P. Farsetti

Long-term comparative results in patients with congenital clubfoot treated with two different protocols

Background: Long-term follow-up studies of adults who had been treated for congenital clubfoot as infants are rare. The purpose of this study was to review and compare the long-term results in two groups of patients with congenital clubfoot treated with two different techniques. In both groups, treatment was started within the first three weeks of life by manipulation and application of toe-to-groin plaster casts, with a different technique in each group. At the end of the manipulative treatment, a posteromedial release was performed when the patient was between eight and twelve months of age in the first group and a limited posterior release was performed when the patient was between two and four months of age in the second group. Methods: At the follow-up evaluations, all patients were interviewed and examined, and standing anteroposterior and lateral radiographs and computed tomography scans of the foot were made. The results of treatment were graded according to the system of Laaveg and Ponseti. Numerous angular measurements were made on the radiographs, and the measurements in the two groups were compared. Results: The first group, which included thirty-two patients (forty-seven clubfeet), was followed until an average age of twenty-five years. The second group, with thirty-two patients (forty-nine clubfeet), was followed until an average age of nineteen years. In the first group, there were two excellent, eighteen good, eleven fair, and sixteen poor results. In the second group, there were eighteen excellent, twenty good, six fair, and five poor results. According to the system of Laaveg and Ponseti, the mean rating in the first group was 74.7 points and that in the second group was 85.4 points. Conclusions: In the second group, use of Ponsetis manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot. In our hands, this operation did not prevent relapse, and neither cavovarus nor forefoot adduction was completely corrected. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Long-term Results of Treatment of Fractures of the Medial Humeral Epicondyle in Children

Background: The treatment of isolated, displaced fractures of the medial humeral epicondyle in children is controversial. Both plaster cast immobilization without reduction and open reduction and internal fixation have been advocated. The purpose of this long‐term retrospective study was to analyze the functional and radiographic results of both nonsurgical and surgical management of these injuries. Methods: Forty‐two patients who had had an isolated fracture of the medial humeral epicondyle with displacement of >5 mm at an average age of twelve years (range, eight to fifteen years) were evaluated at an average age of forty-five years (range, thirty to sixty-one years). The patients were divided into three groups that were comparable with regard to the amount of fracture displacement, age at the time of the fracture, age at the time of follow‐up, sports activities and occupation, and duration of follow‐up. In Group I (nineteen patients), the fracture had been treated with a long-arm plaster cast without reduction of the displaced medial epicondyle. In Group II (seventeen patients), open reduction and internal fixation with either Kirschner wires or a T‐nail had been performed. In Group III (six patients), the epicondylar fragment had been excised with suture reattachment of the tendons and the medial collateral ligament. Results: According to a functional grading scale, there were sixteen good and three fair results in Group I. All but two patients were seen to have nonunion of the fragment on follow‐up radiographs, but all had a normal result on valgus stress-testing of the elbow. The range of motion of the elbow was either normal or minimally decreased, and the grip strength of the ipsilateral hand was normal. There were fifteen good and two fair results in Group II. All patients had union of the medial epicondyle, with various radiographic deformities of the medial epicondyle, but the functional results were similar to those of the Group-I patients. The Group-III patients had four poor and two fair results. Four had constant pain at the elbow and paresthesias in the distribution of the ulnar nerve. One patient had a restricted range of motion of the elbow, four patients had an unstable elbow, and three patients had decreased grip strength of the ipsilateral hand. Conclusions: In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long‐term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long‐term results are poor.

Primary subtalar arthrodesis for the treatment of comminuted intra-articular calcaneal fractures

We report the short- and mid-term results in six patients (seven feet) affected by markedly comminuted intra-articular calcaneal fractures (Sanders type IV), treated by primary subtalar arthrodesis. The average age at surgery was 40 years. In all patients, arthrodesis of the subtalar joint was performed using a limited lateral approach to the calcaneus; it was stabilised with two or three cannulated screws. No patient had a preliminary reduction and internal fixation of the fracture. The time from injury to surgery averaged 20 days because all of the patients had associated visceral and/or other skeletal injuries. All of the patients were followed up clinically and radiographically 2 times, at an average of 12 months and 53 months after surgery. At the short-term follow-up, the mean AOFAS score was 70 points; the X-rays showed a complete fusion of the subtalar joint in all seven feet, without any sign of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints. In all cases, an altered shape of the calcaneus was present. At the mid-term follow-up, the mean AOFAS score increased to 85 points; in one patient, radiographic signs of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints were present and, in another patient, only talo-navicular joint was present, although both patients were free from pain. The difference between the two AOFAS scores was statistically significant. We believe that primary subtalar arthrodesis performed for markedly comminuted Sanders type IV calcaneal fractures yielded good mid-term results, and it is especially indicated when surgical treatment is delayed for whatever reason. A preliminary open reduction and internal fixation to restore the normal height of the calcaneus before performing the subtalar arthrodesis, as suggested by several authors, does not seem indispensable to obtain good clinical results.

Chondrolysis of the hip complicating slipped capital femoral epiphysis: long-term follow-up of nine patients.

Nine patients with chondrolysis secondary to slipped capital femoral epiphysis of the hip were followed up from a minimum of 7 to a maximum of 19 years (average, 13.7 years) after the onset of the disease. The degree of slipping of the proximal epiphysis of the femur was severe in five patients and moderately severe in four patients. The nine patients were treated with non-weight bearing, antiinflammatory drugs, and physical therapy. The disease had a good resolution, with gradual regression of pain, and radiographs showed restoration of the joint space in an average of 10 months. At follow-up, mild coxalgia after prolonged activity was present in five patients, whereas in the one patient with concomitant avascular necrosis, pain was much more intense. All patients had some limitation of range of motion of the hip. It was most restricted in two patients, one with associated avascular necrosis and one with a severe slip. In all patients, radiographs showed restoration of the joint space. In the group with severe degrees of slipping, there were marginal osteophytes of the femoral head and the acetabulum. Significant arthrosis was present in the patient treated conservatively and in the patient with associated ischemic necrosis. In this long-term study of chondrolysis secondary to slipped capital femoral epiphysis, the overall prognosis was benign and was determined by the degree of slipping of the proximal epiphysis of the femur and concomitant aseptic necrosis. However, the authors believe that the patients with radiographic signs of degenerative joint disease may have a poor long-term prognosis.

Fractures of the olecranon in children. Long-term follow-up of 39 cases.

Thirty-nine patients, who had received a fracture of the olecranon at an average age of 7.4 years, were reviewed at an average age of 32 years, in order to evaluate the results of treatment. All patients had reached skeletal maturity at follow-up. Thirty-four fractures were treated conservatively and five, surgically. Of the 34 fractures treated conservatively, six also had surgical treatment of associated fractures. We identified five patterns of fracture on the basis of the anatomic site of the fracture line, the interfragmentary displacement and the presence of an associated lesion. According to our grading scale, 34 patients had a good result, two a fair result and three a poor result. We observed poor results in only 7.6% of cases, even though 85% of the patients had received an intraarticular fracture. We believe that the long-term prognosis of olecranon fractures in children is related to the anatomic site of the fracture line, to the interfragmentary displacement and to the presence of an associated lesion. Conservative treatment may be indicated when the interfragmentary displacement is less than 2 mm. The presence of an associated lesion is a negative prognostic factor.

Fractures of the neck of the fifth metacarpal bone. Medium-term results in 28 cases treated by percutaneous transverse pinning

The purpose of this study was to report the medium-term results in 28 patients affected by closed displaced fractures of the neck of the fifth metacarpal bone (boxers fracture) with an associated severe swelling of the hand, who were treated with percutaneous transverse K-wire pinning, to verify the effectiveness of this surgical treatment. We opted for this treatment in all cases in which malrotation of the fifth finger and volar angulation of the metacarpal head greater than 30° were associated with a severe swelling of the hand. All the patients were reviewed clinically and radiologically at an average of 25 months after surgery. At the final follow-up, no patient reported residual pain. All patients had full extension of the fifth finger, except two in whom we observed a limitation of the extension of the fifth metacarpophalangeal (MP) joint of about 10°, without significant impairment of hand function. All patients had at least 90° flexion of the fifth MP joint and full range of motion of the interphalangeal (IP) joints. No patient had rotational deformity of the fifth finger with a deficit of grip strength. At the final follow-up, a residual palmar angulation of the head of the fifth metacarpal was found in three patients, with a mean of 7°. The disabilities of the arm, shoulder and hand (DASH) scale had a mean value of 5, and all patients considered their result as good or excellent. We recommend percutaneous transverse pinning in all boxers fractures in which operative treatment is indicated, especially in patients with severe soft-tissue swelling. The surgical procedure is easy to perform, and surgical results are generally good.

CT Study on the Effect of Different Treatment Protocols for Clubfoot Pathology

In congenital clubfoot, residual deformities are not well-documented and they may change depending on different treatments. To identify the treatment that provides better outcome at maturity, we studied the computed tomography of two cohorts of patients affected with congenital clubfoot who were treated using two distinct protocols. Forty-seven clubfeet were treated according to the traditional protocol of our hospital and 61 were treated according to the Ponseti technique. The normal feet of the unilateral deformities served as controls. All patients were followed to skeletal maturity. The ankle torsion angle and the declination angle of the neck of the talus were higher than normal but different only in patients treated with the traditional method. The calcaneocuboid angle was lower but only in patients treated with the Ponseti method. The shape of the talar joints was altered in many feet regardless of protocol. The CT images suggest the modifications of the torsion angle of the ankle, the declination angle of the neck of the talus, and the calcaneocuboid angle at maturity are related to the treatment protocol followed. The Ponseti manipulative technique provided better anatomical results in comparison to our traditional technique.

The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Radiographic classification of coronal plane femoral deformities in polyostotic fibrous dysplasia

BackgroundFibrous dysplasia of bone is a skeletal dysplasia with a propensity to affect the femur in its polyostotic form, leading to deformity, fracture, and pain. The proximal femur is most commonly involved with a tendency to distal progression, thereby producing the typical shepherd’s crook deformity. However, there are few data on the spectrum and progression of femoral deformities in polyostotic fibrous dysplasia.Questions/purposesThe purposes of this study were (1) to develop a radiographic classification for polyostotic fibrous dysplasia; (2) to test this classification’s intra- and interobserver reliability; and (3) to characterize the radiographic progression of polyostotic fibrous dysplasia in a population of patients with the condition who were treated with a variety of approaches at several centers.MethodsWe retrospectively reviewed radiographs of 127 femurs from 84 adult patients affected by polyostotic fibrous dysplasia. Fifty-nine femurs had undergone one or more operations. The radiographs were evaluated in the coronal plane for neck-shaft angle and angular deformities along the whole femoral shaft down to the distal epiphysis. Four observers evaluated each film two times at intervals; intra- and interobserver reliability testing was performed using the kappa statistic. Eighty-nine femurs (70%) were available for followup to evaluate for progression at a mean of 10 years (range, 6–20 years).ResultsSix reproducible patterns of deformity were identified in both untreated and operated femurs: type 1 (24%), normal neck-shaft angle with altered shape of the proximal femur; type 2 (6%), isolated coxa valga with neck-shaft angle > 140°; type 3 (7%), isolated coxa vara with neck-shaft angle < 120°; type 4 (20%), lateral bowing of the proximal half of the femur associated with normal neck-shaft angle; type 5 (14%), like in type 4 but associated with coxa valga; and type 6 (29%), like in type 4 but associated with coxa vara. Interobserver and intraoberver kappa values were excellent, ranging from 0.83 to 0.87. In 46 of the 89 femurs (52%) for which longitudinal radiographic documentation was available, there was progressive worsening of the original deformity, although the pattern remained the same; types 1 and 2 tended not to progress, whereas types 3 to 6 did.ConclusionsA reproducible radiographic classification of polyostotic fibrous dysplasia-associated femoral deformities is proposed, which can serve as a tool for assessing and treating these deformities. After reviewing the radiographs of 127 femurs, we identified six reproducible patterns of femoral deformities.Level of EvidenceLevel III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Giant intra-articular extrasynovial osteochondroma of the knee: a report of two cases

We report two cases of a giant extrasynovial osteochondroma of the knee located in the infrapatellar fat pad region, in two females who were 58 and 71 years old respectively. Both patients had noticed the mass many years before our first clinical observation. In both patients, at physical examination a solid, firm and hard mass was palpable in the anterior part of the knee in Hoffa’s fat pad region, and the range of motion of the knee was severely restricted and painful. CT scan examination with 3D-reconstruction showed two large, calcified neoformations behind the patellar tendon, between the apex of the patella and the proximal third of the tibia. In both cases, the mass was completely resected surgically through an anterior longitudinal approach. At histological examination, the excised masses consisted of an outer layer of hyaline cartilage without significant chondrocyte atypia and an inner region of bone trabeculae formed by endochondral ossification. At follow-up, 8 and 4 years after the operation, both patients were pain-free, with complete recovery of the range of motion of the knee and without any clinical or radiographic evidence of recurrence. The authors believe that intra-articular extrasynovial osteochondroma of the knee is a primary metaplasia of Hoffa’s fat pad. Usually, the tumor develops slowly and asymptomatically over many years. The treatment of choice is a marginal resection of the mass, although a biopsy should be considered in some cases. Recurrences are extremely rare.