Haim Shtarker

Correction of combined angular and rotational deformities by the Ilizarov method.

Deformities of the lower extremities are often a combination of angular and rotational components. The rotational component of combined deformities may be difficult to measure using plain radiography. Based on the current study, the computed tomography rotational malalignment test was developed. Evaluation of lower extremity alignment was done on 56 patients. Rotational malalignment was diagnosed in 14 limbs of nine patients. In all patients, correction of angular and rotational deformities was done simultaneously using an Ilizarov external fixator. The frame included a standard angular distraction system and a derotation block interconnected via an additional empty ring. In all cases, successful correction of angular and rotational deformities was achieved. The pain was eliminated in all seven patients having preexisting chronic joint pain. There were no cases of deep infection or nonunion. This simple and reliable method allowed precise analysis of the deformity in the transverse plane. Preoperative frame construction incorporating the derotational module decreased the time of the operation and allowed one-stage correction of rotational and angular deformities without additional manipulations.

Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children.

Background: Supracondylar fractures of the humerus in children are frequently managed by closed reduction and percutaneous pinning. Insertion of medial and lateral pins is more stable than lateral pinning alone, but carries an increased risk for ulnar nerve damage. This study describes the use of electrical stimulation concurrent with medial pin insertion as a monitoring technique for avoiding iatrogenic ulnar nerve injury. Methods: A retrospective review was conducted on 138 children, mean age 5.6 years (SD±2.5), who were admitted to the hospital between 2007 and 2010 with uncomplicated supracondylar fractures, Gartland type II and above, and intact neurovascular presentation. The location of the ulnar nerve was identified and marked preoperatively by observing twitch contractions in response to electrical stimulation. The medial pin served as an active electrode during pin insertion, and repeated stimulation throughout the insertion process ensured no contact with the response of the ulnar nerve. After pin insertion, ulnar nerve stimulation was used again to ensure nerve continuity viability. Results: All fractures were stabilized with 2 to 4 cross K-wires (size 1.6 mm), with number depending on stability of the fracture. The children were discharged home 2 days after fracture fixation, with no iatrogenic ulnar nerve injury observed in any of the children. The only postoperative complication involved 2 cases of anterior interosseus nerve neuropraxia, which resolved spontaneously after 4 to 6 months. Primary fracture healing was achieved without nonunions or delayed unions in all cases. Conclusions: Ulnar nerve stimulation before and during the percutaneous pinning of supracondylar fractures in children is a simple, economical, and easy-to-implement technique that can prevent iatrogenic ulnar nerve injury. Level of Evidence: Level IV.

Case 119: Adolescent with Bilateral Femoral and Tibial Rotational Deformity (Miserable Malalignement Syndrome) Combined with Proximal Tibial Varus and Recurvatum

A fourteen-year-old female with significant knee pain due to bilateral rotational malalignment syndrome, varus-recurvatum deformity of the proximal tibiae, excessive joint laxity, and no previous treatment underwent external left femoral de-rotation osteotomy with locking intramedullary nail fixation and tibial/fibular osteotomy followed by gradual correction of multiplanar deformity using hexapod-type TL-Hex circular external fixation. 1 Brief Clinical History The patient is a 14-year-old female who suffered from bilateral chronic knee pain and was not treated previously. She was diagnosed with the miserable malalignment syndrome (MMS) characterized by substantial bilateral internal femoral torsion and external tibial torsion associated with 15 of genu varum, 20 of genu recurvatum, and significant joint laxity (Figs. 1, 2, 3, and 4). Her computed tomography rotational malalignment test (CTRMT) revealed 37 and 38 of internal femoral torsion and 47 and 49 of external tibial torsion on the left and right lower extremities, respectively (Fig. 5). She had normal hip joint and ankle joint range of motion and was otherwise healthy and neurovascularly intact. 2 Preoperative Clinical Photos and Radiographs See Figs. 1, 2, 3, 4 and 5. 3 Preoperative Problem List • Bilateral internal femoral torsion (38 on the right and 37 on the left) • Bilateral external tibial torsion (49 on the right and 47 on the left) *Email: hshtarker@gmail.com *Email: haimsh@netvision.net.il Limb Lengthening and Reconstruction Surgery Case Atlas DOI 10.1007/978-3-319-02767-8_70-1 # Springer International Publishing Switzerland 2014

Case 5: Adolescent Unstable Tibial Fracture Treated Initially with Closed Reduction and Plaster Cast Immobilization Converted to TL-Hex External Fixation due to Residual Displacement

Fifteen-year-old male with an unstable displaced tibial middle/distal shaft fracture treated initially by closed reduction and plaster cast fixation that was converted to TL-Hex circular external fixation due to residual lateral translation and recurvatum. 1 Brief Clinical History The patient is a 15-year-old male who was hit by a car while crossing a street and sustained a closed tibial shaft fracture at the level of middle/distal thirds (Fig. 1). He was treated initially by closed reduction and plaster cast immobilization. However, the fracture remained unstable and displaced with a half-of-diameter lateral translation and 10 of recurvatum (Fig. 2). 2 Preoperative Clinical Photos and Radiographs

Surgical Treatment of Displaced Calcaneal Fractures

Calcaneal fractures (2% of all fractures) are usually the result of high energy injuries, falls from a height and road traffic accidents [1]. These fractures are the most common tarsal fractures and 60–75% of them are displaced intra-articular fractures. Calcaneal fractures are more common in males (90%), mostly industrial workers, 41–45 years of age. Ten per cent have associated fractures of the spine and 25% have other extremity injuries. The economic impact is enormous since about 20% of the patients are totally incapacitated for 3–5 years [1–3]. Despite advances in imaging, surgical techniques and surgical devices the functional results of displaced intra-articular fractures are not optimal and the literature still reveals controversy surrounding classification and treatment [4]. The purpose of this review is to present the anatomical and radiological structure of the calcaneus and various clinical aspects and surgical modalities for these types of fractures.