E. Ezra

SIMPLE BONE CYSTS TREATED BY PERCUTANEOUS AUTOLOGOUS MARROW GRAFTING: A PRELIMINARY REPORT

We prospectively evaluated the percutaneous injection of autogenous bone marrow for the treatment of active simple bone cysts in ten consecutive children with cysts in the proximal humerus, proximal femur or tibia. The treatment included percutaneous biopsy, aspiration of fluid and the injection of autogenous bone marrow aspirated from the iliac crest. All the patients became painfree after a mean of two weeks and resumed full activities within six weeks. All ten cysts consolidated radiologically and showed remarkable remodelling within four months. Review at 12 to 48 months showed satisfactory healing without complications. Percutaneous injection of autologous bone marrow appears to be an effective treatment for active simple bone cysts.

Efficacy of prenatal ultrasonography in confirmed club foot

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot. The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot.

Primary Subacute Osteomyelitis of the Axial and Appendicular Skeleton

Subacute osteomyelitis is not uncommon. Owing to its insidious onset, mild symptoms, and inconsistent supportive laboratory data, diagnosis and treatment are usually delayed. We report a retrospective review of 28 consecutive patients with subacute hematogenous osteomyelitis. Based on a review of the literature and our experience, we reached the following conclusions: Recognition of the subacute form of osteomyelitis as a separate clinical condition distinct from the acute form will lead to early institution of an aggressive, conservative treatment protocol. We adopted Roberts modification of Gledhills classification, but believed that one type of radiologic presentation was missing and should be added as type VII–that is, sclerosis of flat bones with neither erosive nor destructive processes. This disease responds very favorably to appropriate antibiotic therapy. Surgery should be reserved for persistent infection symptoms despite appropriate therapy or performed when lesions are indistinguishable from bone tumors by use of all available imaging modalities.

Epiphyseal involvement of simple bone cysts.

Epiphyseal involvement of a simple bone cyst (SBC) is uncommon. Eight patients are reported in whom an SBC was found to cross the growth plate, involving the epiphysis in seven patients and the apophysis in one. All patients had more than two pathologic fractures. In seven patients growth disturbance was found. Functional impairment did not develop in any patient. Radiographically, all lesions presented a characteristic involvement of the epiphysis and metaphysis in various proportions. Only one of four cysts treated with methylprednisolone acetate injections showed incomplete healing; the others failed to respond. After percutaneous grafting of autologous bone marrow, three of seven cysts healed and the others attained incomplete healing. Epiphyseal involvement of SBC should be considered a more aggressive form of an active lesion.

A simple and efficient surgical technique for subungual exostosis.

Subungual exostosis is a benign osteochondral tumor usually involving the distal phalanx of the great toe. The lesion most frequently occurs in the second and third decades of life and is rare before the age of 10 years. There are few reports of its occurrence in children, and most of them advocate partial or complete nail excision to treat this lesion successfully. We report our experience with six children and adolescents using a simple surgical technique that involves approaching the exostosis under the nail to preserve nail coverage. Rapid recovery and excellent cosmetic appearance were achieved immediately after the operation.

Congenital absence (ankylosis) of the knee

A congenital, unilateral, fixed flexion deformity in a neonate was diagnosed as a congenital absence of the knee. A single cartilage mass, with fusion of the lower femoral and upper tibial ossification centres, was demonstrated by imaging studies. This condition has been reported in the literature only once before. Surgery on our patient, which was performed at the age of two years, consisted of separation of the fused cartilaginous anlage and gradual correction of the deformity using an Ilizarov frame.

Hemimetatarsal transfer: a unique solution for postaxial metatarsal duplication.

Many operations have been described for the reconstructive treatment of foot congenital anomalies involving multiplication of toes and metatarsi. We describe a surgical procedure designed to solve the problem of postaxial polydactily with complete duplication of metatarsi. We successfully performed hemimetatarsal transposition of the hypoplastic metatarsal bone with its intact metatarso-phalangial joint to the base of the extra metatarsus. We achieved good alignment of the lateral ray with restoration of the metatarsal weight-bearing touch points. Functional and cosmetic results of the procedure were excellent.