Noam Bor

Chronic anterior monteggia lesions in children: report of 4 cases treated with closed reduction by ulnar osteotomy and external fixation.

Background: Chronic, subacute, and chronic Monteggia fracture dislocations of the elbow are challenging problems. The literature generally recommends complex open reconstructive procedures. We present an alternative, minimally invasive, percutaneous method with external fixation. Methods: This was a retrospective review of 4 cases presenting with chronic Monteggia lesions with anterior dislocation of the radial head. Results: Reduction of the radiocapitellar joint was successfully achieved in all patients after ulnar osteotomy and gradual correction using the Ilizarov external fixation. Open reduction or reconstruction of the radio-ulnar-capitellar joint and/or ligament was not undertaken. The patients were between 9 and 11 years of age at the time of injury. The time from injury to treatment was between 3 and 56 months. At follow-up of an average of 3.5 years (range, 2 to 6 y), all patients had full movement of the elbow and normal function of the forearm. Radiographically, all radial heads were well reduced and the ulnar osteotomy showed remodeling. Conclusions: The technique is relatively simple and avoids the risks and technical challenges of open osteotomies, open reduction, and ligament reconstruction. Gradual reduction of the radial head with the aid of an external fixation is a safe and effective method of treatment for chronic Monteggia lesions.

Gradual Correction of Congenital Radioulnar Synostosis by an Osteotomy and Ilizarov External Fixation

PURPOSE To report the method, outcome, and complications with Ilizarov external fixation for correction of congenital radioulnar synostosis with fixed forearm pronation greater than 60°. METHODS We treated 4 patients with an average age of 11 years (range, 9-13 y). Three patients had bilateral deformity and 1 had deformity of the right forearm only. All forearms were classified as type 3 according to Cleary and Omer. Indications were severe (> 90°) bilateral pronation deformity in 3 patients, with a mean preoperative pronation deformity of 100° (range, 90° to 110°), whereas 1 patient had unilateral right forearm deformity treated for cultural reasons. All patients underwent osteotomy at the level of the synostosis and gradual correction of the deformity using an Ilizarov external fixation device. RESULTS Mean supination position of the forearms after the correction was 15° (range, 0° to 30°). Two patients experienced neurapraxia of the radial nerve attributed to acute initial partial correction of the deformity in the operating room; the correction was returned to its original position, resulting in complete neurological recovery. One patient experienced a pin track infection, which we treated successfully with oral antibiotics. CONCLUSIONS Our small series demonstrated the ability to gradually correct forearm rotation deformities greater than 90° using Ilizarov external fixation devices.

Correction of Cubitus Varus After Pediatric Supracondylar Elbow Fracture: Alternative Method Using the Taylor Spatial Frame.

Background: Cubitus varus is a well-reported complication of supracondylar fracture of the humerus potentially resulting in cosmetic problems, impaired function, and malpractice claims. Traditional methods of correcting malunited distal humeral fractures involve complex osteotomies that have a high complication rate, require a large exposure, and challenging fixation. We present a technique of gradual correction using a percutaneous transverse osteotomy and 3 dimensional correction with a Taylor Spatial Frame. Methods: This was a retrospective, IRB-approved study of 12 patients between 2006 and 2010, with cubitus varus after a malunited pediatric supracondylar fracture. The average age at initial injury was 5+8 years. The average age of the patients at surgery was 8+8 years. We measured technical (radiographic parameters and complications), functional (clinical carrying angle, range of motion, QuickDash), and satisfaction domain (questionnaire) outcomes at a minimum follow-up of 6 months. Results: The osteotomy healed in all patients by 10 weeks after the index surgery. The mean external fixator time was 10 weeks. The average preoperative and postoperative humeroulnar angles for the affected elbow were 23 degrees varus and 5.8 degrees valgus, respectively. This was statistically significant (P<0.001). The mean preoperative and postoperative carrying angles were 22 degrees of varus and 5.8 degrees of valgus. This was statistically significant (P<0.001). The results of the QuickDash assessment showed that patients were doing very well with regard to the use of their upper extremity. The mean symptom/disability score was 0.80. No major complications or neurovascular complications were encountered. Overall satisfaction with the procedure was high. Conclusions: The Taylor Spatial Frame as used in this case series provides the experienced surgeon another safe, accurate, and reliable method to correct cubitus varus after pediatric supracondylar fracture. We used in 7 of our 12 cases, a previously unreported pattern of distal humeral pin fixation that allows for a very distal metaphyseal osteotomy, close to the deformity apex. This is a biplanar delta configuration that straddles the olecranon fossa and is appropriate for both children and adults. Level of Evidence: Level IV.

Subacute osteomyelitis of the talus mimicking arthritis of the ankle joint: a case report with 16 years follow-up.

A 7-year-old girl suffering from subacute osteomyelitis of the talus is presented. The main presenting symptoms were mild pain and limping. Owing to the relatively benign course and the rarity of the disease, there was a delay in the diagnosis of about 7 weeks. Laboratory investigation indicated inflammation rather than infection. Roentgenological signs of osteomyelitis appeared at a later stage. Treatment included surgical exploration, curettage, and antibiotics. The patient was seen 16 years later, at the age of 23 years, and there were no sequelae of the infection clinically or radiographically. This study presents the existence of this rare disease, so that it can be promptly diagnosed, possibly avoiding surgical intervention.

Treatment of intra-articular distal radius fractures by the volar intrafocal Kapandji method: a case series.

At present, the most common treatment for intra-articular fractures with a volar fragment is open reduction and internal fixation with a volar locking plate. This manuscript describes and evaluates the safety and efficacy of a modified Kapandji technique with insertion of a volar Kirschner wire for osteosynthesis of intra-articular distal radius fractures with a volar fragment. Four patients treated with the “volar Kapandji technique” completed follow-up of at least 12 (12 to 54) months. The mean age was 43 (23 to 53) years. The mean Disability of the Arm, Shoulder, and Hand score was 21.7 (0 to 41) and the mean Patient-Rated Wrist Evaluation score was 12.9 (0 to 25.8). The mean loss of flexion was 13.7 (0 to 30) degrees, the mean loss of extension was 10 (0 to 30) degrees, the mean loss of supination was 0 degrees, and the mean loss of pronation was 10 (0 to 20) degrees. There was no loss in dorsal angulation, radial inclination, or radial length compared with the other hand. No early or late complications were recorded.

Can a linear external fixator stand as a surgical alternative to open reduction in treating a high-grade supracondylar humerus fracture?

Objective High-grade pediatric supracondylar humerus fractures are commonly treated with closed reduction and internal fixation with percutaneous pinning. When this fails, open reduction followed by internal fixation is the widely accepted procedure of choice. Use of a lateral external fixator was recently described as an optional procedure, but evidence is scarce. Methods We investigated the outcomes of upper limbs treated by either open reduction with internal fixation or closed reduction and external fixation. Results Twenty-one patients completed the long-term follow-up; 11 underwent open reduction, and 10 underwent external fixation. Most patients in both groups reported excellent satisfaction. In both groups, the modified Disabilities of the Arm, Shoulder, and Hand score was extremely low and the average elbow range of motion was almost identical. Radiographic analysis consisting of Baumann’s angle and the carrying angle revealed no statistical difference between the two groups. Discussion Optional treatment using a linear external fixator for complex nonreducible supracondylar humerus fractures yielded acceptable clinical and radiographic results, as with open reduction. Our sample size was small, but the promising results may assist in the implementation of an alternative surgical procedure, especially in more complicated cases involving flexion-type fractures or severe soft tissue damage and swelling.

Intermediate to Long-Term Results of Femoral Neck Lengthening (Morscher Osteotomy).

Background: Femoral neck lengthening and transfer of the greater trochanter were introduced by Morscher as treatment for patients with coxa breva and overgrowth of the greater trochanter. In this study we evaluated intermediate and long-term results of this operation. Methods: We reviewed clinical and radiographic results of 18 patients (20 hips) who were treated by Morscher osteotomy. Ten patients had Perthes disease, 4 had developmental dysplasia of the hip, and 4 had avascular necrosis of the hip. The median age at surgery was 16 years [interquartile range (IQR): 14 to 17.5]. The median follow-up period was 7 years (IQR: 4.5 to 10). All patients were evaluated clinically by means of Harris Hip Score (HHS) before and after surgery. Results: Preoperative clinical examination revealed that all patients had a limp and a positive Trendelenburg test. Median HHS was 72.5 (IQR: 69 to 83). Postoperatively, the Trendelenburg test was negative in 14 hips and positive in 6 hips. Postoperative median HHS was 94.5 (IQR: 89 to 96). Radiographic examination showed progression of osteoarthritis in 3 patients. One operation failed and was converted to total arthroplasty (total hip replacement) after 4 years. Two hips required total hip replacement 10 years after the operation. Leg length discrepancy was reduced in 17/20 hips. Overall patient satisfaction level was good-excellent in 12 patients, fair in 4, and bad in 2 patients. Postoperative complications included blade migration (1 patient (and wire breakage (2 patients). Conclusions: Morscher osteotomy can be effective for the treatment of patients with short femoral neck and overgrowth of the greater trochanter with a positive Trendelenburg test and mild leg length discrepancy. A congruent nonarthritic hip joint is a prerequisite for the success of the operation. Level of Evidence: Level IV.