Mark Eidelman

Treatment of Graf’s Ultrasound Class III and IV Hips Using Pavlik’s Method

AbstractWhen Pavlik introduced his method of treating congenital dislocation of the hip, he emphasized reducing the rate of osteonecrosis. Graf’s method of sonographic evaluation afforded earlier accurate diagnosis and subsequent treatment of developmental dysplasia of the hip. To ascertain whether treatment duration, gender, age at diagnosis, clinical stability, and/or treatment onset correlate with the risk of osteonecrosis in Graf Type III or IV hips, we clinically and sonographically screened 18,067 neonates (36,134 hips) for developmental dysplasia of the hip over a 4-year period; 151 had Graf Type III or IV hips, and 78 of these were treated by us and had known outcomes. Of these 78 hips, 65 (0.18%) had Graf Type III and 13 (0.036%) had Graf Type IV hips. Sixteen of the 65 Type III hips (25%) reduced spontaneously. Using Pavlik’s method, reduction was achieved in 46 of 65 (88.5%) Type III hips and eight of 13 Type IV hips. None of the hips treated exclusively by Pavlik’s method developed osteonecrosis. Thus, the method achieves one of Pavlik’s original goals of decreasing osteonecrosis incidence to close to zero. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Neonatal incidence of hip dysplasia: ten years of experience.

AbstractThe advantages of sonographic examination are well known, but its main disadvantage is that it might lead to overdiagnosis, which might cause overtreatment. Variations in the incidence of developmental dysplasia of the hip are well known. We ascertained the incidence of neonatal sonographic developmental dysplasia of the hip without considering the development of those joints during followup. All 45,497 neonates (90,994 hips) born in our institute between January 1992 and December 2001 were examined clinically and sonographically during the first 48 hours of life. Sonography was performed according to Graf’s method, which considers mild hip sonographic abnormalities as Type IIa. We evaluated the different severity type incidence pattern and its influence on the total incidence during and between the investigated years. According to our study, sonographic Type IIa has major effects on the incidence of overall developmental dysplasia of the hip with a correlation coefficient of 0.95, whereas more severe sonographic abnormalities show relatively stable incidence patterns. Level of Evidence: Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by 'flexion-extension cross-pinning' technique.

No consensus exists concerning the best pin configuration for displaced supracondylar fractures of the humerus in children. Although cross-pinning is the most stable biomechanically, this configuration may cause iatrogenic ulnar nerve palsy. For the last 7 years, we have been using a three-pin fixation technique with insertion of two K wires from the lateral side (elbow in full flexion) and the third wire through the medial side (elbow in full extension). We used this technique in 67 displaced supracondylar fractures without any complications related to the ulnar nerve. The technique provides excellent stability and eliminates the risk of iatrogenic ulnar nerve palsy.

Treatment of Complex Tibial Fractures in Children With the Taylor Spatial Frame

Most tibial shaft fractures in children can be treated with closed reduction and cast fixation, but some fractures need external or internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator that can correct 6-axis deformities with computer accuracy. This article reports our experience using the Taylor spatial frame as a rewarding treatment modality for complex tibial fractures in children and adolescents.

Treatment of arthrogrypotic foot deformities with the Taylor Spatial Frame.

Background Treatment of foot deformities in arthrogryposis is a challenging problem. Most deformities are very rigid clubfeet, such as deformities with severe equinus, supination, cavus, hindfoot varus, and forefoot adduction. Vertical talus with severe rocker bottom is also common. Traditional approaches included casting and soft tissue release, which are usually only partially successful. We describe our experience with the treatment of arthrogrypotic foot deformities with the Taylor Spatial Frame. Methods Over a period of 5 years, we treated 7 patients (10 feet) with various arthrogrypotic foot deformities. There were 4 girls and 3 boys with a mean age 10.6 years (range: 4 to 16 y). Six patients had clubfoot deformities and 1 had vertical talus. All patients had previous surgeries, including soft tissue release in 8 feet and Ilizarov correction in 3 feet. Three patients underwent bilateral correction, 3 patients underwent midfoot osteotomies, and 2 patients had supramalleolar osteotomies and lengthening to compensate for growth arrest of the distal tibia. The remaining feet had correction of their deformities by soft tissue distraction. Six patients underwent correction using a Butt frame and 5 by standard frame configuration. Results All patients achieved the preoperative correction goal and their frames were removed at an average of 16.1 weeks (range: 14 to 18 wk). Complications included pin tract infections in 4 patients. One patient had iatrogenic regenerate translation that was reduced by a residual program, 1 patient had recurrence of equines, and another had partial recurrence of forefoot supination. Two hindfoot varus deformities were successfully treated by calcaneal osteotomy at the time of Butt frame removal. Conclusions On the basis of our preliminary experience, we believe that the Taylor Spatial Frame is a reliable and accurate method of correction of complex foot deformities in children with arthrogryposis. Level of Evidence Level 4, Case series.

Correction of residual clubfoot deformities in older children using the Taylor spatial butt frame and midfoot Gigli saw osteotomy.

Background: Residual clubfoot deformities in older children are a difficult surgical problem. The foot is stiff and almost always has already undergone some surgical intervention. The traditional approach includes soft-tissue release or osteotomy and external fixation (usually with an Ilizarov frame). Methods: In this study, we summarized our experience with the treatment of residual clubfoot deformities in older children using a percutaneous midfoot Gigli saw osteotomy and the Taylor spatial frame. There were 11 children in the study, with a mean age of 14.7 years, and mean frame fixation time was 15.1 weeks. Because the primary problems in these children were midfoot and forefoot deformities (forefoot adduction, supination, and cavus), a Butt frame was applied after the midfoot osteotomy. Results: At the time of frame removal, the goal of deformity correction was achieved in all the children. Two patients had partial recurrence of the deformities and were reoperated. One patient with residual supination is planned to be operated close to maturity. Complications included superficial pin-tract infection in 5 patients and premature consolidation of the osteotomy that needed reosteotomy. Conclusions: On the basis of our experience, we believe that midfoot osteotomy and correction by Taylor spatial frame is an effective and reliable surgical option for this challenging problem. Level of Evidence: Level 4—case series.

Submuscular plating of femoral fractures in children: the importance of anatomic plate precontouring

Despite many treatment options, the treatment of metaphyseal pediatric femoral fractures remains to be controversial. Fixation of most metaphyseal femoral fractures in older children is difficult to perform. Recently, bridging fixation of such fractures by submuscular plating has become popular. Plate precontouring as close as possible to anatomic bony structure is important, as the femur will subsequently reduce to the contour of the plate with screw placement. Our technique is using plates that are anatomically precontoured to a cadaver adolescent femur to ensure proper postoperative alignment. In this study we evaluate the effectiveness of submuscular plating performed in our institution using this technique, in 11 patients. All fractures united with good alignment. No major complication occurred. In conclusion, submuscular plating of adolescent femoral fractures with precontoured plates is an effective, predictable, and safe procedure.

Surgical treatment of residual osgood-schlatter disease in young adults: role of the mobile osseous fragment.

Osgood-Schlatter disease is a well-known condition in late childhood characterized by pain over the tibial tubercle. This condition usually resolves spontaneously at skeletal maturity. Few patients develop pain over the tibial tubercle. Radiological examination demonstrates a round regular ossification over the tubercle. Treatment is usually symptomatic, but occasionally surgical treatment is necessary, usually due to the development of a painful ossicle. This article reports our experience with refractory Osgood-Schlatter disease in 22 patients. Most patients were operated under local anesthesia. A midline longitudinal skin incision was used, followed by subperiosteal dissection of the osseous fragment. The knee was put in soft dressing. Patients were encouraged to resume daily activity immediately postoperatively. No wound complications were noted. All patients returned to their previous level of physical activity within 12 weeks postoperatively. All but 1 were free of pain on kneeling or direct pressure over the knee joint. Based on our experience, we devised a treatment algorithm. We believe that the key factors for successful surgical treatment are clear visualization of separation on lateral knee radiographic view and a clinical mobility positive test (firm grasping of the prominent part of the tubercle and its sliding movement). Our results are uniformly good; the only failure related to mistaken inclusion criteria where the lateral radiograph did not show a distinctly separated fragment.

Deformity correction using supramalleolar gigli saw osteotomy and Taylor spatial frame: how to perform this osteotomy safely?

Supramalleolar osteotomy (SMO) is useful for the correction of various deformities around the ankle joint, especially deformities of the distal tibia secondary to partial growth arrest, foot equinus, and hindfoot deformities. By definition, this osteotomy cuts through the tibia and fibula approximately 2–3 cm above the ankle joint. It can be performed by various techniques, each of them have advantages and disadvantages. Gigli saw SMO can be performed percutaneously with minimal soft tissue dissection, leaving a very smooth bone surface, which is especially useful for the correction of rotational deformities. Over a period of 6 years we performed eight gigli saw SMO in seven male patients and one female patient with a mean age of 13.6 years. All patients had multiplanar deformities with some shortening (range 15–40 mm) and underwent correction and lengthening by Taylor spatial frame. Treatment goal was achieved in all patients with minimal complications. On the basis of our experience, we believe that gigli saw SMO can be performed safely. This osteotomy, in conjunction with the Taylor spatial frame, became our treatment of choice for the correction of ankle and hindfoot deformities. The evidence is level 4, case series.

A novel elastic exsanguination tourniquet as an alternative to the pneumatic cuff in pediatric orthopedic limb surgery.

We describe our experience with a novel surgical exsanguination tourniquet (S-MART; OHK Medical Devices, Haifa, Israel) in clinical pediatric orthopedics. We evaluated the surgical exsanguination tourniquets properties and clinical use in 51 patients and compared our observations with our long-standing experience with the Esmarch bandage, pneumatic tourniquet and sterile stockinet. Using the surgical exsanguination tourniquet, we found superior exsanguination quality, quick application and the ability to place the occlusion ring closer to the surgical field. No side effects or ischemic complications were observed. After removal, the skin under the ring was intact in all cases. We conclude that the surgical exsanguination tourniquet is safe and valuable in our practice.