Jong Sup Shim

Treatment of brachymetatarsia by distraction osteogenesis.

Abstract: Metatarsal lengthening by distraction osteogenesis was performed on 17 brachymetatarsia patients with 39 metatarsal bones. To lengthen the first metatarsal in an attempt to prevent development of varus deformity of the hindfoot after lengthening, horizontal lengthening in the anterior direction was performed rather than lengthening through the anatomical axis. In addition, care was taken to ensure that the fourth metatarsal bone screw did not interpose with the fifth extensor tendon during the fourth metatarsal lengthening. Lengthening was successful except in 1 case with mean lengthening of 19.5 mm (48.8%) for the first metatarsal and 17.1 mm (36.2%) for the fourth metatarsal. Because of joint stiffness, plantar capsulotomy was performed on 7 cases, 6 of which had been previously operated on bilaterally. Varus deformity of the hindfoot after the first metatarsal lengthening and entrapment of the fifth extensor tendon after the fourth metatarsal lengthening was not detected in any case.

Discoid lateral meniscus in children: clinical manifestations and morphology.

The authors investigated the correlation between the clinical manifestations and the morphology of discoid lateral meniscus. Thirty-eight children, age 5 to 17 years, with 39 cases of discoid lateral meniscus underwent an arthroscopic procedure and magnetic resonance imaging. The two most frequent preoperative clinical manifestations were pain and extension block. In 19 cases without surface tear, the most frequent clinical manifestation was extension block. In the sagittal magnetic resonance images, the mean thickness of the anterior portion of the discoid lateral meniscus (7.77 mm) in the group with extension block exceeded that (4.02 mm) in the group without extension block. Extension block was significantly more common in patients with the anterior hypertrophy type and the slab (anterior-posterior diffusely hypertrophic) type than in the posterior hypertrophy type by the modified Hall classification. As a result, extension block was significantly correlated with the morphology of the menisci. Also, the thickened anterior portion of the discoid lateral meniscus may be considered one of the mechanical factors that limit knee extension.

Treatment of congenital muscular torticollis in patients older than 8 years

The authors treated congenital muscular torticollis by sternocleidomastoid muscle release in 32 patients over 8 years of age who had not received any prior medical treatment or in whom torticollis had recurred since initial treatment. The results were analyzed to compare clinical results after an average of 39 months (range 24-74 months) by dividing the patients into two groups: patients who were still in the growing period (group 1, n = 19) and patients who had finished growth (group 2, n = 13) at surgery. According to the total score table by Cheng et al (which includes motion deficits, craniofacial asymmetry, scar, band, head tilt, and subjective assessment), there were 13 excellent and 6 good results in group 1 and 2 excellent, 8 good, and 3 fair results in group 2. The clinical results were statistically less successful in group 2 than in group 1 by Chengs score table (P < 0.05). However, most patients showed marked improvement in neck motion and head tilt, with satisfactory functional and cosmetic results. Thus, in patients older than school age, even for those who have finished growth, sufficient unipolar or bipolar release of the sternocleidomastoid muscle and intensive postoperative care are expected to yield satisfactory treatment results.

The musculoskeletal manifestations of Prader-Willi syndrome.

Background Prader-Willi syndrome (PWS) is a rare genetic disorder with an associated anomaly in chromosome 15, and has been reported to increase prevalence of scoliosis, but little information is available regarding its association with other musculoskeletal manifestations. The aim of this study was to evaluate musculoskeletal manifestations in 36 patients with PWS and to determine the effects of risk factors, such as, sex, age, genotype, and body mass index (BMI) on PWS. Methods The investigators subjected 36 patients with PWS to a complete physical examination and radiographic assessment at an orthopaedic clinic using a single protocol. Demographics, genetic analysis findings, diagnosis, fracture and surgical histories, walking age, and ambulatory status were recorded. Age, sex, height, weight, and BMI were assessed. A systemic physical examination was performed at the orthopaedic clinic. Radiographic evaluations were assessed, including those of the spine, hip joints, lower extremities, and feet. Results Obesity was not found to be correlated with sex, genotype, scoliosis, kyphosis, hip dysplasia, limb malalignment, or foot abnormalities. Of the 36 patients, 23 (63.9%) had scoliosis (the scoliosis group) and 13 did not (the nonscoliosis group). Female sex was found to be significantly associated with scoliosis [11 (47.8%) of 23 in the SG vs. 1 (7.7%) of 13 in the NSG; P=0.0253]. No intergroup difference was found regarding age, genotype, BMI, or other musculoskeletal abnormalities. However, scoliosis was found to be significantly associated with limb malalignment (P=0.04589). Six patients showed kyphotic deformity associated with scoliosis. In addition, kyphoscoliosis was found to be significantly associated with the presence of a foot abnormality (P=0.01607) and severe limb malalignment (P=0.00344). Hip dysplasia was present in 8 of the 36 patients (22.2%). Limb malalignment was present in 28 patients (77.8%), and 18 (50%) had bilateral or unilateral genu varum deformity. Foot abnormalities were present in 17 patients (47.2%). Conclusions This study shows a high prevalence of spinal deformity, limb malalignment, and foot abnormality in PWS. The prevalences of musculoskeletal abnormalities were not found to be affected by age, genotype, or obesity. However, several musculoskeletal abnormalities were found to be correlated with each other, namely, scoliosis and limb malalignment, kyphotic deformity, and foot abnormality or severe limb malalignment. The authors recommend that pediatric orthopaedic surgeons conduct systemic clinical and radiographic evaluations for scoliosis, hip dysplasia, foot abnormalities, and lower limb malalignment annually, because musculoskeletal problems can be concealed by obesity.

Prognostic Factors of Septic Arthritis of Hip in Infants and Neonates: Minimum 5-Year Follow-up

Background The authors conducted the present study to identify clinical and radiological prognostic factors in infants and neonates with septic arthritis of the hip. Methods The authors retrospectively reviewed the records of 31 patients with septic arthritis of the hip. All of the patients were younger than 18 months old. Follow-up periods ranged from 5 to 17 years. The following potential variables for predicting the prognosis were included in the assessment: gender, age, underlying diseases, duration of symptoms, changes of hip joint in X-ray, concomitant osteomyelitis, elevation of erythrocyte sedimentation rate and C-reactive protein, sepsis, pus drainage, synovial fluid culture, and infecting organisms. Clinical and radiological prognoses were analyzed at the final follow-up. Results Univariate analysis demonstrated that radiological prognoses were poorer in patients who had underlying diseases, a longer duration of symptoms, and pus drainage. However, on multivariate analysis, only the variable-duration of symptoms-was found to be statistically related with a poor radiological prognosis. Conclusions Although poor prognosis for patients with several underlying diseases and radiological changes has already been established, a favorable outcome might be expected with prompt surgical drainage and appropriate antibiotics.

Remodeling After Lateral Closing-wedge Osteotomy in Children With Cubitus Varus

The purpose of this study was to evaluate the effectiveness of supracondylar lateral closing-wedge osteotomy of the humerus in children and the postoperative remodeling of the lateral condylar prominence. Lateral closing-wedge osteotomy for cubitus varus deformity was performed in 52 children. In all cases, medial translation for decreasing lateral condylar prominence or transposition of the ulnar nerve was not performed. Mean patient age was 8.8 years. Mean follow-up was 42 months. Clinical and radiological results were analyzed at last follow-up. Mean range of motion of the elbow in flexion and extension improved significantly (P<.05). Mean humeroulnar angle and mean shaft-condylar angle were significantly corrected (P<.05), and the angles between the affected and contralateral sides were not significantly different at last follow-up. Mean lateral condylar prominence index significantly decreased from 38.8% to 3.4%, and mean lateral condylar prominence amount decreased from -31.6% to -65.0% (P<.05 and P<.05, respectively). The amount of lateral condylar prominence remodeling was statistically correlated with the severity of preoperative cubitus varus, length of follow-up, and age at operation (P<.05 for all). The mean change in lateral condylar prominence amount in patients younger than 11 years (36.6%) was significantly greater than the mean change in lateral condylar prominence amount in patients aged 12 years or older (20.4%) (P=.001). Supracondylar lateral closing wedge osteotomy of the humerus is a simple and effective operation for correction of cubitus varus in children younger than 11 years with a considerable amount of lateral condylar prominence remodeling.

Complications of distraction osteogenesis in brachymetatarsia: Comparison between the first and fourth brachymetatarsia

BackgroundRecently, distraction osteogenesis has been widely used to treat brachymetatarsia. However, few papers have compared complications associated with this treatment. The purpose of the present study was to compare the complications between the first and fourth brachymetatarsia treated by distraction osteogenesis. MethodsWe performed distraction osteogenesis to 83 metatarsals in 41 patients between 1999 and 2012. A total of 30 metatarsals received treatment for the first metatarsal (Group A) while 53 metatarsals received treatment with the fourth metatarsal (Group B). ResultsThe complication rate in Group A (40%) was higher than that in Group B (18.9%). Those who had high percentage of lengthening gain were more likely to have complications. A cut-off value for lengthening gain developing complication was 41.3%. ConclusionComplication incidence after distraction osteogenesis was increased when lengthening gain was more than 41.3% for brachymetatarsia. In the 1st metatarsal lengthening, the most common complication was stiffness. In contrast, complications of the 4th metatarsal lengthening were pin-track infection and angular deformity.

Recurrence of a Unicameral Bone Cyst in the Femoral Diaphysis

Diaphyseal unicameral bone cysts of the long bone are generally known to originate near the growth plate and migrate from the metaphysis to the diaphysis during skeletal growth. In the case of unicameral bone cysts of diaphyseal origin, recurrence at the same location is extremely rare. We report a case of recurrence of a unicameral bone cyst in the diaphysis of the femur that developed 8 years after treatment with curettage and bone grafting. We performed bone grafting and lengthening of the affected femur with an application of the Ilizarov apparatus over an intramedullary nail to treat the cystic lesion and limb length discrepancy simultaneously.

The Efficacy of Percutaneous Lateral Hemiepiphysiodesis on Angular Correction in Idiopathic Adolescent Genu Varum

Background Percutaneous lateral hemiepiphysiodesis of the lower extremity is a simple and excellent method to correct the angular and length problems cosmetically. However, the efficacy of percutaneous lateral hemiepiphysiodesis is not well established in the literature. The purpose of this study was to evaluate the efficacy of percutaneous lateral hemiepiphysiodesis for angular corrections in adolescent idiopathic genu varum patients with proximal tibia vara and identify the factors affecting the amount of deformity correction of the lower limb in the coronal plane. Methods We retrospectively reviewed 20 patients (40 lower limbs) who had percutaneous lateral hemiepiphysiodesis on the proximal lateral tibia between 1997 and 2010. Radiographic evaluations were made using (1) the hip-knee-ankle angle and (2) the length of the tibia. Furthermore, the intercondylar distance was evaluated at the level of the knee joint. Preoperative factors (gender, age, body mass index, intercondylar distance, preoperative hip-knee-ankle angle, remaining growth of tibia, and calculated correctable angle) were analyzed, as well as their correlation with the degree of the actual correction angle. Results The amount of coronal deformity of the lower limb was improved from its preoperative state. The median average of hip-knee-ankle angle improved from 8.0° (interquartile range [IQR], 7.0° to 10.0°) preoperatively to 3.0° (IQR, 2.5° to 4.0°) at the final follow-up (p < 0.001). The median percent ratio of the angular correction was 60% (IQR, 50% to 71.3%). The correlation coefficients were –0.537, 0.832, 0.791, and 0.685 for the bone age, preoperative hip-knee-ankle angle, the remaining growth of tibia, and calculated correctable angle, respectively. Conclusions Despite the excellent cosmetic outcome of percutaneous lateral hemiepiphysiodesis on the proximal lateral tibia in adolescent idiopathic genu varum, the effect was limited in most cases. For optimum results, surgery a few months earlier is recommended, rather than at the calculated operation time.

Treatment of Brachymetatarsia by Distraction Osteogenesis: Operative Technique and Results

Purpose: To report on a new operative technique of distraction osteogenesis and its results in brachymetatarsia. Materials and Methods: 17 patients (39 metatarsal bones) formed the basis of this study (male:female-2:15). To prevent varus eformity of the hindfoot after lengthening, all screws were inserted at the same level from the medial aspect of the first metatarsal bone for horizontal distraction in the anterior direction, rather than distraction in the direction of the anatomical axis. Also, care was taken to ensure that the screw for the fourth metatarsal bone did not interpose with the fifth extensor tendon. Results: All cases achieved atisfactory lengthening and bony union, except 1 case. The healing index increased with patient’s age. Plantar capsular release was performed in seven ases, six of which had been previously operated on bilaterally. There was no indfoot varus deformity or entrapment of the fifth extensor tendon on final follow up. Conclusion: Varus deformity of the hindfoot can be prevented by horizontal istraction of the first metatarsal bone. Also, entrapment of the fifth extensor tendon can be prevented by careful handling of the fifth extensor tendon during operation on the 4th metatarsal bone. Complications of stiffness or of an increase in treatment period were mainly found in bilaterally operated or relatively old (over 20 year-old) patients.