Daniel Weigl

Monitoring of the sciatic nerve during hamstring lengthening by evoked EMG

Traction injury to the sciatic nerve can occur during hamstring lengthening. The aim of this study was to monitor the influence of hamstring lengthening on conduction in the sciatic nerve using evoked electromyography (EMG). Ten children with spastic cerebral palsy underwent bilateral distal hamstring lengthening. Before lengthening, the evoked potential was recorded with the patient prone. During lengthening, it was recorded with the knee flexed to 90 degrees, 60 degrees and 30 degrees, and at the end of lengthening with the hip and knee extended. In all patients, the amplitude of the evoked EMG gradually decreased with increasing lengthening. The mean decrease with the knee flexed to 60 degrees was 34% (10 to 77), and to 30 degrees, 86% (52 to 98) compared with the pre-lengthening amplitude. On hip extension at the end of the lengthening procedure, the EMG returned to the pre-lengthening level. Monitoring of the evoked EMG potential of the sciatic nerve during and after hamstring lengthening, may be helpful in preventing traction injury.

Immobilisation of forearm fractures in children: EXTENDED VERSUS FLEXED ELBOW

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.

Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic-impregnated cement rods.

Background Chronic osteomyelitis (CO) is rarely encountered in developed countries and is especially rare in children and adolescents. However, on occurrence, it can pose a difficult therapeutic challenge necessitating a combination of aggressive surgical treatment and prolonged antibiotic administration. Methods Four patients were treated for CO in the Pediatric Orthopaedic Unit at Schneider Childrens Medical Center between June 2005 and December 2006 and were reviewed retrospectively. Surgical treatment consisted of debridement and lavage, reaming of the intramedullary canal and insertion of gentamycin-impregnated polymetamethacrylate rods into the canal and beads around the infection site. At rod removal reaming and lavage were repeated. Antibiotic treatment was initiated with intravenous cephalothin, followed by prolonged oral treatment according to bacterial sensitivity. Results Cement rods and beads were removed 16 to 62 days after insertion. Intravenous antibiotics were continued for 6 weeks (3-13) and total antibiotic treatment length was 16 weeks (10-37). Total treatment time from presentation to full resolution averaged 8 months (2-18). One patient sustained a fracture requiring osteotomy and correction. At mean follow-up of 41 months from rod removal (36-46), all patients are asymptomatic and fully functional with no clinical signs of infection. C-reactive protein is within normal limits in all 4 patients. Conclusions The method presented combining reaming, lavage and local and systemic antibiotic treatment was found to be safe and effective in the treatment of CO, eradicating the infection and preventing further tissue loss. Level of Evidence Therapeutic study, clinical case series: level IV.

Botulinum toxin for the treatment of spasticity in children: attainment of treatment goals.

Forty patients (mean age 5 years) with a spastic disorder treated by botulinum injections (53 sessions) were evaluated for functional outcome in terms of achievement of their individual predetermined goals of treatment, rated on a modified Goal Attainment Scale from 1 (worsening function) to 4 (improved gross motor function). At the 2-week follow-up, 40% had a score of 1, 33% a score of 2, and 13% a score of 3; 12% showed no functional change. Botulinum treatments failed to significantly improve the gross motor function in this patient group. Treatment goals and expectations should clearly be established beforehand.

Small-fragment wounds from explosive devices: need for and timing of fragment removal.

The management of soft tissue small-fragment wounds caused by bombs remains controversial. The authors analyzed the outcome of low-energy foreign body injuries in 10 pediatric victims of suicide bomber attacks treated in their institution over a 2-year period. Two died during primary surgery. The eight survivors underwent a total of 10 procedures for removal of foreign bodies. Average follow-up was 24.1 months. The indications for the procedures were analyzed by the time of their performance: immediate, as part of the primary emergency operation (n = 2); intermediate, within 2 weeks after injury (n = 3); and late, more than 2 weeks after injury (n = 5). The results showed that all operations performed for objective indications were done within the immediate or intermediate period, whereas those done for subjective reasons were all but one performed in the late period. By the final follow-up visit, all foreign bodies had been removed. In conclusion, fragment removal is best done during the primary procedure if it does not pose a significant risk of complications.

Fractures and refractures after femoral locking compression plate fixation in children and adolescents.

Background: Locking compression plates (LCPs) are being increasingly utilized in fixation of fractures and osteotomies in the pediatric population. However, plate insertion or removal may pose a risk of femoral fractures or refractures. The goal of this study was to analyze failure patterns associated with LCPs and identify possible contributing factors. Methods: The sample included all patients who underwent fixation of femoral fractures or osteotomies utilizing straight LCPs at a tertiary pediatric medical center from 2004 to 2009. All were followed up until fracture union. The charts and radiographs were reviewed, and data on demographics, indications, surgical technique, and timing of plate removal were summarized. In cases of failure, the timing, circumstances, fracture location, and refixation method were recorded. Results: Thirty-seven patients underwent 41 straight LCP fixations during the study period. The indication for surgery was acute femoral fracture in 25 procedures (25 patients) and elective osteotomy or limb lengthening in 16 procedures (12 patients). Thirty-five plates were removed after complete clinical and radiographic union. The time from plate fixation to removal averaged 13 months (range, 5 to 34 mo) in the fracture group and 17.6 months (range, 7.5 to 28 mo) in the osteotomy group. Five procedures (12%) were complicated by femoral fractures or refractures: 2 occurred after the index surgery—1 at the proximal screw and 1 through the original fracture site, with plate breakage. Three patients sustained refractures after plate removal, all at the original fracture or regenerate site: 1 after a fall and 2 spontaneously. The average time from plate removal to refracture was 18 days (range, 10 to 30). There were no differences in demographics, timing, or technique between patients with and without complications. Conclusions: Although LCPs are considered flexible fixators, they may carry the risk of overstiffness, similar to external fixators. Further clinical and biomechanical studies are needed to evaluate risk factors for fractures or refractures, particularly in children. There seems to be an increase in risk of refracture immediately after plate removal. Caution should be taken in the first weeks after plate removal. Level of Evidence: Level IV.

Correction of Lower Limb Deformities in Children With Renal Osteodystrophy by the Ilizarov Method

Background: Children with renal osteodystrophy (ROD) may develop severe angular deformities of the limbs. Various methods, both medical and surgical, have been described for correction of these deformities, but a literature search showed only 1 child previously treated by the Ilizarov method. The purpose of this study was to characterize the deformities found in our group of patients and to describe our experience in treating these patients with the Ilizarov method. Methods: Correction of angular deformity by the Ilizarov method was performed on 8 limb segments in 5 patients with ROD. Mean age was 14.9 years. Two patients were on hemodialysis, and 3 had functioning kidney grafts. Surgery was deferred until stabilization of metabolic parameters. Results: There was 1 varus and 7 valgus deformities. Preoperative coronal deformity averaged 29 degrees (18-38 degrees). The Ilizarov apparatus was used in all cases. Correction time averaged 23 days (20-28 days). The time from completion of correction to frame removal averaged 71 days (48-113 days). There were no changes in metabolic parameters or frequency of hemodialysis throughout the treatment. Restoration of a normal mechanical axis was achieved in 4 of the 5 patients. One case failed due to intraarticular instability. There were no major complications. Minor complications included pin tract infections, which responded to antibiotic treatment, and premature consolidation in 1 case. Follow-up averaged 6.5 years (1-10 years). The alignment obtained at surgery was maintained in all 4 patients, and they are functional and symptom-free. The patient for whom the surgery failed remains wheelchair-bound. Conclusions: The Ilizarov method was found to be safe and effective for correction of malalignment due to ROD. Optimization of metabolic parameters is essential before surgery and throughout correction. The procedure is contraindicated in patients with significant intraarticular knee pathology. Level of Evidence: Level IV. Retrospective case series.

Referred Knee Pain in Posterior Dislocation of the Hip

Traumatic hip dislocation occurs relatively rarely in children less than 5 years of age. Although the prognosis is better in this age group than in adults, hip dislocation is still considered an orthopedic emergency, and reduction should be done as soon as possible. Awareness of the presenting symptoms, including referred pain and knee complaints, is important to prevent delayed diagnosis and to facilitate prompt reduction.

Compartment syndrome because of acute hemorrhagic edema of infancy: a case report and literature review.

UNLABELLED Acute hemorrhagic edema of infancy (AHEI) is a benign, self-limiting vasculitis that usually resolves completely without any sequelae or a need for active therapy. To our knowledge, compartment syndrome because of AHEI has not been reported. Chart data for a single case were reviewed and reported in a retrospective study. A 19-month-old male presented with petechial rash and swelling of the left lower leg. AHEI was diagnosed clinically and confirmed by skin biopsy. On the basis of the clinical appearance, compartment syndrome of the foot was suspected. Measurements of compartmental pressures in the foot were well above the commonly cited ranges and a fasciotomy was performed. Following the operation, there was a marked clinical improvement in the limb perfusion. The child was discharged on the 20th day with marked clinical improvement; both active and passive leg movements were intact. We suggest that pediatric orthopedic surgeons should be familiar with this entity and its rare complication. LEVEL OF EVIDENCE V - case report.

Corrective lower limb osteotomies in children using temporary external fixation and percutaneous locking plates

Abstract Background We describe a new method for corrective osteotomy and the fixation of lower limb deformities in children. Methods Following osteotomy, the desired position is obtained and temporarily stabilized using an external fixator. Definitive fixation is performed with a plate and locking screws inserted percutaneously under fluoroscopic guidance. The procedure was performed in 18 segments in 11 patients. Corrections were performed in all planes. Results The mean follow up was 18 months (range 6–36 months). All patients were corrected to within 2° of that which was planned. Union was obtained in 16 segments in ten patients within 6–16 weeks. Conclusions The method was found to be effective for the correction of deformity in the pediatric population. Advantages compared to conventional methods include minimal soft tissue dissection and the ability to adjust the position before definitive fixation.