Leonhard E. Ramseier

Femoral Fractures in Adolescents: A Comparison of Four Methods of Fixation

BACKGROUND The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. METHODS We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. RESULTS The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for débridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required débridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. CONCLUSIONS External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

Treatment of neuromuscular and syndrome-associated (nonidiopathic) clubfeet using the Ponseti method.

Background: Clubfeet are associated with many neuromuscular and congenital conditions. Nonidiopathic clubfeet are typically thought to be resistant to nonoperative management. The Ponseti method has revolutionized the treatment of patients with idiopathic clubfeet. The purpose of this study was to describe the use of the Ponseti method in the treatment of patients whose clubfeet are associated with a neuromuscular diagnosis or a syndrome. Methods: All patients with clubfeet who were treated at the Hospital for Sick Children, Toronto, from 2001 to 2005 were reviewed. Patients were included only if a neuromuscular condition or a syndrome associated with clubfeet could be identified and if the primary treatment was at our institution. Twenty-three patients with 40 nonidiopathic clubfeet and 171 patients with 249 idiopathic clubfeet have been treated with a minimum follow-up time of 1 year. The outcomes evaluated included the number of casts, the percentage of patients requiring percutaneous Achilles tendon lengthening (tenotomy of the Achilles tendon [TAT]), rate of recurrences, rate of failures, and the need for additional secondary procedures. Results: The mean age at presentation for nonidiopathic clubfeet was 11 weeks. The mean follow-up time was 33 months, and the mean number of casts was 6.4; a percutaneous TAT was necessary in 27 (68%) of 40 feet. Failure of the Ponseti casting occurred in 4 (10%) of the 40 feet. Recurrence requiring additional treatment occurred in 16 (44%) of 36 feet. Additional procedures included second percutaneous TAT, limited posterior/plantar release, or complete posteromedial release totaling 11 (28%) of 40. When compared with idiopathic clubfeet, nonidiopathic clubfeet required more casts and had a higher rate of failures, recurrences, and additional procedures than idiopathic clubfeet. Conclusions: Although not as successful as for idiopathic clubfeet, when the Ponseti technique is applied to nonidiopathic clubfeet, correction can be achieved and maintained in most patients. Level of Evidence: Prognostic level 2.

Treatment of open femur fractures in children: comparison between external fixator and intramedullary nailing.

Background: Open femur fractures in children are uncommon and usually associated with other injuries. In adults, there is a current trend to treat open fractures with intramedullary (IM) devices. The goal of this study was to compare external fixator (EF) to IM devices in the treatment of open femur fractures in children. Methods: Diaphyseal femur fractures without growth plate involvement were included. Thirty-five patients (12 IM; 23 EF) were identified. Age, hospital stay, polytrauma, mechanism of injury, and Gustilo-Anderson grade were recorded. Follow-up was at least until the fracture was clinically and radiographically healed. Results: Patients with EFs were 5.2 times more likely (95% confidence interval, 1.05-25.5) to have any complication. Excluding pin track infections, patients with EFs were 2.7 times as likely (95% confidence interval, 0.567-13.2) to have a complication. Refractures occurred only in the EF group (6/23, 26%) and not in the IM nailing group (P = 0.062, Fischer exact test). These were associated with varus malunions-all 3 of the EF group with more than 15 degrees of varus at fracture union suffered a refracture. Conclusions: Treatment of open femur fractures in children is a challenging problem. Treatment with IM devices had fewer complications than the EF. We think that whenever possible, the use of IM devices for the treatment of open femur fracture in children should be considered, especially grade 1 open injuries. If EFs are used, avoiding varus malunion may decrease the refracture rate, and secondary change to an IM device should be considered. Level of Evidence: Comparative cohort study. Grade 3 level of evidence.

Arthropathy of the knee joint caused by synovial hemangioma.

Degenerative changes resembling hemophilic arthropathy may be a complication of synovial hemangioma in the knee. It is thought that arthropathy is caused by repeated bleeding episodes similar to the joint disease in hemophilia. Four children aged 4 to 9 years at surgery were treated by anterior open synovectomy for intra-articular synovial hemangiomas. At open surgery the cartilage of all patients showed changes on the surface with yellow hematin staining in all cases, without ulceration in three patients but one, who showed severe degenerative changes at age 9 years. At 15 months follow-up the patient with severe degenerative changes had severely impaired flexion and mild extension deficit. The three others were asymptomatic at 1 to 6 years follow-up. The magnetic resonance images were typical and can be considered pathognomonic; however, the referral diagnosis included the correct diagnosis in none of them. Treatment should be initiated as early as possible to reduce the risk of damage to the cartilage. Treatment by complete open synovectomy in these four patients was performed without significant bleeding problems, and no recurrence was seen.

Femoral and tibial torsion measurement in children and adolescents: comparison of 3D models based on low-dose biplanar radiography and low-dose CT.

OBJECTIVE The purpose of this study was to evaluate the interchangeability and reliability of femoral and tibial torsion measurements in children using 3D models based on biplanar radiography compared with CT measurements. MATERIALS AND METHODS Femoral and tibial torsion were measured in 50 patients (mean age, 10.9 years; range, 4.7-14.8 years) using 3D models based on low-dose biplanar radiography by two independent readers. Measurements on transverse CT images by two independent readers served as the reference standard. Intermethod and interreader agreement was calculated using descriptive statistics, intraclass correlation coefficient (ICC), and Bland-Altman analysis. RESULTS Femoral and tibial torsion were -6°-65° and 6°-51° for 3D models based on biplanar radiography and -13°-59° and 4°-52° for CT measurements. The average difference (±SD) between the two methods was 4.9°±3.8° and 5.5°±4.1°, respectively. The intermethod ICC for biplanar radiography was 0.90 (95% CI, 0.87-0.92) for femoral torsion and 0.75 (0.68-0.80) for tibial torsion. The interreader ICC was 0.93-0.97. Mean measurement differences between the two biplanar radiography readers were 3.4° (0.0°-11.0°) for femoral torsion and 3.9° (0.0°-15.0°) for tibial torsion. Mean interreader differences at CT were 3.3° (0.0°-9.0°) for femoral and 3.0° (0.0°-10.0°) for tibial torsion. There was no trend for larger intermethod differences with decreasing age of the children. CONCLUSION Femoral and tibial torsion measurements in children using 3D models based on biplanar radiography are comparable to CT measurement results. Despite skeletal immaturity, torsion measurements in children on biplanar radiography seem to be as reliable as those on CT images.

Rotationplasty (Borggreve/Van Nes and modifications) as an alternative to amputation in failed reconstructions after resection of tumours around the knee joint

Failure of reconstructions as a result of infective or aseptic loosening and massive bone loss may make amputation necessary. If neurovascular structures can be preserved to keep a functional foot, rotationplasty may be considered an option. Four patients treated for malignant bone tumours (two osteosarcomas, one Ewing sarcoma, and one malignant fibrous histiocytoma) of the proximal tibia and distal femur (n=2 each) at the ages of 13 to 21 years had reconstructions that failed 3, 4, 5, and 15 years later. In three patients the cause was intractable infection, and in one loosening with shortening and deficiency of the extensor mechanism. The patients had the option to contact patients who had had rotationplasty as the primary procedure for tumours or severe femoral deficiencies. In two patients an AI-type rotationplasty was done, in one a type AII rotationplasty, and in the fourth a modification with shortening of the lower leg but retention of the knee joint. There were no postoperative complications such as persisting infections, fractures, or pseudarthrosis. All patients are active and are able to go alpine skiing or snowboarding. The main advantage of procedures in which a sensory-motor functional foot is retained is to avoid neuroma pain or phantom sensations. The foot allows for active knee movement of the orthoprosthesis and full weight bearing. It is of great psychological help for the patients to have contact during the decision-making with patients who have had similar procedures. It should be considered as an alternative to amputation.

Metabolic and orthopedic management of X-linked vitamin D-resistant hypophosphatemic rickets

PurposeTherapy of vitamin D-resistant hypophosphatemic rickets (VDXLR) consists of oral phosphate and vitamin D supplements. Bone deformities, pain, and small stature can occur even in children with good compliance, requiring surgical correction and bone lengthening. However, only few surgical reports are available.MethodsTwelve patients (three males) with VDXLR were followed at our institution. Median age at diagnosis was 3 9/12 years (range, birth to 11 10/12) with a follow-up period of 7 8/12 years (1 9/12–30) and age at last follow-up of 13 6/12 years (2–30). Eight patients underwent surgical correction, three of them in combination with bone lengthening. The corrections were performed at the end of growth in three patients. Clinical endpoints were height, leg axis, and pain.ResultsSingle bilateral surgical correction was performed in six patients; one patient each had three and five corrections. Bone lengthening was performed in three patients. At last follow-up, the height of seven operated patients was within normal range. In addition, leg axis was normalized in six patients with mild genua vara in two. Only one patient complained of intermittent pain. Bone healing was excellent; surgical complications were rare. There was no radiological evidence of degenerative arthropathy.ConclusionsMedical treatment remains the main pillar of therapy in children with VDXLR. In case of bone deformity, surgery can safely be performed, independent of age or bone maturation. All patients were satisfied with the results of axial corrective surgery and bone lengthening, and in the majority only one corrective intervention was needed.

Multiple subungual soft tissue metastases from a chondrosarcoma.

Chondrosarcoma metastasises to the lungs and from there to other organs. A patient with several metastases in the soft tissues of the fingers and toes had previously been treated for a chondrosarcoma of the foot. Subungual metastases of chondrosarcoma are unusual and there is no evidence based treatment. We therefore treated the lesion of the finger by total resection of the nail (R0).

Distal Humeral Fractures of the Adult

Purpose:Retrospective case series carried out to identify factors influencing the outcome of ORIF of distal humeral fractures in adults and to compare different elbow scoring systems.Patients and Methods:Twenty-eight consecutive distal humeral fractures sustained by 27 patients were treated by open reduction and internal fixation.Results:Anatomical or near anatomical reduction was achieved in 25 cases. Fifty-six months (Range: 24–103) after surgery, 24 elbows were subjectively rated as good or excellent and 4 as fair or poor. The mean DASH Score was 24% and the mean Mayo Elbow Score 85%. The level of satisfaction significantly correlated with pain, stability, development of arthritis, heterotopic bone formation, range of motion, the condylar angle of alignment, as well as lack of further surgery.Conclusion:ORIF of distal humeral fractures lead to acceptable results even in elderly patients and in the event of complications.

Results of treatment of malignant soft tissue tumours in the groin

Soft tissue sarcomas of the inguinal region are a challenge with regard to achieving clear margins, reconstruction of the femoral vessels, and soft tissue coverage. Six men aged 39 to 48 years and one woman of 56 were treated for soft tissue sarcomas of the groin. All patients were treated with local en bloc resections including the femoral artery, vein, and nerve. In two patients the soft tissue defect was covered primarily with an ipsilateral rectus abdominis muscle flap, in two others (because of wound dehiscence) coverage was achieved with the opposite rectus abdominis muscle pedicle flap as we were afraid of closure of the ipsilateral deep epigastric vessels. In the others local measures were sufficient, however, wound healing was usually delayed. Histopathological examination showed tumour-free margins in each case. One patient developed a local recurrence, but had had no radiotherapy because of problems with wound healing. A high rate of local tumour control in soft tissue sarcomas of the inguinal region can be achieved with the combination of surgical resection and radiotherapy. No compromise should be made with aggressive soft tissue coverage to protect the vascular reconstruction, control wound healing after neoadjuvant radiotherapy, or allow immediate adjuvant radiotherapy. At primary wound closure we would generally use an ipsilaterally distally pedicled rectus abdominis muscle flap if the deep epigastric vessels can be preserved or – if the ipsilateral vessels need be resected to achieve clearance of tumour - use a contralateral flap.