years had developed hindfoot valgus because of weakness of the tibialis posterior muscle. He required talonavicular fusion and flexor hallucis to tibialis posterior muscle transfer. Patients operated at the age of older than 8 years neither had ankle nor hindfoot deformity. We concluded that resection of the middle shaft of the fibula for the purpose of a vascularized fibula graft, leaving a 6 cm distal fibular stump in children younger than 6 years old, may give rise to abnormal growth of the distal tibial physis, leading to valgus ankle. The entire proximal fibular resection for the similar purpose in a 6-year-old child may give rise to weakness of tibialis posterior and hindfoot valgus.

Residual nonunion following vascularised fibular graft treatment for congenital pseudarthrosis of the tibia: a report of two cases

Resection and reconstruction using a vascularised fibular graft is a viable alternative treatment for congenital pseudarthrosis of the tibia, although distal junctional nonunion and residual deformity are known complications that are difficult to treat. We illustrate 2 cases in which bony union was achieved following a technique using fibular grafting and intramedullary nailing, without additional bone grafting. This technique was feasible because of hypertrophy of the fibular graft.

Outcome of traumatic hip dislocation in children.

We reviewed 13 patients without an underlying syndrome with traumatic hip dislocation between 3 and 10 years of age (mean 4.8 years) at the time of injury. The final reviews were between 1 and 11 years (mean 6 years). All children had posterior dislocation, except one, who had an anterior dislocation. Time taken from trauma to reduction was less than 6 h in three patients, 6 h to 1 day in two patients, 1 day to 3 weeks in seven patients, and 4 weeks in one. All of them underwent closed reduction, except two, who required open reduction through a posterior approach. All patients had excellent hip function and radiographic result on the basis of Garret classification, except for one with limping at 4 years after trauma. The patients treated with hip spica after reduction (10 patients) did not have recurrent dislocation whereas two out of three patients who were treated without postreduction hip spica developed recurrent dislocation. One out of 13 patients without an underlying syndrome and a 6-year-old patient with Down syndrome with neglected hip dislocation and radiological avascular necrosis at presentation recovered with congruent hip following a complete and maintained reduction. This case series suggested that closed reduction was possible for cases of neglected hip dislocation for up to 3 weeks. Open reduction through the posterior approach was safe in neglected irreducible posterior hip dislocation. Those hips that underwent complete reduction and were maintained reduced with hip spica had an excellent functional outcome even in the presence of avascular necrosis. This is a level IV study.

Proximal femoral focal deficiency as a manifestation of Antley-Bixler syndrome: a case report

We report a case of the Antley-Bixler syndrome in an 11-year-old girl. She presented with bilateral proximal femoral focal deficiency, right clubfoot, left radiohumeral synostosis, bilateral ear hypoplasia, cleft palate, tongue tie, missing teeth, congenital heart disease, a pelvic kidney with hydronephrosis, and mental retardation. Proximal femoral focal deficiency has never been reported before as a manifestation of Antley-Bixler syndrome. Her mother was exposed to radiation during an intravenous urogram done in the first trimester of pregnancy. Exposure to radiation has not been implicated as a cause of Antley-Bixler syndrome.

A modified surgical technique for neglected fracture of lateral humeral condyle in children.

Operative treatment for neglected fracture of lateral humeral condyle (LHC) is difficult because of contracted muscle, fibrous tissue formation, and indistinct bony edges. Its success depends on the ability to preserve blood supply during the surgery. We retrospectively reviewed eight cases of neglected fracture of LHC in children treated with open reduction with selected multiple ‘V’ lengthening of common extensor muscle and internal fixation. The patients were between 3 and 8 years of age. The period of neglect was between 3 and 20 weeks. Four patients with displacement of more than 10 mm and neglect for 5 weeks or more required lengthening of common extensor muscle aponeurosis. The follow-up assessments were between 1 and 6.3 years with a mean of 4.4 years. All patients had union by 2 months. They gained improvement of flexion range of motion between 60° and 120° with a mean of 86.3°. Loss of final range of motion compared with the normal side was between 5° and 35° with a mean of 10°. No patient had limitation of activities or pain. Six cases had excellent and two cases had good Dillon functional score. All patients had lateral condyle prominent with different severities. There was one mild avascular necrosis and one fishtail deformity. Both of them had almost full range of motion. All patients had early physeal closure, except one, who had only 1 year follow-up. There was no case of progressive valgus deformity. Children with neglected fracture of LHC would benefit from anatomical reduction and internal fixation through a proper exposure and if indicated combined with multiple ‘V’ lengthening of common extensor muscle aponeurosis. This is a level IV study.

Developmental dysplasia of hip screening using ortolani and barlow testing on breech delivered neonates.

ABSTRACT INTRODUCTION We conducted this study to compare the specificity and sensitivity of the Ortolani and Barlow tests performed by dedicated examiners, and to ascertain the incidence of developmental dysplasia of the hip (DDH) in breech babies. METHODS A dedicated examiner underwent specific training and testing by a paediatric orthopaedic surgeon. Routine examiners were medical officers who had basic training in medical school and were briefly trained by their superiors. The dedicated examiner examined 170 babies. Thirty babies including 5 babies with positive tests (according to the dedicated examiner) were examined by a blinded routine examiner. RESULTS of Ortolani and Barlow tests on 30 babies were compared with ultrasound examination by blinded radiologist. RESULTS Five babies had positive Ortolani and Barlow tests. The routine examiner did not detect positive Ortolani and Barlow tests. CONCLUSION The incidence of positive Ortolani and Barlow tests among breech babies was 2.8%. Result of Ortolani and Barlow tests by dedicated hip screener were better than results performed by routine examiner. KEY WORDS Ortolani and Barlow, Dedicated Examiner, Routine Examiner, Breech, Ultrasound.

Clinical Measurement of the Tibio-femoral Angle in Malay Children

Background: This study was conducted to find out the age when tibiofemoral angle starts to be in valgus and reaches maximum angle. The differences of the angles between genders were also studied. Methodology: This cross sectional study on tibiofemoral angle was conducted among 160 normal healthy children using clinical measurement method. The children between 2 18 months to 6 years old were assigned to 5 specific age groups of 32 children with equal sex distribution. Result: This study had shown a good inter-observer reliability of tibiofemoral angle measurement with intraclass correlation coefficient (ICC) of 0.87 with narrow margin of 95% confident interval (95% CI: 0.73, 0.94). The mean tibiofemoral angle for children at 2 , 3 , 4 , 5 and 6 years old were 2.25° (SD=0.53), 8.73° (SD=0.95), 7.53° (SD=1.40), 7.27° (SD=1.14) and 6.72° (SD=0.98) respectively. The age when they achieved maximum valgus tibiofemoral angle was 3 years old. The maximum mean (SD) tibiofemoral angle for boys, girls and all children were 8.91° (SD=1.17), 8.56° (SD=0.62) and 8.73° (SD=0.95)respectively. The mean tibiofemoral angle showed no statistically significant difference between girls and boys except for the 5-year-old group, in which the mean TF angle for girls was 7.560 (SD=0.95) and for the boys was 6.970 (SD=1.26) with p-value of 0.037. Conclusion: Measurement of tibiofemoral angle using the clinical method had a very good inter-observer reliability. The tibiofemoral angle in Malay population was valgus since the age of 2 years with maximum angle of 8.730 (SD=0.95) achieved at the age of 3 years.

Breakage of an intramedullary rod after bone union in congenital pseudoarthrosis of the tibia: a report of two cases

We report 2 patients with congenital pseudoarthrosis of the tibia who underwent intramedullary Rush rod transfixation through the ankle joint following refracture and nonunion of vascularised fibular grafting 6 and 8 months earlier. After 9 and 5 years, both Rush rods were broken at the level of the ankle joints, while the reconstructed area was solidly united. The growth of the distal tibia increased the distance of the tips of the broken rod and hence the ankle joint motion. The broken tips may damage the articular cartilage and result in valgus deformity of the ankle and limb length discrepancy.

Ankle reconstruction and lengthening strategy in type II fibular hemimelia: a report of two cases

Limb lengthening of fibular hemimelia is associated with progressive ankle valgus deformity. We reported a successful tibial lengthening in fibular hemimelia without recurrence of ankle valgus in 2 cases. The procedure involved 2 stages. First stage was a resection of the fibular remnant followed by a bending osteotomy through the distal tibial physis before the age of 2 years old. The second stage was a tibia lengthening up to 25% of its original segmental length performed at the age of 5 years old. There was neither progressive ankle valgus nor distal tibial growth arrest observed at 4 years follow-up.

Leg Length Discrepancy: Dynamic Balance Response during Gait

Balance in the human bodys movement is generally associated with different synergistic pathologies. The trunk is supported by ones leg most of the time when walking. A person with poor balance may face limitation when performing their physical activities on a daily basis, and they may be more prone to having risk of fall. The ground reaction forces (GRFs), centre of pressure (COP), and centre of mass (COM) in quite standing posture were often measured for the evaluation of balance. Currently, there is still no experimental evidence or study on leg length discrepancy (LLD) during walking. Analysis of the stability parameters is more representative of the functional activity undergone by the person who has a LLD. Therefore, this study hopes to shed new light on the effects of LLD on the dynamic stability associated with VGRF, COP, and COM during walking. Eighteen healthy subjects were selected among the university population with normal BMIs. Each subject was asked to walk with 1.0 to 2.0 ms−1 of walking speed for three to five trials each. Insoles of 0.5 cm thickness were added, and the thickness of the insoles was subsequently raised until 4 cm and placed under the right foot as we simulated LLD. The captured data obtained from a force plate and motion analysis present Peak VGRF (single-leg stance) and WD (double-leg stance) that showed more forces exerted on the short leg rather than long leg. Obviously, changes occurred on the displacement of COM trajectories in the ML and vertical directions as LLD increased at the whole gait cycle. Displacement of COP trajectories demonstrated that more distribution was on the short leg rather than on the long leg. The root mean square (RMS) of COP-COM distance showed, obviously, changes only in ML direction with the value at 3 cm and 3.5 cm. The cutoff value via receiver operating characteristic (ROC) indicates the significant differences starting at the level 2.5 cm up to 4 cm in long and short legs for both AP and ML directions. The present study performed included all the proposed parameters on the effect of dynamic stability on LLD during walking and thus helps to determine and evaluate the balance pattern.