Ann M. Capelli

Blount's disease: a retrospective review and recommendations for treatment.

Thirty-two patients treated for Blounts disease were retrospectively reviewed. The results of treatment were assessed by clinical and radiographic parameters and arbitrarily classified good, fair, or poor. Five patients were definitively treated with braces; five extremities were rated good and one poor. Twelve patients were treated with a proximal tibial osteotomy performed before their fifth birthday. Nineteen extremities were rated good, one fair, and three poor. Fifteen patients had their initial surgical procedure after the fifth birthday. Eight extremities were rated good, six fair, and seven poor. Recurrence of the varus deformity secondary to an unsuspected medial bony physeal bar occurred in four patients. Resection of this bony bridge concomitant with a varus correcting osteotomy may be indicated. For severe deformity in older children, several different salvage procedures were used.

Pulseless Arm in Association with Totally Displaced Supracondylar Fracture

Seven children (3-10 years of age) were treated for a type III supracondylar fracture of the humerus. All fractures were reduced and pinned. Closed reduction was performed in four patients; three required open reduction. Before reduction six of the seven patients did not have a distal palpable pulse in the involved forearm. After reduction of the fractures all patients had a pulseless arm and a seemingly viable hand. Doppler pulses were absent or greatly diminished compared with the normal side in all involved extremities. Six patients underwent immediate antecubital fossa exploration of the brachial artery without arteriogram; one patient, referred to us from another facility, underwent angiography followed by immediate exploration. In three patients the brachial artery was directly damaged or transected and was repaired via saphenous vein graft, with reestablishment of distal pulses in each case. In the other four patients the brachial artery was kinked or entrapped at the fracture site, necessitating microdissection to mobilize the vessel and reestablish pulses in each case. At an average follow-up of 30 months, all seven patients had normal circulatory status, including a radial pulse. All fractures had healed, and all extremities had a normal carrying angle and normal elbow motion. Immediate exploration of the antecubital fossa should be considered if an extremity remains pulseless (to palpation and Doppler) after reduction and stabilization of significantly displaced supracondylar fractures of the humerus.

Treatment of severe torsional malalignment syndrome.

Over a 7-year period (1984-1991), nine patients (aged 10-18 years) with 13 involved extremities were operatively treated for symptomatic severe torsional malalignment of the lower extremity and associated patellofemoral pathology. Physical examination and analysis of gait revealed severe rotational deformity characterized by excessive femoral anteversion and external tibial torsion. The cosmetic and functional pathologic effect of this torsional malalignment was centered about the knee joint. In all patients, conservative treatment, including therapy for muscle strengthening and nonsteroidal medication, was unsuccessful in alleviating suspected patellofemoral pain. Subsequent definitive operative treatment in all 13 extremities consisted of corrective osteotomies, internally rotating the distal part of the tibia or externally rotating the distal part of the femur or both. Osteotomies were performed as close to the knee joint as possible. No additional soft-tissue procedures were performed directly to affect patellar tracking. All osteotomies healed without complications. At an average follow-up of 2 years + 7 months (range, 18-48 months) overall, patients had an improvement in gait pattern, extremity appearance, and a marked decrease in knee pain.

Congenital longitudinal deficiency of the tibia.

Fifty-seven patients (seventy-one limbs) who had congenital longitudinal deficiency of the tibia (tibial hemimelia) were retrospectively categorized according to radiographic type (Types 1 through 4, as described by Jones et al.). At an average follow-up of nine years, fifty-six of fifty-seven patients walked independently. An ablative surgical procedure was performed on sixty-one of the seventy-one lower extremities. According to the classification of Jones et al., fifty-four limbs had a Type-1 (a or b) or Type-2 deficiency. In twenty-two of these extremities, disarticulation of the knee was performed; in twenty-five, a Syme amputation; and in one, a Chopart amputation. The ipsilateral foot was retained in six extremities that had a severe Type-1 or Type-2 deficiency. Medial transfer of the fibula (the Brown procedure) generally yielded less than satisfactory results; in ten of fourteen extremities, one or more additional operations were needed. Seventeen extremities were classified as having a Type-3 or Type-4 deficiency; Syme amputation was done in nine and Chopart amputation, in four. Despite satisfactory reconstruction of the ankle, a Syme amputation was necessary in most extremities that had a Type-4 deficiency because a major leg-length discrepancy was projected. In four limbs that had a Type-3 or Type-4 deficiency, the foot was retained.

Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders.

We studied the results of 140 STA-peg arthroereisis procedures performed for the treatment of planovalgus foot deformity in 78 ambulatory children with neuromuscular disease. Patient age at surgery ranged from 2 + 2 to 14 + 11 years, with a mean of 7 + 9 years. Patients were followed up for an average of 4 + 6 years. The ultrahigh-molecular-weight polyethylene (UHMWPE) STA-peg implant is inserted laterally into the subtalar joint such that its stem extends inferiorly into the calcaneus and its collar abuts the inferior surface of the lateral process of the talus, thereby blocking excessive valgus tilt of the calcaneus. All but five patients (nine feet) had concomitant soft-tissue procedures to balance the foot. The talocalcaneal angle and the talar declination angle were measured on lateral radiographs preoperatively, postoperatively, and at the latest follow-up visit. Patients were evaluated for the presence of pain and hindfoot valgus deformity. Satisfactory results were achieved in 135 (96.4%) feet. Results were unsatisfactory in one foot of each of five patients who had bilateral procedures; one was painful, and four developed varus. The STA-peg was removed in these five patients. No infections or adverse tissue reactions to the STA-peg implant were observed. STA-peg arthroereisis, combined with satisfactory muscle-balancing procedures, can predictably achieve control of planovalgus foot deformity in children with neuromuscular disorders and may obviate the need for long-term orthotic wear.

Pemberton pelvic osteotomy and varus rotational osteotomy in the treatment of acetabular dysplasia in patients who have static encephalopathy

Forty-four patients (fifty-two hips) who had static encephalopathy and acetabular dysplasia were managed with a Pemberton osteotomy as part of a comprehensive operative approach. Thirty-three patients had quadriplegia and were unable to walk; the remaining eleven patients had diplegia and could walk. The age at the time of the operation ranged from four years and five months to sixteen years and five months, as an open triradiate cartilage is a prerequisite for the Pemberton procedure. Concomitant operative procedures included a varus rotational osteotomy in fifty of the involved hips, a soft-tissue release in thirty-seven hips, and an open reduction in thirteen hips. The mean center-edge angle preoperatively was -11 degrees (range, -80 to 17 degrees), which improved to a mean of 27 degrees (range, 5 to 62 degrees) at the time of the latest follow-up. The mean duration of follow-up was four years (range, two years to eight years and eight months). At the time of writing, none of the hips had redislocated but one hip had subluxated. Eight of the hips had been painful preoperatively, but none of these was painful at the time of the most recent follow-up. One patient who had not had pain in the hip preoperatively had pain at the time of the follow-up evaluation. There were no complications attributable to posterior uncovering of the hip. The age of the patient at the time of the operation had no discernible effect on the result.

Elevation of the medical plateau of the tibia in the treatment of Blount disease.

Seven children, between ten and thirteen years old, had elevation of the medial plateau of the tibia for correction of severe varus deformity secondary to Blount disease. The deformity was severe (grade V or VI according to the system of Langenskiöld and Riska) in all patients; the average preoperative varus deformity, determined by the angle formed by the femoral shaft and the tibial shaft, was 25 degrees. The goal of the operation was restoration of a more normal configuration of the articular surface of the proximal end of the tibia. This was accomplished by direct elevation of the depressed medial tibial plateau. All patients had an osteotomy to correct the alignment of the tibia. The osteotomy was performed concomitant with the elevation of the plateau in three patients, before the elevation in three, and after the elevation in one patient. Four patients had a concomitant osteotomy of the femur to align the knee joint parallel to the floor. The results were good in five patients and fair in two.

Management of lower-extremity deformities in osteogenesis imperfecta with extensible intramedullary rod technique: a 20-year experience.

Twelve patients (seven boys, five girls) who had osteogenesis imperfecta were treated with an extensible-rod system in 21 femurs and 15 tibias. Indications for use of extensible rods were multiple fractures, long-bone deformity prohibiting bracing and ambulation, and significant remaining linear growth. The average patient age at the time of placement of the extensible rods was 6 + 8 years (range, 2 + 4-10 + 10). Six femurs were treated with overlapping Rush rods; Bailey-Dubow rods were used in the remaining femurs and in all tibias. The average length of follow-up was 5 + 9 years (range, 2 + 0-3 + 2). Preoperatively, four of the 12 patients had never walked; postoperatively, all were ambulators with varying levels of assistance. Fourteen complications occurred, 12 of which required operative revision of the extensible rods. The average time between primary extensible rodding and revision was 5 + 1 years. No complications have occurred to date related to the use of overlapping Rush rods. No growth disturbance resulted from the use of the extensible-rod systems.

Pemberton osteotomy for the treatment of developmental dysplasia of the hip in older children

A retrospective analysis was done of the results of the Pemberton osteotomy for the treatment of developmental dysplasia of the hip in 16 hips of 14 children older than 7 years. The average age of the patients at the time of surgery was 11+6 years and the average follow-up was 4+10 years. Eleven hips required one or more surgical procedures concomitant with the Pemberton osteotomy to achieve a concentric and congruous reduction of the hip joint. None of the hips developed avascular necrosis of the acetabular fragment. The center-edge angle improved from a preoperative average of 1 degree to an average of 30 degrees at the most recent follow-up. Correction of acetabular dysplasia was noted in 14 of the 16 hips, as demonstrated by the improvement in the acetabular index, the center-edge angle, and the Severin class. We believe that the Pemberton osteotomy can be a safe and effective procedure for the treatment of developmental dysplasia of the hip in the older child.

Premature closure of the triradiate cartilage: a potential complication of pericapsular acetabuloplasty.

A case of premature triradiate cartilage closure secondary to a Gill acetabuloplasty performed at age 14 months is reported. The deficiency in acetabular development and failure of the pelvis to grow to its anticipated height is documented. A proximal femoral redirectional osteotomy and an innominate osteotomy performed near maturity improved femoral head coverage and hip biomechanics. Acetabuloplasties performed adjacent to the triradiate cartilage typically do not have any adverse effect on its function. Despite this low risk of injury to the triradiate cartilage after a Gill or Pemberton acetabuloplasty, long-term follow-up is recommended to observe acetabular development. Premature closure is most likely to occur if the bone graft used to maintain fragment displacement crosses the triradiate cartilage.