Bojan Bukva

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period

BACKGROUND The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA). PATIENTS AND METHODS The study was performed at the University Childrens Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed. RESULTS There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation. CONCLUSION IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

Femoral neck fractures in children and the role of early hip decompression in final outcome

BACKGROUND Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome. PATIENTS AND METHODS The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Childrens Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications. RESULTS The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients. CONCLUSION Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression.

A prospective randomised non-blinded comparison of conventional and Dorgan's crossed pins for paediatric supracondylar humeral fractures.

BACKGROUND Closed reduction and percutaneous pinning are the preferred treatment of displaced supracondylar humeral fractures in children. The purpose of this study is to evaluate the non-standard Dorgans method and compare its results with those of the standard percutaneous cross pinning method in treatment of unstable or irreducible Gartland type II and III supracondylar humeral fractures in children. PATIENTS AND METHODS This was a prospective evaluation of 138 consecutive patients with Gartland type II or III extension supracondylar humeral fractures referred to University Childrens Hospital during a four-year period. The patients were randomized into two groups: the first group, comprised of 71 patients, was treated with standard pin configuration and the second group, comprised of 67 patients, underwent Dorgans method. The study included 88 boys and 50 girls aged 1.5-11.4 years (mean 6.5±2). At initial presentation 8.7% (n-12) fractures were classified as Gartland type IIa, 25.4% (n-35) as Gartland type IIb and 65.9% (n-91) as Gartland type III. RESULTS Flynns criteria were used to evaluate the results. An excellent clinical outcome was reported in about 90% of patients (n-90) treated with standard pin configuration and 89.5% (n-60) of patients treated with Dorgans method. There were no statistically significant differences in outcomes between the groups in terms of their gender, age, fracture types, function and cosmetics. Neurological lesions were observed in 9.9% of patients (n=7) who were treated using the standard configuration Kirschner pins, while in those treated by Dorgans method neurological complications were not observed. However, the procedure time was longer (mean 36.54±5.65min) and radiation exposure significantly higher (mean 10.19±2.70 exposures) in the group that was treated using Dorgans method, compared to the conventional method (mean 28.66±3.76min and 7.54±1.63 exposures). CONCLUSION Two laterally inserted crossed pins provide adequate stability with good functional and cosmetic outcome for most unstable paediatric supracondylar humeral fractures with no risk of iatrogenic ulnar nerve injury.

Late presentation of congenital pseudarthrosis of the clavicle

Congenital pseudarthrosis of the clavicle is a rare clinical entity, first described in 1910. We report on a 15 year old girl, who presented with a painless lump over mid-portion of right clavicle at her routine newborn examination, which was subsequently diagnosed as a congenital pseudarthrosis when she got into adolescence period. Here we explore its pathogenesis, elaborate on its diagnoses and differential diagnoses in paediatric patients, and comment on its distinct treatment.