Zaid Al-Aubaidi

Three-dimensional imaging of the spine using the EOS system: is it reliable? A comparative study using computed tomography imaging.

The aim of this study was to evaluate the precision of three-dimensional geometry compared with computed tomography (CT) images. This retrospective study included patients who had undergone both imaging of the spine using the EOS imaging system and CT scanning of the spine. The apical vertebral orientation was also measured using the EOS imaging system and by CT. Other measures such as the Cobb angle and apical vertebral rotation and translation were used as the control variables to evaluate the potential discrepancy between the standing position in EOS imaging and the supine position in CT scanning. The apical vertebral orientations were 8.7° for the first measurement and 8.4° for the second measurement made by the first author, and 10.3° for the measurement made by the second author. The average of these measurements was 9.3° compared with 6.6° (P=0.65) obtained on CT scanning. The precision of EOS-based measurements of vertebral rotation has never been tested in clinical practice. Although it has limitations, this study suggests that the results obtained using EOS are comparable to those obtained on CT.

Radial neck fractures in children treated with the centromedullary Métaizeau technique.

BACKGROUND Radial neck fracture in children is infrequent but when not managed accurately can lead to complications. Different methods have been developed for the reduction and fixation of this fracture. The purpose of this retrospective study is to evaluate our results using the Métaizeau centromedullary technique. MATERIALS AND METHOD Our series comprises 19 children with displaced radial neck fractures treated in our institution in the period 2004-2008. One patient was excluded because of a very complex fracture dislocation of the elbow (exclusion criteria). Two patients refused to participate in the follow-up leaving 16 who were treated with this technique. Patients were evaluated clinically and radiologically. For the clinical evaluation, we used the Métaizeaus classification. The subjective evaluation was done using the DASH score, and the Steeles classification was used for the evaluation of the radiological results. FINDING/RESULTS: We found good clinical and radiological outcomes. The mean DASH score was 3.06. Patients who had undergone open reduction had inferior outcome. CONCLUSION Our results are comparable to other studies. This study confirms the Métaizeau technique as an excellent treatment option for displaced paediatric radial neck fractures.

Patient outcomes in the operative and nonoperative management of high-grade spondylolisthesis in children.

Background: The optimal management of high-grade spondylolisthesis in the growing child is controversial. Some authors have advocated for surgery in all cases regardless of symptoms. Surgical intervention results in a >10% risk of complications with increased risk of neurological injury associated with slip reduction maneuvers. There is a paucity of literature regarding nonoperative management in this setting. This study sought to obtain outcome measures in pediatric patients with high-grade spondylolisthesis managed either operatively or nonoperatively. Methods: Database review was performed to identify patients with a high-grade (Meyerding grade III to V) spondylolisthesis managed either operatively or nonoperatively. Retrospective radiographic and chart review was performed. Patients were then contacted by phone to obtain current quality-of-life measurements using the Scoliosis Research Society (SRS)-30 questionnaire. Results: Fifty-three patients were identified for inclusion in the study and 49 were contacted for 92% follow-up. Twenty-four patients were treated with operative intervention, and 25 patients were initially treated nonoperatively, but 10 went on to require surgical intervention. Mean age at presentation was 12.6 years (range, 8 to 17 y) and mean age at follow-up was 20.1 years (range, 10 to 29 y). There were no outcome differences between the groups. A more kyphotic slip angle was associated with worse SRS-30 outcome scores across all groups. In the nonoperative group, the slip angle was significantly larger in patients who failed conservative treatment (34±17 degrees) than in those who remained nonsurgical at final follow-up (20±14 degrees). Slip angle in the operative group was 27±14 degrees. In surgical patients, an older age at surgery was associated with better SRS-30 outcome scores. Conclusions: Nonoperative management or “watchful waiting” of the minimally symptomatic or asymptomatic child with a high-grade spondylolisthesis is safe and does not lead to significant problems. Operative intervention for the symptomatic patient achieves similar long-term results compared with patients whose minimal symptoms do not warrant surgery. Delayed surgical intervention does not result in worse outcomes. Regardless of treatment modality, patients with a more kyphotic slip angle tend to have a poorer prognosis. Level of Evidence: Level III.

The role of fat pad sign in diagnosing occult elbow fractures in the pediatric patient: a prospective magnetic resonance imaging study

In 1954, Norell described the ‘fat pad sign’ for the first time. This refers to the radiological visualization of the elbow fatty tissue. This is a prospective study with the aim of clarifying the relation between the presence of a positive fat pad sign on the lateral radiograph and the type of injury verified on MRI. From January to December 2010, 31 children were diagnosed primarily with a positive fat pad sign. An above-the-elbow cast was applied and all patients were referred for an MRI within a few days. All patients were recommended a clinical follow-up and informed about the MRI results. After revision, five patients were found to have a negative fat pad sign and were excluded. This resulted in a total of 26 patients, 10 men and 16 women, mean age 10±2.62 years. The time between the injury and the initial radiological examination was 0.8±0.27 days and the MRI was obtained on an average of 6.6±3.84 days. A total of 12 patients had an injury of the left side and 14 of the right side. The MRI showed a posterior positive sign in all except five cases and six occult fractures, which accounts for 23%. Nineteen patients (73%) had a bone bruise. All patients except one had a normal range of movement with no pain on the last clinical examination after 2–3 weeks. The presence of a positive fad pad sign is not synonymous with occult fractures. Finding occult fractures on MRI does not alter the final treatment of these patients. On the basis of this study and review of other similar studies, pediatric patients who presented with elbow effusion verified on conventional radiographs could be treated with a cast for 2–3 weeks and extra clinical or radiological controls did not seem to be indicated. Level of evidence: Level III, development of diagnostic criteria on the basis of consecutive patients.

Anterior distal tibial epiphysiodesis for the treatment of recurrent equinus deformity after surgical treatment of clubfeet.

Abstract The treatment of clubfeet has changed constantly. Before the acceptance of the Ponseti serial casting, extensive surgical release was widely used. The treatment of relapse in these surgically treated clubfeet can be very challenging. Many methods have been used ranging from osteotomies to new posteromedial release, or correction using the Ilizarov fixator. Supramalleolar osteotomy was practiced for the treatment of residual equinus. The aim of this study is to evaluate the effect of anterior epiphysiodesis of the distal tibia on recurrent equinus deformity in patients with clubfeet treated surgically. Methods We evaluated 25 children (31 feet) with recurrent equinus deformity after surgical treatment of clubfoot treated in our institution from 2003 through 2009. There were 16 boys and 9 girls, of whom 11 had recurrent equinus deformity on the left side, 8 on the right side, and 6 on the bilateral side. Three patients were treated with Richard staples and 22 were treated with 8-plates. Patients were examined clinically and radiologically, preoperatively. The mean dorsiflexion of the ankle was 2.5 degrees (−5 to 10 degrees) and the anterior distal tibial angle (ADTA) was 85 degrees. The patients were followed postoperatively and evaluated clinically and radiographically. The plates or staples were removed if the desired effect of around 15 degrees of dorsiflexion was achieved, or the ADTA shifted >15 degrees. Results Mean follow-up was 22 months. Mean improval of dorsiflexion was 2 degrees, with a mean of dorsiflexion of 4.5 degrees, and mean radiological changes of ADTA were 13 degrees. We found no correlation between the radiographic changes and the clinically measured dorsiflexion. Conclusions The use of anterior distal tibial epiphysiodesis does not seem to give a clinically significant improvement in dorsiflexion of the ankle despite a marked shift in the ADTA.

The proportion of distal fibula Salter-Harris type I epiphyseal fracture in the paediatric population with acute ankle injury: a prospective MRI study.

Ankle injuries are common among the paediatric population. There are few prospective studies utilizing MRI to diagnose a clinically suspected Salter–Harris type I of the distal fibula (SH1FDF). The aim of this study was to examine the proportion of clinically suspected SH1FDF in children. All paediatric patients with ankle injury, seen at the emergency room from September 2012 to May 2013 at a single institution, underwent a standardized clinical examination, and their radiographs were obtained if found necessary. All images and data were recorded prospectively and patients suspected of having SH1FDF were referred for MRI of the ankle joint. Out of 391 paediatric patients seen at the emergency room with ankle injury, 38 patients had a clinical suspicion of SH1FDF. A total of 31 patients, 18 male and 13 female, with a mean age of 10±2.86 years, were included in the study. Only seven patients were excluded from the study. MRI was obtained on an average of 6.9±2.87 days. None of the included patients had evidence of SH1FDF on MRI. Our study and review of the literature verifies the high false-positive rate of clinically suspected SH1FDF. Most children had ligamentous lesions, bone contusion or joint effusion, rather than SH1FDF.

A bone cyst treated with corticosteroid installation in an osteopetrotic child.

Bone cysts in patients suffering from osteopetrosis are uncommon. A pathologic fracture might cause therapeutic difficulties because of the osteosclerotic bone. We describe a patient with an autosomal dominant osteopetrosis suffering from a large bone cyst in the proximal femur. The cyst was treated with local injections of corticosteroid and healed completely after 2 injections. To our knowledge, this is the first time that the occurrence of bone cysts has been reported in osteopetrotic patients, which responds effectively and lastingly to steroid injection.

Microdose acquisition in adolescent leg length discrepancy using a low-dose biplane imaging system

Background Children with leg length discrepancy often undergo repeat imaging. Therefore, every effort to reduce radiation dose is important. Using low dose preview images and noise reduction software rather than diagnostic images for length measurements might contribute to reducing dose. Purpose To compare leg length measurements performed on diagnostic images and low dose preview images both acquired using a low-dose bi-planar imaging system. Material and Methods Preview and diagnostic images from 22 patients were retrospectively collected (14 girls, 8 boys; mean age, 12.8 years; age range, 10–15 years). All images were anonymized and measured independently by two musculoskeletal radiologists. Three sets of measurements were performed on all images; the mechanical axis lines of the femur and the tibia as well as the anatomical line of the entire extremity. Statistical significance was tested with a paired t-test. Results No statistically significant difference was found between measurements performed on the preview and on the diagnostic image. The mean tibial length difference between the observers was −0.06 cm (95% confidence interval [CI], −0.12 to 0.01) and −0.08 cm (95% CI, −0.21 to 0.05), respectively; 0.10 cm (95% CI, 0.02–0.17) and 0.06 cm (95% CI, −0.02 to 0.14) for the femoral measurements and 0.12 cm (95% CI, −0.05 to 0.26) and 0.08 cm (95% CI, −0.02 to 0.19) for total leg length discrepancy. ICCs were >0.99 indicating excellent inter- and intra-rater reliability. Conclusion The data strongly imply that leg length measurements performed on preview images from a low-dose bi-planar imaging system are comparable to measurements performed on diagnostic images.

Operative treatment of completely displaced clavicle shaft fractures in children.

To the Editor: It was with great interest that I read the article entitled “Operative Treatment of Completely Displaced Clavicle Shaft Fractures in Children,” which concluded that treating the displaced midshaft clavicle fractures in children is a safe and effective procedure. I do have some comments, questions, and concerns regarding this article though! Midshaft clavicular fractures in adults were traditionally treated by nonoperative means. Through the last 10 years, there has been increasing interest in this fracture type and the outcome of nonoperative treatment versus operative treatment. The need for a more invasive method of treatment emerged because of the complications of nonoperative treatment for the midshaft of the clavicle in adult and this was concluded by the Canadian study. This is the largest and the only randomized study, which showed that the outcome in the operative group was superior to the nonoperative group and the complications rate, was lower. These complications can be in the form of high rate of nonunion and shortening of the shaft, which can lead to the internal rotation of the whole shoulder. We could all agree that one cannot compare the results in the adult with the pediatric patient. To my knowledge, there is no single study on the pediatric patient that shows the possibility of similar complications. There have been some reports that showed duplication of the clavicle because of a form of sleeve lesion in the distal clavicle, when the fracture takes place in the puberty. In some cases, it was necessary to resect the protruding part of the clavicle due to pain. Regarding this particular article, I think that many readers would be curious to know: what was the indication of choosing the operative treatment instead of the traditional nonoperative. The other question which pop up in my mind when I read this article was: does this treatment choice occurred in consultation with the patients and their families? It is mentioned that the youngest patient was 7-year-old; I wonder: what was the indication for operating such a young child? There was also 11-yearold female with head trauma, which was operated on after 9 days. To my knowledge, patients with head trauma and fractures heal very quickly and have tendency to form a big callus. I can see that the surgery was performed on this patient after 9 days! It would be also very interesting to know how stabile the fracture was at that time. It is mentioned that there are 2 patients who suffered from persistent scar sensitivity. I just wonder whether the patients and their families knew about the possibility of this complication and yet chose the operative treatment! Last but not least, the x-ray which is used in this article does not show a severely displaced fracture. In the study of Kubiak and Slongo, the indication of choosing the operative treatment was very clear, and this can justify the choice of the treatment. The treatment of the severely displaced lateral clavicle fracture in the age group above 13 years can be discussed, but in the younger child one should be very careful to choose the operative treatment, especially knowing that there will be a second surgery to remove the metal. I do not have a randomized study that shows nonoperative treatment is better in the pediatric patient, but we can agree that it is a very safe and effective one. We all learned from the Ponseti clubfoot experience that it is not always an advancement to be aggressive and treat operatively. Although it is mentioned in the article that it should be interpreted within the context of the study design, I am still very concerned about the conclusion of this article!