Tamer Ahmed EL-Sobky

Subtrochanteric valgus osteotomy in developmental coxa vara

Background: Valgus subtrochanteric osteotomy is the gold standard surgical treatment of developmental coxa vara. Nevertheless, there has been no consensus on the method of fixation and osteotomy details. In the literature, there are few reports on employing rigid internal fixation methods that preclude the need of postoperative immobilization. We present early radiologic and clinical outcome of a modified Y shaped subtrochanteric valgus osteotomy fixed with precontoured DCP. Patients and Methods: Ten patients with 10 hips of developmental coxa vara were subjected to a corrective Y-shaped subtrochanteric valgus femoral osteotomy. All the cases were fixed by a precontoured small dynamic compression plate (DCP). There were six males and four females. The right hip was affected in four patients and the left hip in six. The average age at the presentation time was 5.1 years (range 4–9 years). Clinical evaluation was done by IOWA hip score. Results: Clinically, the IOWA hip score improved postoperatively significantly (P<.05). The average preoperative head shaft angle was 94° (range 85°-100°) and the average post-operative head shaft angle was 120° (range 115°-125°). Postoperatively, the average epiphyseal-Hilgenreiner angle and the head-shaft angle fell into the normal values. No recurrence of deformity was reported. Conclusion: The Y-shaped subtrochanteric valgus osteotomy with rigid internal fixation precludes the use of external immobilization attained satisfactory clinical and radiologic results with no evidence of deformity recurrence on the short-term follow-up.

Bony reconstruction of hip in cerebral palsy children Gross Motor Function Classification System levels Iii to V: a systematic review

Hip dislocation is a common source of disability in cerebral palsy children. It has been remedied by various reconstructive procedures. This review aims at providing the best evidence for bony reconstructive procedures in cerebral palsy hip migration. The literature extraction process yielded 36 articles for inclusion in this review. There is fair evidence to indicate that the comparative effectiveness of femoral versus combined pelvifemoral reconstruction favours pelvifemoral reconstruction. All except one were retrospective articles with a significant degree of selection and performance bias and confounding variables that limited the validity and generalizability of the conclusions. The findings of this systematic review provide fair evidence for the use of adequate soft tissue and combined pelvifemoral reconstruction in the management of hip migration in none and minimally ambulatory cerebral palsy children in the short and long term. This has been shown in studies with a summed sizable patient population. There is limited evidence available that would support the use of soft-tissue and isolated femoral reconstruction. In the context of these retrospective and biased studies, it is extremely difficult to identify, with great precision, predictors of surgical success. Future studies should consider prospective designs that allow for bias control, strict patient selection criteria and incorporation of validated quality-of-life scales.

A case of infantile osteopetrosis: The radioclinical features with literature update ☆

Background Osteopetrosis is a rare hereditary metabolic bone disorder characterized by generalized skeletal sclerosis caused by a defect in bone resorption and remodelling. Infantile autosomal recessive osteopetrosis is one of three subtypes of osteopetrosis and the most severe form. The correct and early diagnosis of infantile osteopetrosis is important for management of complications and for future genetic counselling. Diagnosis is largely based on clinical and radiographic evaluation, confirmed by gene testing where applicable. Methods Therefore, in this case study the classical clinical and radiological signs of a boy with infantile osteopetrosis will be presented with a comprehensive literature update. The differentiating signs from other causes of hereditary osteosclerosing dysplasias are discussed. Results This case study and review of available literature show that there tends to be a highly unique clinical and skeletal radiographic pattern of affection in infantile osteopetrosis. Conclusion Although tremendous advances have been made in the elucidation of the genetic defect of osteopetrosis over the past years, the role of accurate clinical and radiological assessment remains an important contributor to the diagnosis of infantile osteopetrosis.

Eumycetoma Osteomyelitis of the Calcaneus in a Child: A Radiologic-Pathologic Correlation following Total Calcanectomy

Fungi are unusual causes of pedal osteomyelitis in children and adolescents. Eumycetoma is a chronic cutaneous and subcutaneous infection caused by various genera of fungi. A provisional diagnosis of foot mycetoma is made after clinical assessment. Radiologic-pathologic correlation is an essential supplement for the accurate diagnosis of osteoarticular infections. This paper aims to sensitize orthopedic surgeons, radiologists, and pathologists to the importance of correlative imaging findings in relation to surgical and microscopic pathology in osteoarticular infections, specifically eumycetoma osteomyelitis of the foot. From our review of the published data, the present case is the first report of radiologic-pathologic correlation in eumycetoma osteomyelitis of the calcaneus. This paper describes a case of eumycetoma osteomyelitis of the calcaneus in a child in which diagnostic X-rays and magnetic resonance imaging (MRI) were correlated with the surgical and microscopic pathologic features, for establishing an appropriate diagnosis and treatment. We conclude that there is a significant agreement between radiologic and pathologic evaluation for assessment of eumycetoma osteomyelitis of the calcaneus. Radiologic-pathologic correlation amplified our interpretation of imaging information available on plain radiographs and MRI and augmented diagnostic confidence. Similarly, anatomic-histopathological correlations consolidated diagnostic accuracy.

Current paediatric orthopaedic practice in hereditary multiple osteochondromas of the forearm: a systematic review

Introduction: This systematic review aims to answer three research questions concerning the management of hereditary multiple osteochondromas of forearm in children: What is the best available evidence for the currently employed surgical procedures? What patient characteristics are associated with better prognosis? What disease characteristics are associated with better prognosis? Methods: We searched the literature using three major databases with no publication date restrictions. To enhance search sensitivity and maintain precision we used keywords/subject terms correlating with patient population, problem and interventions. We used strict inclusion/exclusion criteria to improve validity evidence. Results: The search process yielded 34 eligible studies with a total of 282 patients (315 forearms). We comprehensively analysed study and patient demographics and interventions and outcomes. Eleven studies (32%) had a long-term follow-up and 31 studies (91%) were retrospective. Of the total number of forearms, ulnar lengthening +/− associated procedures was used in 210 forearms (66.7%), isolated osteochondroma excision in 65 forearms (20.6%) and isolated distal radius hemiepiphysiodesis in 15 forearms (4.7%) among others. Discussion: Ulnar lengthening can restore radiologic anatomy, improve appearance and to a lesser extent objective clinical parameters like joint range of motion on the short/intermediate term. Isolated osteochondroma excision can relief pain and satisfy cosmetic concerns occasionally. There is poor evidence to suggest that surgery improves quality of life or function. Predictors of surgical success in regard to patient and disease characteristics remain elusive. Natural history and prospective randomized control studies where the control group receives no treatment should be rethought. They have the potential for bias control and identification of the ideal surgical candidate. The complex interplay between the confounding variables has undermined the capability of most studies to provide well-grounded evidence to support and generalize their conclusions. Valid quality of life scales should supplement objective outcome measures.

Open reduction internal fixation versus external fixation with limited internal fixation for displaced comminuted closed pilon fractures: A randomised prospective study

Background Pilon fractures involve the dome of the distal tibial articular surface. The optimal treatment for high-energy pilon fractures remains controversial. Some authors advocate the use of open reduction and internal fixation (ORIF) to avoid articular incongruence. Others advocate the use of bridging external fixation with limited internal fixation (EFLIF) to reduce soft tissue complications. Literature reports of prospective studies comparing the radioclinical outcomes of ORIF and EFLIF in high-energy fractures are scarce. Retrospective studies have their limitations because of insufficient randomisation. The objective of this randomised prospective study is to compare the clinical, radiologic and functional outcomes of displaced and comminuted closed pilon fractures, Rüedi and Allgöwer type II and III, treated by either ORIF or EFLIF. Materials and Methods Forty-two patients were selected for the study. Twenty-two patients were subjected to ORIF and 20 patients were subjected to EFLIF. We used the American Orthopaedic Foot and Ankle Society score as a standard method of reporting clinical status of the ankle. Patients were followed-up clinically and radiologically for over 2 years after the surgical treatment. Results The results of ORIF and EFLIF in treatment of high-energy pilon fractures are equally effective in terms of functional outcomes and complication rates on the short term. Conclusion Soft tissue integrity and fracture comminution seem to have a significant influence on outcomes of intervention. A prospective multicentre study with a larger sample size that controls for other associated variables and comorbidities is warranted. Level of evidence Level II.

A Neglected Markedly Displaced Medial Epicondyle Fracture with Simultaneous Ulnar Nerve Palsy in an Adolescent

Humeral medial epicondyle fractures constitute around 15% of pediatric elbow fractures. Up to 60% occur in association with elbow dislocations. Knowledge of potential imaging pitfalls when examining acute elbow fractures in children contributes significantly to accurate diagnosis. Nevertheless, management of missed pediatric medial epicondyle fractures has rarely been reported. We present an 11-year-old boy with a neglected and severely displaced medial epicondyle fracture with concurrent ulnar nerve palsy. We performed neural decompression, fragment excision, and muscular and capsuloligamentous reconstruction of the medial elbow. This study demonstrates that the surgical outcome of a late presenting fracture can be satisfactory in terms of function and neural recovery. It also underscores the importance of careful interpretation of elbow imaging including normal anatomic variants.

Orthopaedic manifestations of Proteus syndrome in a child with literature update

Background Proteus syndrome is a rare developmental disorder of unknown aetiology. It is a disorder characterized by postnatal overgrowth affecting multiple tissues. Proteus syndrome is most frequently manifested in skeletal changes. As manifestations of Proteus syndrome are highly variable, and many are found in other overgrowth syndromes, and due to inconsistent application of diagnostic criteria, the literature has more reports of patients misdiagnosed than correctly diagnosed. The purpose of this study is to report the clinical and radiographic patterns of affection of the musculoskeletal system in Proteus syndrome in the light of the proposed diagnostic criteria and cases reported in the literature. Methods The clinical and radiographic musculoskeletal characteristics of a child with Proteus syndrome are illustrated along with a literature update. The orthopaedic manifestations in our patient are correlated to cases and proposed diagnostic criteria reported in the literature. Results The study of the presented case and review of available literature show that there tends to be a highly characteristic pattern of skeletal abnormalities in Proteus syndrome. Conclusion The rarity of Proteus syndrome and the variability of signs make the diagnosis challenging. Clinical and radiographic examinations are important contributors to the diagnosis. The clinical utility of the reported cases is significantly dependent on consistent application of diagnostic criteria that augment diagnostic accuracy. The present case reinforces the need for supplementary musculoskeletal imaging modalities to be implemented in the diagnosis of Proteus syndrome.