Alexander Wild

Risk-benefit analysis of prophylactic pinning in slipped capital femoral epiphysis.

There is a broad and controversial discussion about the surgical procedure and the type of hardware for internal transfixation of the epiphysis and metaphysis in slipped capital femoral epiphysis (SCFE). Prophylactic pinning is even more controversial. One hundred and nine patients showing SCFE underwent a one-stage bilateral fixation of the epiphysis with three or four Kirschner wires (pins). From these 109 patients (69 male and 40 female), 94 had an unilateral slip and were operated prophylactically on the contralateral side. There were no complications such as avascular necrosis of the femoral head, chondrolysis, bone fracture, failure of metal implant, osteomyelitis or deep wound infection either at the time of surgery or at the minimum follow-up of 1 year with prophylactic pinning in SCFE. Therefore, we consider pinning allows for efficient stabilization, reliably preventing any progression of SCFE on the affected side and, furthermore, prevents the incidence of a secondary slip on the primarily nondisplaced contralateral side. The transfixation of epiphysis and metaphysis with Kirschner wires (pins) shows good subjective and objective long-term results compared with other surgical methods and implants. There is only a low morbidity rate with this method, because reoperations may only become necessary in the younger age group owing to normal growth of the femoral neck, compared with a high benefit from prophylactic surgical treatment of the nonaffected opposite side at the time of unilateral onset of the disease. The pins may no longer catch the epiphysis but further growth will allow for remodeling of the femoral head and for an optimal neck/shaft ratio. In case of further growth and relative shortening of the pins, refixation may become necessary. Therefore, we like to recommend the Kirschner-wire transfixation (pinning) of the epiphysis and metaphysis in patients with SCFE for primary treatment of SCFE as well as for prophylactic pinning of the contralateral side in one sitting.

Correction of length discrepancies and angular deformities of the leg by Blount's epiphyseal stapling

Abstract. The management of leg length difference (LLD) and angular deformities of the leg remains controversial. Numerous treatment options have been proposed over the past years depending on the patients general condition, skeletal age, function, and degree and configuration of the deformity. Our retrospective study consisted of 48 patients with 58 legs treated between 1970 and 1991 by Blounts epiphyseal stapling to equalise length or correct angular deformity. After an average follow-up of 16.5 years, all patients with idiopathic bow-legs or knock-knees (n=12) and 71% of LLD caused by overgrowth (e.g. Klippel-Trenaunay syndrome) showed good and excellent results at skeletal maturity, whereas the results of the treatment of LLD with undergrowth of the leg and angular deformities due to trauma, infection or general dysplasia and malformation were fair to poor because of the difficulty in prediction of growth development and growth potential, allowing only for partial correction of the deformity. Besides the restriction of the stapling procedure due to the aetiology of the deformity, the age of the patients at the time of surgery is important, as it determines the complication rate of this technique (loosening or dislocation of staples). Thus Blounts epiphyseodesis should not be performed before the age of 9 years in girls and 11 years in boys. Conclusion: Blounts epiphyseal stapling can be recommended as a safe procedure with predictably good results in idiopathic angular deformities of the leg and leg length difference caused by overgrowth.

Ultrasound-guided botulinum toxin injection technique for the iliopsoas muscle

Intramuscular botulinum toxin A injections are beneficial for the treatment of functional shortening of the iliopsoas muscle, but it is difficult to achieve precise needle positioning and injection. As a solution to this we present an ultrasound‐guided injection technique for the iliopsoas muscle using an anterior approach from the groin. The procedure was performed 26 times in 13 patients (seven males, six females; mean age 11 years, SD 9 years 8 months; age range 4 to 31 years), 10 times bilaterally. Indications were functional iliopsoas shortening due to cerebral palsy (17 hips), hereditary spastic paraplegia (four hips), and Perthes disease (five hips). In all cases the iliopsoas muscle was identified easily by ultrasound; the placement of the injection needle and injection into the site of interest were observed during real time. No complications were encountered.

Radiological evaluation of unstable (acute) slipped capital femoral epiphysis treated by pinning with Kirschner wires.

Treatment of slipped capital femoral epiphysis is still controversial with regard to the implants used for stabilization and the need for prophylactic treatment of the contralateral, unaffected, side. The objective of this study was to ascertain whether prophylactic transfixation of the epiphysis with Kirschner wires in patients with unstable slipped capital femoral epiphysis resulted in significant disturbance of the growth plate and impairment of further growth of the femoral neck and head. Between 1990 and 1999, 29 patients with unstable slipped capital femoral epiphysis were simultaneously treated with internal fixation of the epiphysis and metaphysis with 3–4 Kirschner wires on the affected and the not (yet) affected side. After a mean follow-up of 3.5 years, we evaluated the hip joints radiologically, analysing different roentgenological parameters (CCD angle, femoral head diameter, length of the femoral neck and sphericity of the femoral head). CCD angle, femoral head diameter and length of the femoral neck showed statistically significant (P<0.001, Students t-test) differences between the affected and unaffected, but prophylactically pinned, sides. Asphericity of the femoral head was found in six cases only on the affected side, whereas all hips, which were operated prophylactically, showed spherical femoral heads at follow-up (P<0.02, Pearsons χ2 test). These results indicate that the slip itself may cause impairment of the femoral growth plate in patients with unstable slipped capital femoral epiphysis and not stabilization with Kirschner wires. Compared with other series from the literature using different implants (screws, nails), prophylactic transfixation of the epiphysis and metaphysis with Kirschner wires is less compromising to the growth plate on the not (yet) affected side.

Is sacral instrumentation mandatory to address pelvic obliquity in neuromuscular thoracolumbar scoliosis due to myelomeningocele

Study Design. Prospective study. Objective. To evaluate the functional outcome of two-stage anterior and posterior instrumented fusion without fixation to the sacrum on 11 patients with neuromuscular scoliosis from thoracolumbar myelomeningocele. Summary of Background Data. To our knowledge, there are no published results of combined anterior and posterior correction and fusion without inclusion of the sacrum in neuromuscular scoliosis from thoracolumbar myelomeningocele. In this article we present our experience and critically evaluate the functional outcome on 11 patients with neuromuscular scoliosis. Patients and Methods. From July 1, 1992 through June 30, 1995, 11 consecutive patients with severe thoracolumbar scoliosis were admitted at our hospital. The mean age at operation was 12 years 9 months (range 9 years 9 months to 14 years 6 months). All patients underwent a two-stage anterior and posterior spinal reconstruction. The patients were evaluated before surgery and after surgery. Results. All patients were observed for a mean of 4 years 11 months (range 42–88 months) from the time of second stage procedure. Before treatment the mean scoliosis was 81° (range 55–110°); this was reduced to a mean of 31° (range 8–70°), and at the final follow-up the correction had deteriorated slightly to a mean of 35° (range 12–80°). No patient had increased neurologic deficit or showed other major complication. Conclusions. Pelvic obliquity in thoracolumbar neuromuscular scoliosis from lumbosacral myelomeningocele spontaneously corrected when the scoliotic deformity is adequately addressed with instrumented fusion without inclusion of the sacrum. The correction obtained remained stable at follow-up. In the absence of a control group we believe that sparing lumbar segments from primary fusion offers these patients a better freedom of mobility.

Removal of lumbar instrumentation for the treatment of recurrent low back pain in the absence of pseudarthrosis

IntroductionRemoval of spine instrumentation for the treatment of recurrent low back pain remains controversial in the absence of pseudarthrosis and when no obvious pain generators are present. It is our practice to offer these patients surgical exploration and removal of instrumentation.Materials and methodsForty-five patients underwent an anterior and posterior lumbar spinal fusion. The removal of instrumentation was performed by the same surgeon and senior author of this paper (MRP). The reason for the revision surgery was recurrent low back and leg pain. All patients had a solid fusion based on a thorough surgical exploration of the fusion mass. Instrumentation was deemed either solid or loose at time of removal based on the purchase at the screw-bone interface. Final outcomes were determined using a functional and satisfactory questionnaire and compared between the two groups (Loose Instrumentation versus Solid Instrumentation).ResultsThe majority of the patients in both groups would recommend the surgery to a family member (79% overall), would have the surgery again themselves (82%) and consider the surgery a success (77%). Pain was significantly decreased from pre-operatively to post-operatively and from pre-operative to final follow-up in both groups. The group of patients with loose instrumentation were significantly more likely to have a successful outcome than the group without loose instrumentation.ConclusionsThis study indicates that the removal of instrumentation in the absence of pseudarthrosis is beneficial in the relief of low back pain and leg pain symptoms. Increased success rates were noted in patients with loose instrumentation. However, this classification was based on inter-operative inspection. Further studies of the ability to diagnose and predict success prior to surgery needs to be done.

The value of ultrasound after shoulder arthroplasty

Abstract Objective. This study was undertaken to evaluate whether sonography is a useful tool in the diagnosis of soft tissue disorders as a possible cause for discomfort and/or pain after shoulder arthroplasty. Design and patients. Static and dynamic ultrasound examinations were performed in the standard sectional planes on 22 patients with 25 hemiprostheses and the results were correlated with the clinical outcome. The stability was determined in the transverse and frontal planes and the clinical results were evaluated according to the Constant and Swanson scores. Results. Several pathological changes were detected: rotator cuff lesions, subdeltoid bursitis, changes around the long biceps tendon as well as an increase in intra-articular volume due to effusion and/or synovitis. The correlation of sonographic and clinical results demonstrated that patients with an excellent clinical result showed no or only a few pathological findings on sonography compared with those with a moderate or poor result. Conclusion. Pathological changes of the periarticular tissue in the direct neighbourhood of the implant can be detected by sonography, which can be recommended as a valuable examination technique to evaluate the soft tissue in patients after shoulder arthroplasty.

Treatment of Congenital Spondyloptosis in an 18-month-old Patient With a 10-year Follow-up

Study Design. Case report. Objectives. To present the case of a patient with congenital spondyloptosis treated and followed over 10 years. Summary of Background Data. The surgical management of spondyloptosis in children is variably reported in the literature. Some authors propose that posterior fusion in situ is a safe and reliable procedure, whereas others suggest that reduction of the slipped vertebra may prevent some of the adverse sequelae of in situ fusion, which include nonunion, bending of the fusion mass, and persistent lumbosacral deformity. Many investigators advocate a combined anterior and posterior fusion using instrumentation. Methods. At the time of the first symptoms an 18-month-old boy with congenital spondyloptosis of L5–S1 was referred to the authors’ institution. Because of the progression of pain, neurologic disturbance, mild foot deformity, muscle contractures, and lumbosacral kyphosis, surgical intervention was undertaken. Operative intervention began with a resection of the L5 lamina and wide bilateral L5 nerve root decompression. This was followed by anterior subtotal resection of L5 and interbody bone graft of the morcelized vertebral body for fusion from L5 to S1. The next step was reduction of the spondyloptosis and stabilization by posterior instrumentation L2–S1 with a sacral Cotrel-agraffe device. Results. The procedure achieved almost complete reduction of the spondyloptosis with near-normal restoration of lumbar lordosis allowing more physiologic lumbar spinal biomechanics. There were no neurologic complications. After surgery there was no suggestion of back pain or gait disturbance and no progression of any deformity. Conclusion. In the treatment of severe congenital spondylolisthesis a staged procedure of decompression, reduction, and instrumented fusion is recommended for those cases in which intervention is indicated.

Entwicklung der Beinachse im Kindesalter und Therapieoptionen bei kniegelenknahen Fehlstellungen

Krumme Beine sind ein häufiger Anlass,Kinder beim Kinderarzt oder Orthopäden vorzustellen. Am häufigsten bemerken die Eltern im Kleinkindalter O-Beine sowie einen Innenrotationsgang.Die Beurteilung, ob eine Beinachse noch normal oder pathologisch ist, setzt die genaue Kenntnis der physiologischen Beinachsenentwicklung voraus.Grundsätzlich sind alle 3 Ebenen des Raums zu beurteilen (Frontal-, Sagittal- und Transversalebene), da in jeder Ebene Abweichungen auftreten können.

Osteonekrosen bei Morbus Adamantiades-Behçet: Diagnostik, Therapie und Verlauf

Zusammenfassung.Studienziel : Ziel der vorliegenden Arbeit ist die Zusammenfassung von Daten zur ossären Beteiligung bei Morbus Adamantiades-Behçet (Behçet’s disease, BD, silk road disease), wobei die Diagnose dieser Erkrankung anhand dermatologischer, neurologischer und ophthalmologischer Auffälligkeiten gestellt wird. Die vorliegende Arbeit soll die diagnostischen und therapeutischen Schwierigkeiten, welche sich bei der Behandlung von BD assoziierten Arthritiden und Osteonekrosen ergeben, aufzeigen.Methode :Anhand einer Literatur-Recherche werden die aktuellen Daten über Knochen- und Gelenkbeteiligungen bei M. Behçet zusammengestellt. Beispielhaft wird über den 25-jährigen Verlauf einer Patientin mit M. Behçet, multiplen rezidivierenden Arthralgien und im Krankheitsverlauf auftretenden Osteonekrosen berichtet.Ergebnisse/Schlussfolgerung : Bei therapieresistenten chronischen oder intermittierenden Schmerzen im Bereich der großen Gelenke, sollte insbesondere beim Auftreten von kutanen Ulzerationen, ophthalmologisch-entzündlichen oder neurologischen Symptomen der M. Behçet mit in die Differenzialdiagnostik eingeschlossen werden. Ein frühzeitiges MRT-Screening der befallenen Gelenke sollte bei generell erhöhtem Osteonekrose-Risiko zur Erfassung von kurativ-therapierbaren Frühstadien durchgeführt werden.Summary.Aim : The aim of this study is to review the data of skeletal manifestations of Behçet’s disease (BD, Morbus Adamantiades- Behçet, silk road disease), which is clinically diagnosed by dermatological, neurological and ophthalmological symptoms. This paper demonstrates the diagnostic and therapeutic difficulties in the management of osteonecrosis and recurrent arthritis associated with BD. Arthrogenic symptoms are a well-recognized feature of the syndrome but low in incidence.Method : A literature review served as the database to show the characteristics of osseous and articular manifestations in Behçet’s disease. Furthermore, we present a 25-year clinical follow up of a patient with BD and multiple osteonecrosis.Results/Conclusions : Chronic or intermittent joint pain should lead the physican to include BD into the differential diagnosis especially if there are findings of cutaneous ulcerations, ophthalmological inflammations or neurological symptoms. For detection of osteonecrosis at an early stage, which would allow for successful treatment, MRI scans of at least the symptomatic joints are recommended.