Deborah A. Szymanski

Surgical correction of the snapping iliopsoas tendon in adolescents

Background: There have been very few reports regarding symptomatic snapping of the iliopsoas tendon, and none of those reports have dealt exclusively with an adolescent population. We report our experience with the surgical treatment of this entity in a group of patients who had an average age of fifteen years.Methods: Nine adolescent patients (eleven hips) underwent fractional lengthening of the iliopsoas tendon at the musculotendinous junction because of persistent painful snapping of the hip. A modified iliofemoral approach to the iliopsoas tendon was used. The diagnosis in all cases was made on the basis of the history and a physical examination. Plain radiographs were made for all patients to rule out an osseous intra-articular loose body. Follow-up consisted of personal interviews and physical examinations performed at least two years postoperatively.Results: Preoperatively, all patients had audible snapping with pain localized to the anterior part of the groin. The average duration of symptoms was 2.3 years. Prior to the onset of symptoms, all but one of the patients had been involved in competitive athletic activities. Postoperatively, all patients were able to return to the preoperative level of activity without subjective weakness. The average duration of postoperative follow-up was four years. Hip-flexion strength was noted to be nearly equal to that on the contralateral side. All patients reported that they would have the operation again under similar circumstances. One patient had recurrent snapping but stated that it was less frequent and less painful than the preoperative snapping. Two patients had transient sensory loss in the anterolateral aspect of the thigh.Conclusions: We conclude that fractional lengthening of the iliopsoas tendon at the musculotendinous junction is an effective and safe approach for adolescent patients with persistent symptomatic snapping of the iliopsoas tendon that is unresponsive to conservative measures.

Prevalence of Neural Axis Abnormalities in Patients with Infantile Idiopathic Scoliosis

Background: Although reports in the literature have demonstrated an approximately 20% prevalence of neural axis abnormalities in patients with juvenile idiopathic scoliosis who have a curve of >20°, the prevalence of neural axis abnormalities in patients with infantile idiopathic scoliosis is not well documented. In two previous studies involving a total of only ten patients with infantile idiopathic scoliosis, five patients were noted to have a neural axis abnormality on magnetic resonance images.Methods: The records of forty-six consecutive patients who were seen between 1992 and 2000 at three spinal deformity clinics were retrospectively reviewed. The inclusion criteria included presumed idiopathic scoliosis at the time of presentation, an age of three years or less, a curve magnitude of ≥20°, normal neurological findings, no associated syndromes, and no congenital abnormalities. All patients were evaluated with a total spine magnetic resonance imaging protocol for examination of neural axis abnormalities from the skull to the coccyx.Results: Ten (21.7%) of the forty-six patients were found to have a neural axis abnormality on magnetic resonance imaging. This group included five patients with an Arnold-Chiari malformation and an associated cervicothoracic syrinx, three with syringomyelia, one with a low-lying conus, and one with a brainstem tumor. Eight of these ten patients needed neurosurgical intervention for treatment of the abnormality.Conclusions: The 21.7% prevalence of neural axis abnormalities in this group of patients with infantile idiopathic scoliosis was found to be almost identical to that reported in the literature on patients with juvenile idiopathic scoliosis. Because of the high prevalence of abnormalities and the fact that eight of the ten patients with abnormal findings on magnetic resonance images required neurosurgical intervention, a total spine magnetic resonance imaging evaluation at the time of presentation is recommended for all patients with infantile idiopathic scoliosis who have a curve measuring ≥20°.

Use of an intramedullary rod for treatment of congenital pseudarthrosis of the tibia: A long-term follow-up study

BACKGROUND The treatment of congenital pseudarthrosis of the tibia remains difficult and controversial. The purpose of this study was to evaluate the long-term results of a technique consisting of excision of the pseudarthrosis, autologous bone-grafting, and insertion of a Williams intramedullary rod into the tibia. METHODS Twenty-one consecutive patients with congenital pseudarthrosis of the tibia were managed with this technique between 1978 and 1999, and the results were retrospectively reviewed. The mean age of the patients at the time of the latest follow-up was 17.2 years (range, seven to twenty-five years), and the mean duration of postoperative follow-up was 14.2 years (range, three to twenty years). RESULTS Initial consolidation occurred in eighteen of the twenty-one patients. Refracture occurred in twelve patients; five fractures healed with closed treatment, five healed after an additional surgical procedure, and two ultimately required amputation. Ten patients had an ankle valgus deformity after tibial union. Eleven patients had a residual limb-length discrepancy of >2 cm; six required a contralateral distal femoral and/or proximal tibial epiphyseodesis, two had a tibial lengthening, and one used a shoe-lift. Five patients had an amputation: two, because of a recalcitrant fracture; two, because of a limb-length discrepancy (6 and 9 cm); and one, because of a chronic lower-extremity deformity. CONCLUSIONS This technique produced a satisfactory long-term functional outcome in sixteen of twenty-one patients and should be considered for the management of congenital pseudarthrosis of the tibia.

Use of an Intramedullary Rod for the Treatment of Congenital Pseudarthrosis of the Tibia

The use of an intramedullary rod as described by Williams, combined with implantation of an autogenous bone graft, resulted in union of an established congenital pseudarthrosis of the tibia in nine of ten patients. One patient needed additional bone-grafting before union occurred. The average age at the time of the operation was five years and three months. A rod of the appropriate length was inserted at the site of the non-union, antegrade through the distal part of the tibia and the hindfoot and then retrograde through the proximal fragment. This resulted in splinting of the tibia, ankle, and subtalar joints. Solid osseous union occurred an average of six months after the procedure in all ten patients. Five patients had a refracture of the tibia after the initial consolidation. Three of the five needed one or more additional operative procedures; one was managed with a cast; and one patient, who had been followed for four years before the refracture, did not return for treatment of the refracture. As is the plan with this method of treatment, the distal part of the tibia grew off the rod and the distal tip of the rod was located proximal to the foot and ankle, or it was located more proximally than it had been at the operation, in six patients. The rod was removed from three patients. At an average of six years, all ten patients were able to walk without pain.

Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children.

Background: Recent reports have described osteonecrosis of the femoral head after intramedullary nailing of the femur through the piriformis fossa in children. Other reports have raised concerns about the development of femoral neck narrowing and valgus deformity of the proximal part of the femur after intramedullary nailing through the tip of the greater trochanter. We evaluated the radiographic changes in the proximal part of the femur following intramedullary nailing through the lateral trochanteric area at a minimum of two years postoperatively in twenty-five affected extremities. The mean age of the patients at the time of the index procedure was ten years and six months. Methods: A retrospective radiographic review was performed to look for proximal femoral changes. Specifically, the radiographs were examined for evidence of osteonecrosis. The articulotrochanteric distance, femoral neck diameter, and neck-shaft angle were measured on the initial and final radiographs. Results: No patient had evidence of osteonecrosis of the femoral head. The articulotrochanteric distance decreased by a mean of 0.4 mm, the femoral neck diameter increased by a mean of 4.9 mm, and the neck-shaft angle decreased by a mean of 1.4°. Compared with a group of seventeen patients with adequate initial and final radiographs of the contralateral side, the final mean articulotrochanteric distance was 4.5 mm less on the involved side than on the uninvolved side, the mean femoral neck diameter was 0.7 mm less on the involved side than on the uninvolved side, and the mean neck-shaft angle was 3.2° less on the involved side than on the uninvolved side. No patient had development of clinically important femoral neck narrowing or valgus deformity. Statistically, the likelihood that these data represent a group with a mean 3-mm increase in the articulotrochanteric distance is <1%. The likelihood that these data represent a group with a mean 3.2-mm decrease in the ultimate femoral neck diameter is <1%. The likelihood that these data represent a group with a mean 5° increase in the neck-shaft angle is <1%. Conclusions: Lateral transtrochanteric intramedullary nailing in children who are nine years of age or older does not produce clinically important femoral neck valgus deformity or narrowing, and we did not observe osteonecrosis of the femoral head after this procedure. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children.

Ultrasound scans of the hip were carried out in 132 children with hip pain during an 18-month period to evaluate the hip for the presence of an effusion. Seventy-three of these patients were followed up long enough to ascertain the presence or absence of septic arthritis. The remaining 59 patients were discharged with diagnoses other than septic arthritis but could not be located to confirm the ultimate accuracy of the diagnosis. Four patients were initially determined to have no effusion but subsequently were diagnosed with septic arthritis (false-negative rate of 5%). Two of these patients had inadequate initial ultrasound examinations. Two children had ultrasound examinations that even on retrospective review did not reveal an effusion. Both of these children had had symptoms for <24 hours, and one had a contralateral hip effusion. The authors recommend using the negative results of an ultrasound scan as evidence of the absence of septic arthritis in children with caution when symptoms have been present for <24 hours or when bilateral disease exists.

Septic arthritis of the hip in infancy: long-term follow-up.

At a mean 15-year follow-up, the authors evaluated five hips in five patients who had complete destruction of the femoral head and neck from septic arthritis when they were 3 months old. All patients were treated with a trochanteric arthroplasty in combination with a proximal femoral varus osteotomy at a mean age of 30 months in an attempt to salvage a femoral-pelvic articulation. Results suggest this treatment can provide a stable, painless, and functional hip, with an improved gait and less leg-length discrepancy than predicted if no reconstructive effort were attempted.

Urgent reduction, fixation, and arthrotomy for unstable slipped capital femoral epiphysis.

Background The management of unstable slipped capital femoral epiphysis (SCFE) is controversial. A high incidence of avascular necrosis (AVN) has been reported after unstable SCFE. Methods Twenty-eight consecutive patients with thirty unstable SCFE underwent urgent reduction and fixation with two 6.5-mm cannulated screws. Positional reduction was performed in 25 cases. Arthrotomy was performed percutaneously in 16 cases and as part of an open capsulotomy in 5 cases. Results Slip severity was mild in 13 patients, moderate in 9, and severe in 8. At mean duration of follow-up of 5.5 years (range: 2.0 to 11.2), 4 patients reported groin pain, and 8 patients reported a limp. Four patients developed AVN. One patient experienced slip progression and no patient developed chondrolysis. Conclusions Treatment of unstable SCFE with urgent positional reduction with accompanying arthrotomy and fixation through 2 cannulated screws resulted in a low incidence of slip progression and AVN. Level of Evidence Therapeutic study, level 4 (case series, no or historical control group).

Combined midfoot osteotomy for severe forefoot adductus.

A one-stage procedure combining a closing wedge osteotomy of the cuboid with an opening wedge of the medial cuneiform was used for the treatment of severe forefoot adductus. Results were reviewed in 33 patients (50 feet) followed-up for at least 2 years postoperatively. Clinical and radiographic improvement in forefoot position was achieved in 90% of cases. The mean calcaneo–second metatarsal angle improved from 37° preoperatively to 18° at final follow-up. The mean talo–first metatarsal angle improved from 15° preoperatively to 3° at final follow-up. The medial to lateral column ratio demonstrated 33% improvement after surgical treatment. Two feet were unimproved because of graft migration. Patients younger than age 5 years without a well-defined medial cuneiform ossific nucleus had a high rate of medial graft extrusion with loss of correction. This procedure should be reserved for patients aged 5 years or older. Ten patients followed-up for more than 6 years had no deterioration in results. This procedure provides effective, safe, predictable, and lasting correction of forefoot adductus.

Treatment of Rigid Hypertrophic Posttraumatic Pseudarthrosis of the Tibia in Children Using Distraction Osteogenesis

Posttraumatic tibial pseudarthrosis is a relatively uncommon complication of tibia fractures in children. Although reported as a successful method of treating tibial nonunions in adults, distraction osteogenesis through a nonunion site via ring external fixation has not been described in children. The authors report three consecutive cases of distraction through an angulated, shortened, hypertrophic, posttraumatic nonunion to achieve successful union and concurrent correction of deformity. Distraction was carried out using a ring fixator with computer-guided correction. Union was achieved in each of the three patients with complete correction of deformity and length. Lengthening of 8 to 31 mm was achieved. The length of time in the external fixator ranged from 7 to 27 weeks. Pin tract infections developed in all patients; they were treated successfully using oral antibiotics. No deep infections or other significant complications developed. Each patient was followed up for at least 1 year.