Eitan Segev

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.

Intra- and interobserver reliability analysis of digital radiographic measurements for pediatric orthopedic parameters using a novel PACS integrated computer software program

BackgroundThe between-observer reliability of repeated anatomic assessments in pediatric orthopedics relies on the precise definition of bony landmarks for measuring angles, indexes, and lengths of joints, limbs, and spine. We have analyzed intra- and interobserver reliability with a new digital measurement system (TraumaCad Wizard™).MethodsFive pediatric orthopedic surgeons measured 50 digital radiographs on three separate days using the TraumaCad system. There were 10 anterior–posterior (AP) pelvic views from developmental dysplasia of the hip (DDH) patients, 10 AP pelvic views from cerebral palsy (CP) patients, 10 AP standing view of the lower limb radiographs from leg length discrepancy (LLD) patients, and 10 AP and 10 lateral spine X-rays from scoliosis patients. All standing view of the lower limb radiographs were calibrated by the software to allow for accurate length measurements, using as reference a 1-inch metal ball placed at the level of the bone. Each observer performed 540 measurements (totaling 2,700). We estimated intra- and interobserver standard deviations for measurements in all categories by specialists and nonspecialists. The intraclass correlation coefficient (ICC) summarized the overall accuracy and precision of the measurement process relative to subject variation. We examined whether the relative accuracy of a measurement is adversely affected by the number of bony landmarks required for making the measurement.ResultsThe overall ICC was >0.74 for 13 out of 18 measurements. Accuracy of the acetabular index for DDH was greater than for CP and relatively low for the center–edge angle in CP. Accuracy for bone length was better than for joint angulations in LLD and for the Cobb angle in AP views compared to lateral views for scoliosis. There were no clinically important biases, and most of the differences between specialists and nonspecialists were nonsignificant. The correlation between the results according to the number of bony landmarks that needed to be identified was also nonsignificant.ConclusionsDigital measurements with the TraumaCad system are reliable in terms of intra- and interobserver variability, making it a useful method for the analysis of pathology on radiographs in pediatric orthopedics.

Primary Subacute Epiphyseal Osteomyelitis : Role of Conservative Treatment

Primary subacute epiphyseal osteomyelitis is a rare disease. Owing to its insidious onset, mild symptoms, and inconsistent supportive laboratory data, diagnosis and treatment are usually delayed. The authors report a retrospective review of 16 patients with hematogenous osteomyelitis primarily affecting the epiphysis. In all of these patients an osteolytic lesion developed. In eight patients it was confined to the epiphysis or apophysis alone; in the other patients there was contiguous involvement of the adjacent metaphysis. Complete clinical and radiologic healing was observed in all patients after antibiotic therapy alone. Based on this experience, in view of the controversy in the literature, the authors recommend a conservative treatment policy in the management of both epiphyseal and epiphyseal-metaphyseal subacute osteomyelitis as the treatment of choice. Surgery should be reserved for persistent infection that does not respond to appropriate antibiotic therapy or when bone lesions cannot be distinguished from bone tumors by use of all available imaging modalities.

Effects of long-term administration of n-3 polyunsaturated fatty acids (PUFA) and selective estrogen receptor modulator (SERM) derivatives in ovariectomized (OVX) mice

We studied the beneficial effects of dietary consumption of n‐3 polyunsaturated fatty acids (PUFA) and two selective estrogen receptor modulator (SERM) derivatives (SERM‐I and SERM‐II) and their combined effect on serum lipids, skin dermis and adipose layers, bone marrow adipogenesis, and cytokine secretion in mice. Two different ovariectomized (OVX) models were studied: treatment began immediately post‐OVX in one and 3 months post‐OVX in the other. Our results showed that n‐3 PUFA and both SERMs decreased triglyceride levels in the serum, and that SERMs also decreased serum cholesterol levels while n‐3 PUFA had no similar effect. SERMs had no effect on IL‐6, IL‐1 beta, or IL‐10 levels, but they decreased ex vivo tumor necrosis factor (TNF‐α). N‐3 PUFA decreased secretion of non‐induced IL‐6 and TNF‐α from cultured BMC and IL‐1 beta levels in vivo (i.e., in bone marrow plasma), but its main effect was a significant elevation in the secretion of IL‐10, a known anti‐inflammatory cytokine. OVX‐induced B‐lymphopoiesis was not affected by LY‐139481 (SERM‐I) while LY‐353381 (SERM‐II) exhibited an estrogen‐antagonistic effect in sham and OVX mice and elevated the amount of B‐cells in bone marrow. Fish oil consumption prevented the elevation in B‐lymphopoiesis caused by OVX, but had no curative effect on established augmented B‐lymphopoiesis. This activity could be mediated via the elevation of IL‐10 which was shown to suppress B‐lymphopoiesis. Both SERMs and n‐3 PUFA inhibited the increase in adipose tissue thickness caused by OVX in mice. Our results showed that n‐3 PUFA, could prevent some of the deleterious outcomes of estrogen deficiency that were not affected by SERMs. We observed no significant beneficial effects of the combined administration of SERM‐I, SERM‐II, and PUFA on the studied parameters.The exact mechanism by which polyunsaturated fatty acids exert their activities is still not clear, but peroxisome proliferator‐activated receptors (PPARs) might be involved in processes which are modulated by n‐3 PUFA. J. Cell. Biochem. 90: 347–360, 2003.

Primary chronic sclerosing (Garré's) osteomyelitis in children.

Three children with unifocal nonpyogenic inflammatory bony lesions with a prolonged, fluctuating course are reported. The lesions were located at the metaphyseal region of long bones. Three was progressive sclerosis and hyperostosis in the tibia or femur, such as the changes described in Garrés osteomyelitis. No pus was released by exploration of the lesions. Tissue and blood cultures were negative. The histology was typical of chronic osteomyelitis: the symptoms returned intermittently over several years, together with the development of sclerosis but without disturbance of bone growth. It is not clear whether Garrés chronic sclerosing osteomyelitis is a different entity from chronic recurrent multifocal osteomyelitis.

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.

V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet

Purpose. To report the treatment outcomes of V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet. Methods. 13 patients (14 feet) aged 8 to 18 years underwent V osteotomy via the calcaneus and talus, followed by gradual distraction of soft tissue and bone for foot reconstruction. Eight of the clubfeet were idiopathic and had undergone previous surgeries. The remaining 6 were neurogenic and their pathologies were: Charcot-Marie-Tooth disease (n=2), myelomeningocele (n=2), neurofibromatosis (n=1), and distal arthrogryposis (n=1). Three of them had undergone previous surgeries. The Ilizarov frames were retained for 3 to 6 months and the patients were followed up for 1.8 to 8.9 years. Range of movement of the ankle and foot, appearance and position, gait, pain, function, and patient satisfaction were assessed according to the modified clubfoot grading system. The talo-1st metatarsal angle was measured on anteroposterior radiographs. Results. Scores associated with the appearance and position of the foot, and thus patient satisfaction were significantly improved, but not for range of movement, pain, and function. The mean preoperative and final talo-1st metatarsal angles were 39.7 and 8.7 degrees, respectively (p<0.01). Ten feet achieved the plantigrade position, one had residual equinus, and 3 had residual adduction and supination. Conclusion. Patient satisfaction improved significantly despite no major improvement in pain, function, and range of movement of the ankle and foot. This reflects the importance of the appearance and position of the foot, and justifies the decision to undergo this long and demanding procedure.

A combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children

Purpose. To describe a combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children, and correction of equinus contracture developed after removal of the external fixator using a circular dynamic frame. Methods. Seven children (4 males) aged 4 to 12 (mean, 8) years were treated with 9 free vascularised flaps for 8 limbs (bilaterally in one patient and for a failed flap in another). Patient pathologies included: 3 soft tissue degloving injuries, one soft tissue and bone avulsion, one severe burn contracture, one resurfacing of soft tissue and bone necrosis, and one osteosarcoma resection defect. Free flap reconstruction was delayed in 6 patients (range, 3 weeks to 4 years). Static external fixators were used to stabilise the free vascularised flaps at the time of reconstruction, with the ankle in a neutral position. Results. The mean follow-up was 5 (1–10) years. All flaps but one survived; the failed one was immediately reconstructed with a contralateral, latissimus dorsi flap. One anastomosis following a Kirschner-wire injury was successfully revised. Six patients had pin tract infections and were treated with oral antibiotics. Two patients developed equinus contracture 6 and 3 years later, after removal of the external fixator, and were corrected by distraction, using a dynamic Ilizarov frame. Conclusion. The combined use of a free flap and an external fixator for salvage of lower extremities is useful in children. Late development of equinus contracture can be safely corrected by distraction, without compromising flap viability.

Genu recurvatum in an adolescent girl: hypothetical etiology and treatment considerations. A case report.

Genu recurvatum may be the result of various bony or soft tissue deformities around the knee. We present a case of genu recurvatum with radiological features similar to those seen in infantile fibrocartilagenous dysplasia. The options for surgical treatment are described and discussed.

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.