Background Successful surgical treatment of late presenting infantile tibia vara (ITV) patient requires the correction of oblique deformities. The purpose of this study was to report on a new comprehensive approach to correct and prevent recurrence of these deformities with a single procedure. Methods Medical records of 23 consecutive children (7–18 years) with advanced ITV (29 knees) were retrospectively reviewed after a mean of 7.3 years postoperatively (range: 2–22 years). Indications for the corrective surgery were any child seven year or older with a varus mechanical axis angle (MAA) 10 degrees or greater or a varus anatomical axis angle (AAA) eleven degrees or greater and a medial tibial angle (MTA) slope less than 60 degrees. The deformities were corrected with a dome-shaped osteotomy proximal to the tibial tubercle with a midline vertical extension to the subchondral region of the joint and a lateral hemi-epiphysiodesis. Results At latest follow-up, means and medians of each tibial radiographic axis measurement improved significantly from preoperative values (p<0.001): MAA from 23 degrees to 4 degrees varus, AAA from 25 degrees varus to 1 degree valgus, MTA downward slope from 30 degrees to 78 degrees, posterior medial tibial angle (PMTA) from 59 degrees to 80 degrees. Seventy-nine percent and 74% had good to excellent results based on radiographic criteria and clinical questionnaire for satisfaction, pain and function, respectively. Two abnormal medial tibial plateau types were described. Conclusion This is the first study to use a single stage double osteotomy performed proximal to the tibial tubercle for the late-presenting ITV for children seven years of age or older. In addition to the effective correction of the four major tibial deformities, a lateral proximal tibial hemi-epiphysiodesis minimizes recurrence of tibia vara. A contralateral proximal tibial epiphysiodesis is recommended for treated skeletally immature patients with unilateral disease. Level of Evidence Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.
To answer our provocative title "Pedicle screw instrumentation have we gone too far?" Definitively we can answer that for some spinal deformities instrumented with all-pedicle-screw instrumentation, we have observed cases where the surgeons have gone way too far; in other cases, where such instrumentation was used in a comprehensive and rational manner, the answer to "Have we gone too far" is no, and such use of pedicle screw has improved outcome with minimum complications.
Arthrogryposis multiplex congenita involves stiff contracture of joints and weak atrophic muscles presenting at birth. The two most common forms are amyoplasia and distal arthrogryposis. Amyoplasia affects all 4 extremities: internally rotated shoulders, extended fixed elbows, flexed fixed wrists, extended fixed knees, clubfeet, and decreased muscle volume. Distal arthrogryposis is a group of syndromes with a genetic basis. The distal joints are contracted. Clubfeet and congenital vertical talus are the most common foot deformities. A 10-year-old boy presented with distal arthrogryposis with bilateral congenital tali. He reported having deformed and painful feet and difficulty wearing shoes. His rocker-bottom foot deformities caused him to walk with a heel to heel gait. He also had stiff extended knees. His previous foot surgeries included failed open reduction and pin fixation of the talonavicular joints with Achilles tendon lengthening and capsulotomies. The boy underwent bilateral talectomies and releases of contracted joint capsules and lengthening of multiple extrinsic tendons through separate incisions. The talectomy of each foot was performed via a novel medial surgical approach. At 2-year follow-up, he had normal-appearing plantar grade feet. He had a painless gait, could ambulate independently, and was considered to have an excellent result. This is the first detailed report of performing a talectomy via a medial approach for bilateral congenital tali in a patient with arthrogryposis multiplex congenita. [ Orthopedics . 2020; 43(6):e623–e626.]
Objective:To determine the effectiveness of peri-operative halo-femoral traction in the management of severe scoliosis and kyphoscoliosis -A retrospective review. Methods:The case notes for 94 subjects with severe scoliosis and kyphoscoliosis were studied from 1973 to 2012 from Princess Elizabeth Centre Trinidad, West Indies. The notes studied were based on hospital records, standing pre-operative antero-posterior (AP) radiographs, post traction radiographs, immediate post operative AP x-rays and one year follow up x-rays. The primary outcome measure was coronal curve correction (Cobb's angle) immediately post operatively after patients received halo-femoral traction. Other endpoints were intraoperative time and blood loss, coronal curve at one year and postoperative complication rates. All statistical analyses were conducted using SPSS Inc. statistics for windows version 17.0 Chicago SPSS Inc.Results: Subjects were analyzed by age at date of surgery ( range 11-37 years, mean 17 years), gender ( 80.9% females, 19.1% males), major coronal curve magnitude ( range 60 -130 ⁰, mean 87⁰ ), duration of traction (range 6 -21 days, mean 12 days), types of instrumentation, intra-operative time (range 1. 34 -8.75 hours, mean 3.67 hours), intra-operative blood loss ( range 263 -3259 ml, mean 1190 ml), coronal curve correction post operatively (range 20-100⁰, mean 47⁰) and at 1 year follow up (range 25-80 ⁰, mean 52⁰ ).The commonest post operative complication was hardware migration (8.5 %). Conclusion:The management of severe scoliosis continues to be difficult due to its multi-planar presentation.A useful adjunct to the spinal surgeon's arsenal against major curves is halo-femoral traction. When combined with spinal instrumentation and fusion, this treatment protocol is proven to be safe, tolerable and effective in our local setting.
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