Eb Hoffman

Tuberculosis of the knee.

Fifty-two children with tuberculosis of the knee treated from 1979 to 1999 were reviewed retrospectively. The radiologic appearance of the joint at presentation was predictive of the outcome. Ninety-two percent of the patients had Stage 1 or Stage 2 involvement (synovitis) with or without bony erosions, but had a normal joint space. Treatment with antituberculous chemotherapy without synovectomy had an excellent or good result in all patients with Stage 1 or Stage 2 disease, and there was no difference in outcome whether the knee was immobilized or mobilized. Patients with Stage 3 and Stage 4 disease who had a narrow joint space (arthritic) at presentation had a fair or poor result. In patients with monoarthritis of the knee with nonspecific histologic features and a negative culture, the differential diagnosis between tuberculosis and pauciarticular juvenile rheumatoid arthritis is problematic. The histologic evaluations of biopsy specimens of the synovium of 25 knees from 25 patients were reviewed for synovial lining hyperplasia. The sensitivity for the 17 knees that subsequently were diagnosed as having juvenile rheumatoid arthritis was only 53%. Deoxyribonucleic acid from 13 consecutive joints was subjected to polymerase chain reaction for Mycobacterium tuberculosis infection with only 40% sensitivity for tuberculosis.

Tuberculosis of the knee in children

We reviewed 33 children with tuberculosis of the knee treated during the period from 1979 to 1991. All were treated with triple chemotherapy, using rifampicin, isoniazid and pyrazinamide for nine months. No patient had a synovectomy; surgery was limited to open biopsy or salvage procedures such as posterior release and arthrodesis for late stages of the disease. The radiological appearance of the knee at presentation predicted the outcome. The 30 patients with stage-1 (normal) or stage-2 (osteomyelitic) disease had excellent or good results; the three with narrowed joint spaces in stage 3 or stage 4 (arthritic) had fair or poor results. Early active mobilisation, as against long-term immobilisation, seemed to have no effect on the outcome of stage-1 or stage-2 disease.

Double-elevating osteotomy for late-presenting infantile Blount’s disease: THE IMPORTANCE OF CONCOMITANT LATERAL EPIPHYSIODESIS

We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blounts disease. The mean age of patients was 9.1 years (7 to 13.5). All knees were in Langenskiöld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time. The mean pre-operative angle of depression of the medial tibial plateau of 49 degrees (40 degrees to 60 degrees ) was corrected to a mean of 26 degrees (20 degrees to 30 degrees ), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6 degrees (14 degrees to 66 degrees ) was corrected to 0 degrees to 5 degrees of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2 degrees to 5 degrees of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis.

Tuberculosis of the elbow in children

Ten children with tuberculosis of the elbow treated over a 21-year period from 1979 to 1999 were reviewed retrospectively. At presentation, they had pain and swelling of the joint mainly due to synovitis, and the median symptom duration was 10 weeks. All had a decreased range of movement. All were treated with 9 months of antituberculous chemotherapy without synovectomy. The radiologic stage at presentation, rather than duration of symptoms, predicted outcome. Of the 9 patients with stage 1 or 2 disease (synovitis), 8 had an excellent or good outcome. One stage 2 patient had a posterior dislocation of the radial head and had a fair outcome. The one stage 3 (arthritic) patient had a poor outcome.

French Osteotomy for Cubitus Varus in Children: A Long-term Study Over 27 Years.

Background: Cubitus varus is a cosmetically unacceptable complication of supracondylar fractures of the elbow in children. We have performed the lateral closing wedge (French) osteotomy to correct the varus for 27 years. More complex osteotomies have been described to correct the associated hyperextension and internal rotation deformities and to prevent a prominent lateral condyle. Methods: We retrospectively reviewed 90 consecutive patients (1986 to 2012). The mean age of the patients at surgery was 8.2 years (3 to14 y). The varus angle (mean, 21.4 degrees; range, 8 to 40 degrees) was assessed preoperatively with the humero-elbow-wrist angle. The postoperative carrying angle (mean, 10.4 degrees) and the preoperative and postoperative range of movement were assessed clinically. The lateral condylar prominence index (LCPI) was retrospectively measured at union. Results: Eighty-four (93.3%) of the patients had a good or excellent result. Six (6.7%) had a poor result (residual varus, loss of >20 degrees of preoperative range of flexion or extension or a complication necessitating resurgery). There were no neurovascular complications. The mean LCPI was +0.14. Conclusions: The results of the French osteotomy are comparable with the more technically demanding dome, step-cut translation, and multiplanar osteotomies, with a lower complication rate. The literature reports adequate remodeling of the hyperextension deformity (⩽10 y) and the LCPI (⩽12 y), and that the internal rotation deformity is well tolerated by the patient. Level of Evidence: Level IV—case series.

The orthopaedic management of myelomeningocele

Despite improvement in antenatal care and screening, myelomeningocele remains the most common congenital birth defect, with a reported incidence of 1 - 2.5/1000 patients in the Western Cape, South Africa. The multidisciplinary team involved in the Spinal Defects Clinic at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa consists of neurosurgeons, urologists, orthopaedic surgeons, stomatherapists and orthotists. Orthopaedic surgeons have a protean involvement in the management of myelomeningocele.