Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Vol 1 | Issue 1 | July-Sep 2015 | page:48-50 | EG Mohan Kumar, GM Yathish Kumar.

Authors : EG Mohan Kumar[1], GM Yathish Kumar[1].

[1] Department Of Orthopedic Surgery, KIMS Al Shifa Hospital, Perintalmanna, Kerala, India.

Address of Correspondence
Dr. EG Mohan Kumar
HOD Department Of Orthopedic Surgery, KIMS Al Shifa Hospital,
Perintalmanna, Kerala- 679322 India.
Email- orthomohan@rediffmail.com.

Abstract

Background: Non union fracture femoral neck is one of the common complication of intra capsular fracture neck of femur in children as well as in adults and it is the most challenging problem to treat if femoral head salvage is attempted. Other common complication is avascular necrosis (AVN) of the femoral head with most reported incidences being <15% (range 0% to 67%), which is similar to the complication rate with non-neglected femoral neck fractures. We are reporting a case of 10 year old boy who elsewhere underwent closed reduction and internal fixation with canulated cancellous screw for Delbert type III fracture neck of femur, which subsequently got infected with a draining sinus, non union and AVN of femoral head with complete absorption of the neck in 4 months time.  We received the patient at that stage. He was managed by two stage surgery. Initially the implants were removed the screw tracks were curetted out and filled with antibiotic sponge. After the infection was eradicated osteosynthesis and neck reconstruction was done using fibular strut and cancellous grafts through modified Watson Jones approach and anterior capsulotomy . We avoided metal implants for fear of infection and so also a subtrochenteric osteotomy which require fixation. A hip spica cast was given for 6 weeks. The neck length was restored, vascularity restored and fracture united with an excellently functioning hip.
Keywords: Femur neck fracture, infection, osteosysnthesis.

Introduction
Fractures of the femoral neck in children are not common[1]. They represent fewer than 1% of all the paediatric fractures2. However, complications accompanying these fractures are frequent—specifically avascular necrosis, non union and early closure of the proximal physis of the femur—resulting in decrease of neck length and coxa vara. The incidence of non union varies from 7 to 10%, depending on the location of the fracture in the neck of femur[2,3,4]. Delbet was the first to describe the fractures of the femoral neck. He published the first classification in the French literature. Since then, Colonna[5] has quoted the Delbet classification, which is still accepted in all the literature regarding this subject, and Ratliff[6] has described the evaluation criteria of the results, based on the presence of pain, joint mobility and the child’s capacity to maintain a daily activity. Most of the articles in the literature support bone grafting and a valgus osteotomy with some sort of fixation[7]. Only few cases reported with non union neck of femur treated by fibular strut graft alone without fixation and osteotomy. We feel that our case was unique due to presence of infection which makes the situation complicated. Here, we report a case of paediatric femoral neck fracture which went in for all described complications like AVN, non union, infection and neck resorption which was managed successfully by staged surgery. In the first stage eradication of infection and in second stage osteosynthesis and neck length restoration was attempted.

Figure 1, 2, 3, 4, 5, 6

Case Presentation
A 10 year old boy sustained fracture neck of right femur following fall from tree 4 months back(Fig.1) and was initially treated elsewhere by closed reduction and Canulated Cancellous Screw and K wire fixation(Fig.2), but osteosythesis was failed due to infection and poor fixation. He presented to us with non union, neck resorption, avascular necrosis of head of femur and infection with implants insitu(Fig.3). His WBC count(13000cells/cumm), ESR(40mmhg/hour) and CRP(110) were elevated. X-Ray showed loosening of implants with surrounding osteolysis and he was managed in two stages. Initially implants were removed, debridement was done, screw tracks were curetted out and antibiotic sponge was kept inside the tracks and was put on antibiotics(Fig.4). Once the infection got settled when CRP became normal after two months he was taken up for second stage surgery. He was treated by autologous fibular strut grafting and cancellous graft packing through Modified Watson Jones approach. Intra-operatively he was put on traction table, reduction and alignment was checked under C-ARM guidance(Fig.5), we could restore the length of neck with fibula graft under C-ARM guidance and cancellous gaft harvested from iliac crest was filled around fibula graft bridging fracture site through anterior capsulotomy(Fig.6,7). Patient was immobilized in hip spica cast for 6 weeks(Fig.8), POP was removed and X-ray taken .Gradually hip and knee were mobilized. He was reviewed every month with radiograph which showed good union of fracture and vascularity of the head of femur spontaneously improved(Fig.9,10). Made partial weight bearing with the support of walker at 3 months post op and gradually increased weight bearing. Fracture consolidated by 6 months. At present his fracture is completely united, vascularity of head of femur regained(Fig.10). He has got 1cm shortening of limb and patient is back to school walking without support without any pain. Since the proximal physis is fused he may develop an increase in the present limb length discrepancy which we plan to correct later.

Figure 7, 8

Discussion
Fracture neck of femur in children is a rare injury and can lead to many complications. Nonunion and AVN are very common complication which is nearly equal in neglected and treated cases of fracture neck of femur[8].Infection further adds to challenge in treating these cases. We got chance to treat such a patient with failed osteosynthesis neck of femur with all known complication like infection, pseudoarthrosis, avascular necrosis and neck resorption. Investigation of nonunion of neck of femur should include TC,DC,ESR and CRP to rule out infection especially in failed osteosynthesis, MRI may be required if x-ray features are not conclusive of vascular status of head of femur. In the literature there are few articles about treating this challenging problem. All are supporting valgus osteotomy some sort of fixation, few are supporting fibular grafting and cancellous screw fixation[4,9], but all concerning situations without infection.  We planned to tackle the infection first and go for osteosynthesis with bone grafting alone without osteotomy or use of any hardware for fixation, in view of the subsided infection. Fibular strut graft gave a very good structural support also helped us to maintain the neck length and cancellous graft helped in fracture healing and to some extent improve vascularity of femoral head which made him walk again. Patient may have LLD which is to be addressed at skeletal maturity.

Figure 9, 10

Clinical Relevance
Although fracture neck of femur in children is a rare injury, complications are very common and challenging to treat. Thorough investigations are must before treating these complications of neck of femur fracture. Infection must be ruled out in failed osteosynthesis. In selected cases fibula strut grafting and cancellous grafting allow neck reconstruction and fracture healing without fixation in children. Initial immobilization with spica cast and close follow up and monitoring during post operative period is essential to achieve the goal.

References

1. Miller WE (1973) Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 92:155–187 [PubMed]
2. Ratliff AHC (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542 [PubMed]
3. Chrestian P, Bollini G, Jacquemier M, Ramaherison P (1981) Fractures du col du femur de lénfant. Chir Pediatr 22:397–403 [PubMed]
4. Ratliff AHC (1970) Complications after fractures of the femoral neck in children and their treatment. J Bone Joint Surg Br 52:175–183 .
5. Delbet cited by Colonna PC (1929) Fractures of the neck of the femur in children. Am J Surg 6:793–797.
6. RatliffAHC (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542[PubMed]
7. Pedro F. Tucci Neto, Fernando Baldy dos Reis, José Laredo Filho, , Edison Noboru Fujiki,Henri Bensahel, and Carlo Milani; Nonunion of fractures of the femoral neck in children ;J Child Orthop. 2008 Mar; 2(2): 97–103.
8. Amit Roshan, , The Neglected Femoral Neck Fracture in Young Adults: Review of a Challenging Problem; Clin Med Res. 2008 May; 6(1): 33–39.
9. Nagi ON, Dhillon MS, Gill SS.Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children.J Orthop Trauma. 1992;6(3):306-13.
10. Miller WE (1973) Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 92:155–187 [PubMed]
11. Rang M (1983) Children’s fractures. 2nd edn. J B Lippincott, Philadelphia
12. Canale ST, Bourland WL (1977) Fracture of the neck of the femur and intertrochanteric region of the femur in children. J Bone Joint Surg Am 59:431–443 [PubMed]
13. Ingram AJ, Bachynski B (1953) Fractures of the hip in children. J Bone Joint Surg Am 35:867–886[PubMed]
14. Lam SF (1971) Fractures of the neck of the femur in children. J Bone Joint Surg Am 53:1165–1179[PubMed]
15. Forlin E, Guille BA, Kumar SJ, Rhee KJ (1992) Complications associated with fracture of the neck of the femur in children. J Pediatr Orthop 12:503–509 [PubMed]
16. Hughes LO, Beaty JH (1994) Fractures of the head and neck of the femur in children. J Bone Joint Surg Am 76:283–291 [PubMed]
17. Colonna PC (1928) Fracture of the neck of the femur in childhood. Ann Surg 88:902–907[PMC free article] [PubMed]
18. Weiner DS, O’dell HW (1969) Fractures of the hip in children. J Trauma 9:62–79 [PubMed]
19. Durbin FC (1959) Avascular necrosis complicating undisplaced fractures of the neck of the femur in children. J Bone Joint Surg Br 41:758–765 [PubMed]
20. McDougall A (1961) Fractures of the neck of the femur in childhood. J Bone Joint Surg Br 43:16–28
21. Ogden JA (1974) Changing patterns of proximal femoral vascularity. J Bone Joint Surg Am 56:941–50[PubMed]
22. Trueta J (1957) The normal vascular anatomy of the human femoral head during growth. J Bone Joint Surg Br 39:358–373 [PubMed]
23. Chung SMK (1976) The arterial supply of the developing proximal end of the human femur. J Bone J Surg Am 58:961–970 [PubMed]
24. Sotto-Hall R, Johnson LH, Johnson RA (1964) Variations in the intra-articular pressure of the hip joint in injury and disease. J Bone Joint Surg Am 46:509–516 [PubMed]
25. Drake JK, Meyers MH (1984) Intracapsular pressure and hemartrosis following femoral neck fracture. Clin Orthop Relat Res 182:172–175 [PubMed]
26. Pauwels F (1965) Biomechanics of the locomotor apparatus. English edn. Springer, New York
27. Touzet P, Rigault P, Padovani JP, Pouliquen JC, Mallet JF, Guyonvarch G (1979) Fractures of the neck of the femur in children. Rev Chir Orthop Reparatrice Appar Mot 65:341–349 [PubMed]
28. Trueta J (1968) Vascular pattern of the femoral head during growth. In: Studies of the development decay of the human frame, 2nd ed. J. B. Lippincott, Philadelphia.

How to Cite this Article: Kumar EGM, Kumar GMY. Osteosynthesis in a 10 year old boy with fracture neck of femur, infected nonunion with implants insitu, neck resorption and Avascular Necrosis -A case report. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):48-50.       

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Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

Vol 1 | Issue 1 | July-Sep 2015 | page:16-18 | Ashish Ranade, Gauri Oka.

Authors : Ashish Ranade[1], Gauri Oka[1].

[1] Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004.

Address of Correspondence
Dr Ashish Ranade
Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004.
Email address:ashishranade@yahoo.com

Abstract

Supracondylar humerus fracture is one of the commonest fractures in pediatric elbow. Usually closed reduction and percutaneous pinning is the preferred treatment for most of the displaced fractures. Nowadays closed reduction and percutaneous pinning has become standard of care for majority of displaced supracondylar humerus fractures. Rarely, an open reduction via appropriate approach becomes necessary. Various types of approaches that have been described are anterior, posterior, medial, lateral, and combined approaches. There is ambiguity of information as to selection of approach for doing open reduction in a supracondylar humerus fracture. There is debate about timing of treatment, approach selection and indications for doing open reduction.1 In this article we discuss indications, various types of approaches with their pros and cons and risks involved in open reduction of supracondylar humerus fractures in children.
Keywords: Supracondylar humerus fracture, open reduction, surgical approach.

Introduction
Supracondylar humerus fracture (SHF) is one of the commonest fractures in pediatric elbow. Nowadays closed reduction and percutaneous pinning has become standard of care for majority of displaced supracondylar humerus fractures. Rarely, an open reduction via appropriate approach becomes necessary. Various types of approaches that have been described are anterior, posterior, medial, lateral, and combined approaches. There is ambiguity of information as to selection of approach for doing open reduction in a supracondylar humerus fracture. There is debate about timing of treatment, approach selection and indications for doing open reduction [1]. In this article we discuss indications, various types of approaches with their pros and cons and risks involved in open reduction of supracondylar humerus fractures in children.

Case Example
A 9 year old boy was referred for the treatment of left supracondylar humerus fracture. He had sustained an injury following fall from a tree 10 days ago and was put in an above elbow splint in his village. On examination, radial pulse was present and he was neurologically intact.

Figure 1, 2

The elbow was grossly swollen and there was deep abrasion with blister formation along the elbow crease on the anterior aspect. (Figure 1) There was ecchymosis along anterior aspect of elbow. The radiographs showed posterolaterally displaced type III supracondylar humerus fracture (Figure 2). Under general anaesthesia, closed reduction was attempted. Satisfactory reduction could not be achieved by closed means. Hence, a decision was made to perform open reduction. Considering the anterior wound, combined medial and lateral approach was chosen. Initially, a medial incision was made and the bony spike of the proximal fragment was separated from the brachialis fibres and the median nerve. At this point, reduction was attempted again. In view of difficulty in getting a satisfactory alignment, a lateral incision was made and the interposing tissues were removed. Periosteum was found to be torn on both sides. (Figure 3)After achieving open reduction, the fracture was fixed with crossed k wires and maintained in an AE slab for 3 weeks(Figure 4).  Postoperatively, the patient made uneventful recovery and the fracture healed well in a satisfactory position. The elbow had 5 degrees loss of terminal flexion.

Figure 3, 4

Discussion

Open reduction has been indicated for fractures with vascular injuries, signs of compartment syndrome, failure of closed reduction to achieve satisfactory alignment, and for severe swelling interfering to achieve good reduction [2-7]. In present day scenario, the main indication is failure to achieve satisfactory reduction by closed methods. This could be because of several factors such as instability of the fracture or interposition of neurovascular bundle or brachialis muscle. The overall proportion of supracondylar humerus fractures needing open reduction varies between 3 to 46% based on various studies[2,8-10]. This rate varies between centres and some centres may prefer to do open reductions than using closed methods. Delayed presentation of the fracture is one of the most important factors while discussing open reduction for supracondylar humerus fractures[ 5].
There are several options available for approach selection. There is no clear superiority of one approach over another. Mazzini and co-authors have published a systematic review of literature pertaining to surgical approaches in the treatment of open reduction and pinning[11]. In this review, authors found high frequency of poor results in terms of functional outcomes with posterior approach. High frequency of excellent results was found with the lateral and medial approach and a high frequency of good results within the anterior approach group. A Canadian study sites buttonholing of the proximal fragment through the brachialis muscle and interposition of joint capsule or periosteum between fragments[12]. With the posterior approach , anterior structures such as brachialis, and the neurovascular bundle cannot be accessed and probably the posterior scar leads to limitation of movements of the elbow joint[13]. In the same article, authors have found the change in the carrying angle (cosmetic outcome) as the most common complication seen after an open reduction via the posterior or lateral approach. However, relatively newer studies utilizing posterior approach do not report these complications [7,14]. Medial column communition and internal rotation and/or varus tilt of the distal fragment may be addressed sufficiently through lateral/posterior approach. In review by Mazzini et al, the time to union remains the same irrespective of the approach used. There was higher tendency of ulnar nerve injury in the posterior and lateral approach group. This is attributed to lack of direct visalization of ulnar nerve. Based on the findings, authors recommend anteromedial approach for open reduction[11].
While choosing an approach, one must take into consideration surgeon’s experience and the anatomical structures involved. It is known from various studies that fracture union time and rate of approach related complications are similar with various approaches [7,11].
In a study by Aslan and co-authors, clinical and radiographic results of children with Gartland type 3 supracondylar humerus treated with primary open reduction using four different approaches were studied [7]. Fifty eight patients were treated with either anterior, medial, lateral and , posterior approach. Choice of approach was decided by fracture pattern and neurovascular injury. All fractures were fixed with two lateral entry k wires or crossed k wires as per surgeon’s preference. In this series, three quarters of patients were operated within 24 hours since injury. Flynn criteria were used to measure outcomes. The outcome was comparable in all groups.
Ozkoc and co-authors studied 99 patients with supracondylar humerus fracture. In this group, 44 patients were treated with primary open reduction and k wire fixation and 55 were treated with closed reduction and percutaneous pinning. They found that in the open group the average loss of extension was 6 degrees compared to 0.6 degrees in the closed group[2].
Koudstaal and colleagues have reported the use of anterior approach in 26 children [15]. In another study, Ay and co-authors report their experience of using the anterior approach in 61 children [16]. In both these studies, a transverse incision was used in the antecubital fossa. In both studies, excellent results were noted without any significant loss of elbow movement.
In summary, various options are available for performing an open reduction of a supracondylar humerus fracture. The anterior approach certainly offers advantages of direct visualisation and retraction of entrapped structures. The treating surgeon must choose the appropriate approach based on the indication for open reduction.

Author’s preferred treatment
Our indications for open reduction are as follows:
1) Vascular compromise or disappearance of pulse after doing closed reduction- In this scenario, we suspect the brachial artery likely to be caught between fracture fragments. Hence, we perform an exploration via the anterolateral or anteromedial approach. The vascular structures are explored and reduction of fragments is achieved under vision. We undertake this approach with a vascular/plastic surgeon available in the operation theatre in case the need for vascular repair arises.
2) Inability to achieve satisfactory reduction by closed method- Usually this is encountered in late presentation of fractures with severely swollen elbow. Usually, attempts of closed reduction are made and if satisfactory reduction cannot be achieved, then open reduction is performed. Our preferred approach for this type is usually the anterior approach. However when skin conditions do not permit anterior approach, then a medial and/or lateral approach depending upon the fracture configuration is used.
Open fractures: Usually there is an anterior wound. Anterior approach is used in these cases.

References

1. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence based guideline. J Pediatr Orthop 2012;32:S143-S152
2. Ozkoc G, Gone U, Kayaalp A, Teker K, Peker TT. Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg 2004; 124:547-551.
3. Cramer KE, Devito DP, Green NE. Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1992;6:407-412.
4. Oh CW, Park BC, Kim PT, Park IH, Kyung HS, Ihn JC. Completely displaced supracondylar humerus fractures in children: results of open reduction versus closed reduction. J Orthop Sci 2003;8:137-141
5. Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type –III supracondylar fractures of the humerus. J Bone Joint Surg Br 2006;88:528-530.
6. Mulhall KJ, Abuzakuk T, Curtin W, O;Sullivan M. Displaced supracondylar fractures of the humerus in children. Int Orthop 2000;24:221-223.
7. Aslan A, Konya MN, Ozdemir A, Yougancigil H, Maralcan G, Uysal E. Open reduction and pinning for the treatment of Gartland extension type III supracondylar humeral fractures in children. Strat Trauma Limb Recon 2014;9:79-88.
8. Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008;17:171-178.
9. Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay in perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop 2004;24:245-248.
10. Reitman RD, Waters P, Millis M. Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001;21:157-161.
11. Mazzini JP, Martin JR, Esteban EMA. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review. J Child Orthop 2010;4:143-152.
12. Fleiriau-Chateau P, McIntyre W, Letts WM. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Can J Surg 1998;41(2):112-118.
13. Gruber MA, Hudson OC. Supracondylar fracture of the humerus in childhood. End results study of open reduction. J Bone Joint Surg Am 1964;46:1245-1252.
14. Sibly TF, Briggs PJ, Gibson MJ. Supracondylar fractures of the humerus in childhood: Range of movements following the posterior approach to open reduction. Injury 1991;22(6):456-458.
15. Koudstaal MJ, De Ridder VA, De Lange S, et al. Pediatric supracondylar humerus fractures: The anterior approach. J Orthop Trauma 2002;16(6):409-412.
16. Ay S, Akinnci M, Kamiloglu S, Ercetin O. Open reduction of displaced pediatric supracondylar humeral fracture through the anterior cubital approach. J Pediatr Orthop 2005;25:149-153
.

How to Cite this Article: Ranade A, Oka G. Open reductions- When, How and, Risks. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):16-18.      

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Editorial

Vol 1 | Issue 1 | July – Sep 2015 | page: 1 | Sandeep Patwardhan, Taral  Nagda.

Authors: Dr. Sandeep Patwardhan[1], Dr.Taral  Nagda[2].

Dr. Sandeep Patwardhan: Paediatric Orthopaedic Surgeon, Sancheti Institute for Orthopaedics and Rehabilitation. Pune, India: Email: sandappa@gmail.com
Dr. Taral Nagda: Paediatric Orthoapedic Surgeon, Institute for Paediatric Orthopaedic Disorders, Mumbai and Jupiter Hospital, Thane, India. Email:taralnagda@gmail.com

Editorial

Paediatric orthopaedics is evolving by leaps and bounds on a day to day basis as we have more insights in to biology and access to improved imaging and technology for management. With the changing demographics of the world, India is poised on the crossroads where we have a healthy mix of educated urban literate population who demands the best management at par with the western world. At the same time we have a large volume of children who are subjected to gross neglect due to inability to access healthcare or poor understanding & quality of training in the country with respect to paediatric orthopaedics. There are only about 50- 60 paediatric orthopaedic surgeons for a population of 450 million children. As we march towards improving paediatric orthopaedic services through improved training acquired through western world, we realised the shortcomings of this training with respect to differential needs of our native populations. No amount of literature or fellowship training in the west can prepare us for management of neglected and complicated paediatric orthopaedic conditions. We realised that we will have to evolve our own strategies and share the knowledge through publications for effective management of our children. We found the existing journals restrictive and difficult to access with respect to their norms of publications. Hence the International Journal of Paediatric Orthopaedics (IJPO) which is an attempt to allow easy open access online sharing of knowledge with emphasis to the eastern world and the different requirements of our populations. I am sure that contributions to this journal will foster a better understanding as well as interactions between the western and eastern worlds. We believe we have a spectrum of disease which is unseen and under-reported in current literature but which is still quite relevant to two thirds of the world. IJPO will aim to provide a platform where global interactions are possible and views and opinions can be shared easily. New formats of articles will be encouraged and in the first issue we have an article written in dialectic format and another in case based format along with the usual review formats. We would welcome articles from all over the world and we hope to be able to make it a patient driven Journal along with being evidence based.
We would like to thank the Orthopaedic Research Group and ResearchOne® Publishers in helping us through the process. We would thank our affiliate body ‘International Fractures in Children Symposium’ (I-FICS) for their unconditional support an allowing the launch of the Journal in their annual meeting. We would like to thank every author who has contributed to the first issue and special thanks to all the editorial board members who have shown faith in us and have joined us in an effort to create a world class journal

Sandeep Patwardhan & Taral Nagda

How to Cite this Article: Patwardhan S, Nagda T. Editorial. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):1.          

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The Effect of Guided Growth on Rotational Deformities of the Long Bones: A Biomechanical Study on Sawbone

Vol 1 | Issue 1 | July-Sep 2015 | page:44-47 | Emre Cullu, Mutlu Cobanoglu, Mustafa Kemal Peker.

Authors : Emre Cullu[1], Mutlu Cobanoglu[2*], Mustafa Kemal Peker[3].

[1] Adnan Menderes University Medical School, Deparment of Orthopaedics and Traumatology,
Turkey.

Address of Correspondence
Dr. Mutlu Cobanoglu
Adnan Menderes University Medical School, Department of Orthopaedics and Traumatology, KepezMevkii 09100 Aydın / Turkey
E-mail: drmutlu79@hotmail.com

Abstract

Background: Although temporary hemi-epiphysiodesis is an effective method for correction of frontal and sagittal plane limb deformity in growing children, osteotomy is commonly performed to correct rotational deformities of the long bones. The aim of this report is to improve rotational guided growth with a formula created to calculate the amount of correction.
Methods: A femur sawbone was cut above the trochlear sulcus. Two 8-plates were placed opposite to each other on medial and lateral sides of the cutting line. Three pairs of holes were drilled in three different angles on medial side and lateral side to place two plates on sawbone. The bone was distracted by an intramedullary device. The anteversion angles were measured by computerized tomography. The angles between the femoral axis and the plates were measured on X-ray. A formula was used to calculate the amount of correction.
Results: As the bone was distracted, rotation of the distal part of the cutting line was observed. When the angles between the plates and the long axis of the bone (α) were 50°, 36°, and 26°, the axial rotations were -11.25°, 2.43°, and 7.06° respectively on CT. When the formula was applied, the amounts of corrections were 25.7°, 18.5°, and 13.4° respectively.
Conclusions: This study supports that this technique can be used for correction of rotational deformities of the long bones. It’s said that the wider angle between the plates and the long axis of the bone, the greater rotation. But further experimental studies are required to improve this technique.
Keywords: Rotational guided growth, rotational deformity, temporary epiphysiodesis.

Introduction
There are many options for the correction of angular bone deformities but the standard treatment has been osteotomy. Currently, hemi-epiphysiodesis is considered an effective treatment to correct an axial limb deformity in children [1,2] and Stevens presented a technique using an 8-plate [3]. Although this technique is an effective treatment method for correction of frontal and sagittal plane limb deformities in growing children, osteotomy is still a commonly used surgical technique for rotational deformities of the long bones. In the recent years, it has been thought that a rotational deformity in the horizontal plane of the long bones could be corrected by guided growth and two animal studies, which evaluated guiding rotational growth, were published [4,5]. In this biomechanical study the aim was to improve rotational guided growth with a formula created to calculate the amount of correction. Because of that a sawbone model was designed.

Materials and Methods
One femur foam cortical shell sawbone with a 15 mm diameter canal and 42 cm overall length was used for the model. A left femoral sawbone, two titanium growth 8-plates (Biomet/USA and TST/Turkey), a distractor of an external fixator, a steel spring, a handle of an umbrella were used to construct this model. The sawbone was cut just above the intercondylar sulcus. This cutting line acted as a physeal line. The sawbone was reamed from the fossa priformis with a 12-mm drill for the placement of an intramedullary device to distract the fragments. The sharp ends of the distractor were cut. The distractor, the handle of the umbrella, and the spring were placed into the medullary canal via fossa priformis and fixed with glue gun. The outer part of the handle was cut and used as an antirotation block in the canal. The block was glued to the sawbone through a window opened from posterior surface of the proximal side of the cutting line. This block prevented the rotation of the distractor in the canal. The tip of the spring was fixed with glu to the distal fragment. This spring was placed between proximal and distal fragments. When the device was distracted, the device pushed the spring toward the distal fragment. By this way the lengthening was obtained. Because of the spring, distractor did not create an external rotation force on the distal fragment by itself directly (Figure 1).

Figure 1

Three pairs of holes were drilled in three different angles to place plates on the sawbone, Two 8-plates, whose brands were different, with four screws were used to fix the cutting line and were placed on medial and lateral side of the bone (Fig 2). The different plates of different brands were helpful to differentiate one plate from the other on lateral X-ray. To create external rotation the medial plate was placed obliquely from the proximal anterior region to the distal posterior region, and the lateral plate was placed obliquely from the proximal posterior region to the distal anterior region (Figure 3).

Figure 2 and Figure 3

Fixation of the plates was performed in three different angles. The screws were not tightened completely. An allen wrench was used to distract the intramedullary device on its proximal end. The distances between proximal and distal holes were measured in each plate manually. The angles between the femoral axis and the plates were measured on lateral X-ray. Femoral length (FL) (from the tip of trochanter major to top of intercondylar notch), mechanical lateral distal femoral angle (mLDFA), anatomic posterior distal femoral angle (aPFDA) were evaluated on computerized tomography (CT) scanogram. The femoral anteversion of the sawbone was measured on CT. A flat surface was used to immobilize the sawbone and to standardize the evaluation of the rotation. Retroversion was defined as negative value, anteversion was defined as positive value. All parameters were evaluated on PACS (Picture Archiving and Communication System) radiologic system. A formula was created to calculate that how many degrees the plates should be placed to obtain desired amount of rotation. Depending on the length and angle of the plates, the arc length scanned by the plate was equal to the arc length scanned by the distal fragment until the plate became horizontally. Additionally, the arc length scanned by the distal fragment depended on its radius. The length of the arc (the distance between the first position (B) and the last position (B’) of the distal screw of the medial plate) swept by the plate is equal to the path drawn by the rotation around its axis of the distal region (Figure 4).

Figure 4

The virtually spiral movement of this region along the axis is shown as the progress of the arc on the surface of the cylinder (Figure 5). A full rotation of the arc of the helix is equal to the diagonal line of the open shape of the cylinder.

Figure 5 and Figure 6

The formula which was created to calculate the amount of correction (θ) is demontrated as follows:
BB’ 2Π·ΑΒ·α/360
KK’ 2Π· MK·θ/360
BB’KK’
2Π·ΑΒ·α/360 2Π·MK·θ/360
θ ΑΒ·α /MK
(A: Position of the proximal screw of the medial plate, B: The first position of the distal screw of the medial plate, B’: The last position of the distal screw of the medial plate, α: The angle between long axis of the sawbone and medial plate, M: Center of the distal region of the bone. K: Starting point of the rotation. K’: End point of the rotation. MK=MK’: Radius of the distal region of the bone. θ: Rotation angle)

Results
The FL was 421.79 mm and the anteversion of the sawbone was 8.26° before distraction. When the sawbone was distracted, rotation of the distal fragment was observed without translation (Figure 6). When the angles between the plates and the long axis of the bone (α) were 50°, 36°, and 26°, the axial rotations were -11.25°, 2.43°, and 7.06° respectively on CT and the FLs were 433.38mm, 430.02mm, 429.74mm respectively after full distraction. Thus, the amount of correction (θ) were 19.25°, 5.83°, and 1.20°, respectively. The wider the angle between the plates and the long axis of the bone, the more rotation and lengthening occurred. As the screws were not tightened completely, rotation of the plates, which led to more rotation of the distal fragment and lengthening of the bone, occurred more easily.
In the coronal plane, mLDFA was 87° before lengthening. After lengthening mLDFAs were constant when the α angle were 50° and 36°. But mLDFA was 83° when the α was 26°.
In the sagittal plane, aPDFA was 89° before lengthening. After lengthening aPDFAs were 90° when the α angles were 50° and 36° and aPDFA was 91° when the α angle was 26°.
The distance between the screw holes (AB) was 18 mm, and the radius of the distal fragment of the femur (MK) was 35 mm. When the formula was used, the amounts of correction (θ) were 25.7°, 18.5°, and 13.4°, respectively. None of the calculated degrees of correction were comparable to the CT measurements.

Discussion
Angular deformities around the knee can be corrected with hemiepiphysiodeses in skeletally immature patients [2,6,7]. The epiphysis grows symmetrically under normal conditions. If the physeal plate is compressed from one side, an angular deformity can occur. Mechanical modulation of longitudinal growth by compressive forces is a widely accepted notion, also known as the Volkmann’s law [8]. However, osteotomy is the most commonly used surgical technique for the correction of rotational deformities of the long bones. Furthermore, rotational guided growth are not currently used to correct rotational deformities of the long bones in clinical practise. There are two reported animal studies [4,5]. Arami et al used rabbit femur in their study and to induce external rotation the distal part of the medial plate was positioned posteriorly and to induce internal rotation the distal part of the medial plate was positioned anteriorly. They said that because of the shape of the medial femoral condyle, some technical difficulties occurred and medial plate was placed in desired position in the group of external rotation [4]. The physeal line of the distal femur of rabbit is wavy and not straight. For this reason to place both plates obliquely in different directions on wavy line is not seen feasible. Firstly more straight physeal line is needed. Cobanoglu et al studied on the proximal tibial epiphysis of rabbit to induce external rotation. The reason why they preferred proximal tibia to distal femur could be that the proximal tibia had straighter physeal line than distal femur. They only studied on external rotation group and did not create a formula about prediction amount of rotation [5]. This study is a biomechanical study. And the aim of this study is to create a formula based on the angle between the long axis of the bone and the plates. A distal femoral physeal plate was created by cutting the sawbone just above the trochlear sulcus and two 8-plates were placed on either side of the cutting line. It was thought that if two plates were placed at reverse angles to each other on either side of the bone, the distal fragment would be rotated. According to this theory, the screws in the holes should not be tightened completely to create rotation points or free zones between the plates and screws. These rotation points would cause the plates to spin around the screws like a hinge. The screws were placed as closely as possible to the cutting line, and thus the plate placement angle was increased. We used an intramedullary device to distract the bone. While the sawbone was being distracted, rotation of the distal fragment was obtained and this led to a reduction in the anteversion of the femur due to the placement of the plates. The upper limit of rotation which can be corrected, is due to orientation of the plates and the distance between the proximal and the distal screws. Therefore, insertion of these plates with the greatest angle to the long axis as possible and the greatest distance between the screws as possible will lead greater rotation. These are two important variables in the formula. These variables are related to anatomical properties of the bone such as width and points for plate fixation. The angle between the positions of the plate and the bone axis needs monitoring. For this reason, the position of the plates at the end of the rotational correction is crucial to prevent angular deformities. The important points of this technique are the distance between the proximal and distal screws and the tightness of the screws. The use of long plates results in greater lengthening and rotation, depending on the distance between the holes. When the distance between the proximal and distal screws is as great as possible, increased gap between the fragments and more rotation of the distal fragment are observed. And to be able to obtain rotation of the plate more easily, the screws must not be tightened completely. Another important point is that placement of the plates at the same angle onto the bone. For this reason, the amount of rotation will reveal according to the plate having less angle with bone axis. When the axis of this plate is parallel to the bone axis, the plate will not rotate and causes a deformity. So the deformities of the condyles can affect the rotational measure. Arami et al used inter-plate angle in their study and declared that every 1° of change in this angle corresponded 0.378° of rotational profile difference [4]. In our opinion because of the reasons mentioned above, the rotational profile is dependent on the angle between the plate and bone axis, not inter-plate angle. The CT measurements and calculations using the formula differed from each other. There are three possible reasons for this disparity: First, there was laxity between the screws and the plates, leading to instability between the proximal and distal regions of the sawbone. Second, the sawbone had a circular structure whereas the plates were straight. These incompatible shapes might prevent rotation. Third, the distal region of the bone does not form a precise circle.  This technique has not been performed to humans yet. This biomechanical study supports that this technique can be used for the correction of rotational deformities of the long bones. It’s said that the wider angle between the plates and the long axis of the bone, the greater rotation. But further animal studies are required to demonstrate efficacy of this hypothesis.

References

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J Pediatr Orthop B 2012, 21:109–114
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14. Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, Wright JG. The epidemiology of paediatric supracondylar fracture fixation: A population-based study. Injury. 2014; 45: 701–708Khoshbin A, Leroux T, Wasserstein D, Wolfstadt J, Law PW, Mahomed N, Wright JG. The epidemiology of paediatric supracondylar fracture fixation: A population-based study. Injury. 2014; 45: 701–708
15. Kasser JR. Location of treatment of supracondylar fractures of the humerus in children. Clin Orthop Relat Res. 2005 May;(434):110-3
16. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop 2010;30(5):430-6
17. Lyons, James P. M.D.; Ashley, Edwin M.D.; Hoffer, M. Mark M.D. Ulnar Nerve Palsies After Percutaneous Cross-Pinning of Supracondylar Fractures in Children’s Elbows. J Pediatr Orthop. 1998:18, 43-45
18. Lee YH, Lee SK, Kim BS, Chung MS, Baek GH, Gong HS, Lee JK. Three Lateral Divergent or Parallel Pin Fixations for the Treatment of Displaced Supracondylar Humerus Fractures in Children. J Pediatr Orthop 2008;28:417-422
19. Kocher MS1, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, Hedequist D, Karlin L, Kim YJ, Murray MM, Millis MB, Emans JB, Dichtel L, Matheney T, Lee BM. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Joint Surg 2007;89(4):706-12
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How to Cite this Article: Cullu E, Cobanoglu M, Peker MK. The Effect of Guided Growth on Rotational Deformities of the Long Bones: A Biomechanical Study on Sawbone. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):44-47.          

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Treatment of Neglected and Relapsed Clubfoot with Midfoot Osteotomy: A Retrospective Study

Vol 1 | Issue 1 | July-Sep 2015 | page: 38-43 | Ruta M Kulkarni, Anurag Rathore, Rajeev Negandhi,  Milind G Kulkarni, Sunil G Kulkarni, Arpit Sekhri.

Authors : Ruta M Kulkarni[1], Anurag Rathore[1], Rajeev Negandhi[1],  Milind G Kulkarni[1], Sunil G Kulkarni[1], Arpit Sekhri[1].

[1] Dept. of Orthopaedics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra.

Address of Correspondence
Dr Anurag Rathore
Dept. of Orthopaedics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India.
Email:rathore.anurag18@gmail.com

Abstract

Background: Neglected and residual clubfoot deformities in older children is a difficult surgical problem as the foot in these patients is stiff with some amount of pain and almost always had already undergone some surgical intervention. Basic aim of foot surgeries in such cases is to achieve painless functional plantigrade foot. In this study, a percutaneous dorsolateral closing wedge midfoot osteotomy with correction of angulation and translation deformity was done fixed with k-wires or ilizarov frame. Additional procedures like plantar fascia release and Achilles lengthening procedures were done for associated deformities as required. The aim of this study is to evaluate outcome of the proposed surgical procedure in correction of complex clubfoot deformities.
Methods: Our centre is a tertiary care orthopaedic hospital. A total of 25 patients [32 feet] were included in this retrospective study done from august 2009 to august 2014. Patient aged 5-12 years were selected for the surgical procedure. All the patients were followed up at least up to 18 months after surgery. Both preoperative and postoperative evaluation of patients done clinically, with help of dimeglio score, and radiologically.
Results: Follow up period ranged from 18-30 months. Clinical and radiographic improvement was achieved in all the patients. Dimeglio score improved from 10.63 to 2.93 which denotes good result. All radiographic angles showed correction to near normal values. All the patient showed pain relief and optimal function at 18 month follow-up.
Complications in form of pin tract infection, under correction and skin problems were noted in three, three and five patients respectively.
Conclusion: A percutaneous dorsolateral closing wedge osteotomy in combination with plantar fascia release and Achilles tenotomy is a good alternative procedure for neglected and recurrent clubfoot deformities with minimal complications. This is a joint sparing surgical technique which preserves ankle and foot flexibility.
Keywords: Relapsed, neglected, clubfoot, midfoot osteotomy, dimeglio score.

Introduction
The four basic components of clubfoot are cavus, adduction, varus, and equinus.  Successful correction of clubfoot deformity generally is reported in more than 90% of children two years and younger treated with Ponseti casting even after previous unsuccessful non-operative treatment [1]. Neglected clubfoot include feet that had not been treated in the past and relapsed clubfoot included feet that had undergone one or more surgical procedures but still had deformity [2].  Neglected or relapsed clubfoot deformity remains a major congenital disability in children and adults in developing nations [3]. Approximately 25% of operated clubfeet recur or have marked residual deformity, mainly owing to insufficient primary treatment [4]. The less is sufficient the intervention, the more severe is the relapse or residual deformity [5]. Multiple soft-tissue or bony operations often result in a stiff and painful foot in relapsed clubfoot patients.. These children face difficulties in walking long distances, playing games and carrying out routine daily activities. They are also prone to get repeated wounds at callosities formed over dorsum and lateral border of foot due to inability to wear normal footwear (figure 1 & 2).

fIGURE 1, 2

The goal of management in such patients is to obtain a plantigrade, painless, and functional foot. The patient should be able to use normal footwear at the end of treatment [6]. Numerous soft tissue procedures [releases, tendon lengthening, tendon transfer and redressment by means of an external fixator] and osseous interventions [osteotomies, arthrodesis] have been discussed in the literature which can be used according to “ala cart” approach. Yet, there are no clear guidelines for the surgical management of relapsed clubfoot [7-10]. Extensive soft tissue releases in such relapsed and neglected cases often lead to wound healing problems and persistent deformities whereas procedures like triple arthrodesis is associated with stiffness and ankle arthritis as early as three years postoperatively [11]. Talectomy is associated with a high incidence of Hind foot recurrence, pain, and spontaneous bony ankyloses in the tibio-tarsal joint [12]. We have performed a percutaneous dorsolateral closing wedge midfoot osteotomy along with additional procedures like steindler release, posterior soft tissue release and tendoachilles lenthening as required to correct various clubfoot deformities in neglected and relapsed cases. The osteotomies were either fixed internally with help of k-wires or fixed externally with ilizarov. Ilizarov used mostly in patients having rigid hind foot varus deformity. The aim of this study is to evaluate the clinical and radiological outcome of the proposed surgical technique in correcting the various deformities in neglected and relapsed cases of clubfoot.

Materials and methods
This is a retrospective study conducted at tertiary level orthopaedic hospital. A total of 25 patients with 32 affected foot were included in this study done between august 2009 to august 2014. The patients selected with age more than five years having neglected and relapsed clubfoot deformities including both idiopathic and syndromic varieties. Patients excluded were above 12 years of age or those who were medically unfit for surgery. Approval for the study was given by ethical committee of the institute and informed consent was obtained from all the patients. Data were collected in a predesigned proforma which included detailed history obtained from the informants of the patient including the birth history, developmental history, family history and history of any previous surgery. On clinical examination, the foot was examined to note all the deformities that were present and the rigidity of foot was also examined based on the maximum possible correction achieved by manipulation. It was also determined that whether the rigidity is due to soft tissue tightness or defect in skeletal architecture of foot. The cavus was examined to establish the apex of the deformity. Using the Coleman Block Test, the flexibility of the heel varus was checked. Based on patients clinical examination, a preoperative dimeglio scoring [13] of all the affected foot was done.
Dimeglio classification includes scoring of varus , equinus , derotation of calcaneopedal block and adduction on the scale of 0 to 4 according to severity of deformity. Additional 1 point assigned each for posterior crease , medial crease , Cavus and poor muscle condition. Score of <5 denotes benign, 5-9 is moderate, 10-14 is severe and 15-20 is very severe deformity. AP and weight bearing lateral x-rays of the foot with ankle were taken, also lateral x-ray of foot with ankle is taken in maximum possible dorsiflexion. Talus-1st metatarsal angle and talo-calcaneal angle for adduction, meary’s and hibb’s angle for cavus, tibio-calcaneal angle for equinus were measured preoperatively in all the affected foot.  The patients were evaluated postoperatively for dimeglio score and various radiographic angles. The follow up visits were scheduled at 1st month, 2nd month, 3rd month, 6th month and thereafter at six monthly intervals. Patients were also evaluated clinically for wound condition, position of foot, ankle ROM, neurovascular status of foot and radiologically for union, position of implant and alignment.
Surgical technique: The patient is placed in supine position on a radiolucent table after administering anaesthesia. Tourniquet is inflated after exsanguinating the limb. Local parts are cleaned, painted and draped. Steindler’s release is performed in a percutaneous fashion. Posterior soft tissue release and tendoachilles z-plasty done in few cases with severe equinus. Transverse incision is taken over the cuboid (Fig 3A) and subcutaneous dissection is done. Abductor digiti minimi muscle is encountered at the lower part of cuboid which is retracted away. Two K-wires are inserted, one through distal end of cuboid and second through proximal end of cuboid under IITV guidance (Fig 3B & 3C). The wires are within the cuboid without compromising the distal or proximal articulation of the cuboid. Both the wires are advanced from the dorsolateral aspect of the foot till the medial border of medial cuneiform where they meet. Using an osteotome and mallet, the osteotomy is performed between the k wires (figure 3D & 3E). The wedge is removed with a rongeur. The osteotomy is closed dorsolaterally along with some translation and confirmed with IITV (figure 3F). The osteotomy is fixed with two K-wires through the cuboid (figure 3G) and confirmed under IITV (figure 3H & 3I). In cases where osteotomy could not be completed through lateral incision, it is done through small incision medially over medially cuneiform. In complicated deformities or severe contracture external fixation with Ilizarov foot and ankle frame is done and gradual correction is obtained. The skin incision is closed with ethilon. Tourniquet deflated and sterile dressing is done and below-knee splint in corrected position is given. Postoperative management: Three days of intravenous antibiotics are given along with an epidural for pain relief. A well-padded below knee non weight bearing cast is applied as soon as oedema subsides and the wound is healthy. If associated procedure requires, then above knee cast is applied. Patients are discharged on the fourth or fifth postoperative day and nonweight bearing is advised for six weeks. After six weeks, the Kirschner-wires and cast are removed, and a below knee weight bearing cast applied which is removed after one month and plastic molded ankle-foot orthosis is applied to be worn for six months.

Figure 3, 4
Statistical methods:
Statistical analysis was done by using Microsoft Excel and SPSS-22.
Means and standard deviation score were obtained. Paired t-test was used to compare the mean of preoperative and postoperative values.

Figure 5

Results
A total of 25 children [32 feet] were available for final evaluation. Seven children had bilateral deformity and 18 had unilateral deformity. Among 25 children, 4 [7 feet] were of the neglected type and 21 [25 feet] were of the relapsed type. The age at surgery ranged from 5-12 years with a mean age of 8.16 years [S.D. = 2.05]. The follow-up period ranged from 18-30 months. There were 11 boys and 14 girls. Osteotomy site was fixed with k-wires in 22 patients [28 feet] and with ilizarov in 3 patients [4 feet].
Preoperative Evaluations- of the 32 feet, 6 feet were classified as grade IV, 8 feet were grade III, 15 were grade II and 3 were grade I Dimeglio deformity. The mean preoperative Dimeglio score was 10.63 [S.D. =4.086] which comes under grade III deformity.
Mean preoperative talus-1st metatarsal angle, tibiocalcaneal angle, meary’s angle, hibb’s angle and talocalcaneal angle were -7.59˚, 69.94˚, 5.94˚, 137.53˚ and 10.16˚ respectively.
Follow up Evaluations at one year- Of the 32 feet, 27 feet improved to grade I, 2 feet were grade II and 3 feet were grade III. The mean postoperative Dimeglio score was 2.97 [S.D. =2.868].
Mean postoperative talus-1st metatarsal angle, tibiocalcaneal angle, meary’s angle, hibb’s angle and talocalcaneal angle were 8.53˚, 43.63˚, 1.66˚, 153.78˚ and 34.34˚ respectively.
All the patient showed improvement in clinical and radiological scores (Fig 4) at one year follow up, quantitated with preoperative and postoperative evaluations which proved highly significant statistically (table 2 & 3). All patients noted significant improvement in appearance of feet (Fig 5) and ease in fitting into shoes and were pain free. Union at osteotomy site occurred at an average of 5 weeks.
Complications: Out of 32 feet, 3 developed pin tract infection which resolved with antibiotic treatment, 5 feet had wound healing problem due to previous callosities in neglected cases which healed with regular dressing and 3 feet found with under correction which required revision surgery.
There was no reduction noted in ankle range of motion in any of the case treated With k wires.

table 1

Table 1: Comparison of preoperative and postoperative clinical scores

 

Table 2: Comparison of preoperative and postoperative radiological scores

Table 2: Comparison of preoperative and postoperative radiological scores

Discussion
Residual and recurrent clubfeet deformities are a difficult problem. Feet are stiff and have usually been operated at least once. Traditionally, treatment of stiff clubfoot deformities included extensive soft-tissue release in younger children and osteotomies in older patients. Nearly all patients with severe residual clubfoot [most of our patients] already underwent at least 1 soft-tissue release. Therefore, there is little hope that another release will dramatically improve the situation. Tendon transfer can improve only dynamic deformity and is contraindicated for correcting stiff deformities [14]. Acute osteotomy correction can be a powerful method of correction [15]. The closing wedge osteotomies of Cole basically provided uniplanar correction with very minimal biplanar correction [16]. Jahss created an osteotomy distal to the usual apex of deformity [17]. Japas developed a V-shaped osteotomy that was located near the apex of the deformity but was limited in the degree of multiplanar correction by the ‘V’ limbs of the osteotomy [18]. Akron dome midfoot osteotomy addresses the center of the deformity and provides multidirectional correction [19]. Wicart and Seringe proposed a Plantar Opening-Wedge Osteotomy of Cuneiform Bones combined with selective plantar release and Dwyer osteotomy which the authors hypothesize provides real detwisting of the helicoidal deformity [20]. Shingade et al proposed a single stage procedure including Percutaneous Achilles tenotomy with plantar fasciotomy and dorsal closing wedge osteotomy for the management of neglected or relapsed clubfeet [21]. Our procedure of a dorsolateral closing wedge osteotomy with slight translation and Steindler’s procedure provides correction at the apex of the deformity and allows proper positioning of the foot. Cole et al, recommended the use of plantar release in the form of Steindler or modified Steindler’s release along with the midfoot osteotomy [16, 18, 20, 22]. Jahss et al on the other hand suggested leaving the plantar structures undisturbed so as to support the osteotomy and obviate the need of any internal fixation [17]. We routinely performed the Steindler’s procedure in a percutaneous fashion in all our patients.
We kept the children for a while longer in the cast to ensure solidity of the union which allows weight bearing and full return to activity. We had no case of non-union of the osteotomy.  Wicart-Seringe had a mean post operative Meary’s angle of 6 degrees and 75% of the patients had lower than preoperative Meary’s angle at final follow up [20]. The dorsolateral closing wedge osteotomy used in our study is successful in correcting the cavus and maintaining it, as the post-operative values of Hibb’s and Meary’s angles are near normal values. Most studies have performed additional procedures [steindler’s release for cavus and posterior release for equinus] after the midfoot surgery. One of the goals of our study is to document the associated abnormalities and correct them along with the midfoot surgery in order to give the child a functional limb. All these procedures were done to give the child a functional limb after one surgery only and appropriate postoperative protocols were followed. Also, the absence of loss of range of motion of ankle joint after the midfoot osteotomy shows the efficacy of the post-operative rehabilitation protocol followed by us. The patients were evaluated by the Dimeglio score. The mean score in our study improved from 10.63 to 2.97 with 90% patient showing good result… Giannini et al, reported that 72% of their patients had a good to excellent result while the other 28% had poor to fair result [22]. This shows that our technique and rehabilitation provides a good result in appropriately selected patients. Average follow up duration in our study was 25 months which is less compared to the Akron group where mean follow up was for 17.3 years and the Wicart-Seringe paper where it was 6.9 years. Giannini et al had a mean follow up duration of 7 years [19, 20, 22]. Probably due to the shorter duration of follow up in our study we have not been able to identify those feet which may require triple arthrodesis in the future. Wicart and Seringe reported 33% of patients at final follow up requiring triple arthrodesis [20].

With the proposed surgical procedure, angular and translational deformity correction in 3 planes can be achieved simultaneously in cases of severe neglected and residual clubfoot deformities without need of extensive soft tissue release. This technique is especially effective with low rates of arthritic degeneration and stiffness in adjacent joints and little reduction of ankle and foot flexibility. The proposed midfoot osteotomy initiates forefoot abduction with center of rotation at subtalar joint eventually causing derotation of whole calcaneopedal block which also pushes calcaneum into abduction. So we can correct forefoot adduction, flexible heel varus and cavus by this dorsolateral closing wedge midfoot osteotomy. In some cases of rigid heel varus which cannot be corrected by midfoot osteotomy alone, we might require a calcaneal osteotomy or gradual correction of deformity with ilizarov ring fixator. We found that, with this surgical technique, correction of complex clubfoot deformities was achieved in almost all cases. The only complication reported by the Akron group were superficial skin sloughs in 2 patients and one case of cellulitis [19]. Giannini had 4 cases of wound dehiscence and 2 cases of non-union of the osteotomy [22]. Levitt et al, reported a 30% rate of pseudoarthrosis with a midfoot osteotomy [23]. The most severe complication we encountered was a recurrence of the deformity. No neurovascular injuries were present. The shortening of the foot was also not significant as no patient needed mismatch footwear. Other complications we had in our patients were under correction, pin tract infection and wound healing problems. The Akron group defined failure of their procedure based on the age of the patient, severity of initial deformity, muscle weakness and any forefoot or hind foot deformity requiring surgery. They had an overall satisfactory rate of 76%, while in children more than 8 years the rate was 82% [19]. We defined failure based on the recurrence of deformity. Recurrence for us is increase in dimeglio score and change in radiographic angles to preoperative values.

Conclusion 
On the basis of our study, we conclude that a procedure including percutaneous Achilles tenotomy with plantar fasciotomy and dorsolateral closing wedge osteotomy is a good alternative to conventional procedures for management of
Neglected or relapsed, late presenting clubfoot deformities. Postoperative rehabilitation protocol should be well structured and rigorously adhered to for achieving a functional foot and ankle.

Clinical relevance
The proposed midfoot osteotomy is a minimally invasive procedure done percutaneously providing excellent correction of clubfoot deformities. It is a joint sparing procedure and it does not hampers the mobility at intertarsal and tarsometatarsal joints. It is a cost-effective surgery as the osteotomy is fixed with k wires. In almost all the cases, outcome of this surgical technique is painless plantigrade functional foot.

References

1. Canale ST, Beaty JH. Congenital anomalies of lower extremity. Campbell’s Operative Orthopaedics. 2. 12th ed. philadelphia: mosby; 2013. p. 995-7.
2. Ponseti I. Clubfoot: Ponseti Management. In: Staheli L, editor. 2nd ed: Global-HELP Organisation; 2005. p. 8.
3. JN P. The neglected clubfoot. Tech Orthop. 2005[20]:153-66.
4. Raab P, Krauspe R. [Recurrent club foot]. Der Orthopade. 1999;28[2]:110-6.
5. Vizkelety T, Szepesi K. Reoperation in treatment of clubfoot. Journal of pediatric orthopedics. 1989;9[2]:144-7.
6. Ponseti IV. Treatment of congenital club foot. The Journal of bone and joint surgery American volume. 1992;74[3]:448-54.
7. Davidson RS. Clubfoot salvage: a review of the past decade’s contributions. Journal of pediatric orthopedics. 2003;23[3]:410-8.
8. Dierauer S, Schafer D, Hefti F. [Osteotomies of the mid- and back-foot in recurrent club foot]. Der Orthopade. 1999;28[2]:117-24.
9. Harvey AR, Uglow MG, Clarke NM. Clinical and functional outcome of relapse surgery in severe congenital talipes equinovarus. Journal of pediatric orthopedics Part B. 2003;12[1]:49-55.
10. Laville JM, Collin JF. [Treatment of recurrent or neglected clubfoot by Ilizarov’s appliance]. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur. 1992;78[7]:485-90.
11. Pell RFt, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. The Journal of bone and joint surgery American volume. 2000;82[1]:47-57.
12. Legaspi J, Li YH, Chow W, Leong JC. Talectomy in patients with recurrent deformity in club foot. A long-term follow-up study. The Journal of bone and joint surgery British volume. 2001;83[3]:384-7.
13. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. Journal of pediatric orthopedics Part B. 1995;4[2]:129-36.
14. Myung KS, Noonan K. Anterior tibialis transfer for residual clubfoot
deformity. In: jm F, editor. Operative techniques in Pediatric
Orthopaedics. Philadelphia: Lippincott Williams & Wilkins; 2011. p. 657-65.
15. Paley D. The correction of complex foot deformities using Ilizarov’s distraction osteotomies. Clinical orthopaedics and related research. 1993[293]:97-111.
16. WH C. The treatment of claw foot. J Bone Joint Surg 1940[22]:895-908.
17. Jahss MH. Tarsometatarsal truncated-wedge arthrodesis for pes cavus and equinovarus deformity of the fore part of the foot. The Journal of bone and joint surgery American volume. 1980;62[5]:713-22.
18. Japas LM. Surgical treatment of pes cavus by tarsal V-osteotomy. Preliminary report. The Journal of bone and joint surgery American volume. 1968;50[5]:927-44.
19. Wilcox PG, Weiner DS. The Akron midtarsal dome osteotomy in the treatment of rigid pes cavus: a preliminary review. Journal of pediatric orthopedics. 1985;5[3]:333-8.
20. Wicart P, Seringe R. Plantar opening-wedge osteotomy of cuneiform bones combined with selective plantar release and dwyer osteotomy for pes cavovarus in children. Journal of pediatric orthopedics. 2006;26[1]:100-8.
21. Shingade VU SR, Ughade SN. Correction of neglected or relapsed clubfoot deformity in an older child by single-stage procedure: early results. Curr Orthop Pract. 2012[23]:122-9.
22. Giannini S, Ceccarelli F, Benedetti MG, Faldini C, Grandi G. Surgical treatment of adult idiopathic cavus foot with plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy. A review of thirty-nine cases. The Journal of bone and joint surgery American volume. 2002;84-A Suppl 2:62-9.
23. Levitt RL, Canale ST, Gartland JJ. Surgical correction of foot deformity in the older patient with myelomeningocele. The Orthopedic clinics of North America. 1974;5[1]:19-29
.

How to Cite this Article: Kulkarni RM, Rathore A, Negandhi R,  Kulkarni MG, Kulkarni S G, Sekhri A. Treatment Of Neglected And Relapsed Clubfoot With Midfoot Osteotomy: A Retrospective Study. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):38-43.        

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Controversial Issues in Closed Reduction and percutaneous pinning of Supracondylar Fractures of Humerus in children

Vol 1 | Issue 1 | July-Sep 2015 | page:11-15 | Taral Nagda, Jaideep Dhamele, Chetan Pishin.

Authors : Taral Nagda[1], Jaideep Dhamele[1], Chetan Pishin[2].

[1] Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
[2] Fellow Institute of Pediatric Orthopedic Disorders Mumbai India.

Address of Correspondence
Dr . Taral Nagda
Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
Email address: taralnagda@gmail.com

Abstract

Introduction: Closed reduction and percutaneous pinning is the mainstay in treatment of supracondylar humerus fractures in children. Although most of the issues are quite straight forward, but in certain situations, there exists difference in opinion in literature. Individual/ group of researchers will always find data to favor one approach over other, but the metaanalysis of the entire literature on the topics fails to show any advantage of one over other. We have tried to touch upon few such questions like Pin Configurations, emergency vs delayed fixation, radiation exposure etc. The pattern of the article is quite unique in terms of referencing the references in details and one after the other. The results are then compiled and guidelines are suggested according to current literature.
Keywords: Closed reduction, supracondylar humerus fracture, percutaneous pinning.

Introduction
Percutaneous pinning of supracondylar fracture is one of the commonest procedures in paediatric orthopaedics, yet there remain certain areas of controversy or lack of consensus. This article is prepared in separate dialectic sections each dealing with a unique question. Relevant literature is then reviewed to reach a logical answer.

A] Pin configurations: Lateral v/s Cross
Closed reduction and pinning is a gold standard in the management of displaced supracondylar fractures of humerus in chidren [1]. It allows the elbow to be maintained in a position of relative extension thus minimizing chances of compartment syndrome and vascular compromise yet providing stability and avoiding malunion associated with the fracture. There is an ongoing debate on choice of the the pin configuration while fixing SCFH [2]. In laboratory settings, cross pinning appears to have better stability but in clinical setting both seem to do equally well with additional risk of iatrogenic ulnar nerve palsy with medial pinning. We examined some of recent papers which can guide an orthopedic surgeon solve the dilemma.

Literature 

1. Medial and Lateral Crossed Pinning Versus Lateral Pinning for Supracondylar Fractures of the Humerus in Children: Decision Analysis [1].

Salient Features
-A decision analysis model was designed containing the probability of iatrogenic ulnar nerve palsy and malunion caused by unstable fixation for each of lateral pinning and medial and lateral crossed pinning techniques. The final outcome was function adjusted life year and used as a utility in the decision tree, where function was evaluated using the McBride disability evaluation.
-Medial and lateral crossed pinning and lateral pinning have opposite aspects to each other in terms of mechanical stability and iatrogenic ulnar nerve injury.
-Iatrogenic ulnar nerve injury after percutaneous pinning of a supracondylar fracture of the humerus can be devastating and irreversible, whereas malunion is correctable. Therefore, the authors recommend the lateral pinning technique for supracondylar fracture of the humerus in children.
-If the minimal medial incision technique could reduce the iatrogenic ulnar nerve injury rate down to 0.7%or a surgeon used a crossed pinning technique with an iatrogenic ulnar nerve injury rate of <0.7%, then the medial and lateral crossed pinning technique could be a better choice than the lateral pinning technique.

2. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? [2]

Salient features
-A meta-analysis of the data from pubmed, embase and cochrane library of RCTs.
-Using varoius stastical analytic tools, it was found out that iatrogenic ulnar nerve palsy rate was higher in patients who underwent cross pinning.
-There were no statistical differences in radiographic outcomes, function, and other surgical complications. No significant heterogeneity was found in these pooled results.
-Authors recommended 2 lateral k wires.

3. Meta-Analysis of Pinning in Supracondylar Fracture of the Humerus in Children [3]

Salient Features
-All randomized controlled trials and cohort studies comparing outcomes (ie, loss of fixation, iatrogenic ulnar nerve injury, and Flynn criteria) between crossed and lateral pinning were identified.
-The risk of iatrogenic ulnar nerve injury was 4.3times higher in cross pinning compared with lateral pinning.
-There was no significant difference for loss of fixation, late deformity, or Flynn criteria between the two types of pinning.
-The study concluded that lateral pinning is preferable to cross pinning for fixation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury.

4. Treatment of displaced supracondylar humeral fractures among children: Crossed versus lateral pinning.[4]

Salient features
-108 children were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin
-Fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation.
-Of the 48 type III fractures fixed primarily with two lateral pins, 31 showed intraoperative instability that warranted an additional medial pin. Of the 17 fractures fixed by lateral pins alone, 8 demonstrated significant postoperative instability and 4 of these developed
cubitus varus deformity.
-There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications.
-Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.
-Measures taken to avoid iatrogenic ulnar nerve damage while inserting a medial pin include relative extension of the elbow with a maximum of 60 flexion, after inserting the lateral pin. This should reduce possible ulnar nerve subluxation before inserting the medial pin. In very unstable fractures, a second lateral pin may be needed to provide more stability before partially extending the elbow for safe medial pin placement. If the ulnar nerve and groove can not be identified with confidence, a small incision should be made over the pin insertion site and blunt dissection should be performed down to the bone, to place the pin under direct vision. Dorgan’s technique of inserting crossed pins from the lateral side of the arm, as described by Shannon et al. offers the biomechanical advantages of cross-pinning while avoiding the risk of iatrogenic ulnar nerve injury.

5. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. [5]

Salient features
-Clinical and radiological results of 78 paediatric patients treated with closed reduction and percutaneous pinning
-No iatrogenic ulnar nerve palsy but one iatrogenic radial palsy which recovered in 13 weeks
-All paients were operated within 6 hours of injury
-Authers concluded that In cases were the ulnar nerve is palpable in the ulnar groove, blind percutaneous crossed pin placement is safe. If closed reduction fails or ulnar nerve subluxation cannot be excluded, a medial mini-open approach to visualise the nerve is certainly safer and should be preferred.

6. Biomechanical Analysis of Pin Placement for Pediatric Supracondylar Humerus Fractures: Does Starting Point, Pin Size, and Number Matter? [6]

Salient features
-20 synthetic humeri were sectioned in mid-olecraon fossa, and were directly reduced and fixed with 2 lateral k wires. There were 2 groups, one where both wires had a lateral entry and one group where one wire was put through capitellum and other through more lateral entry. Capitellar group provided greater stiffness in internal and external rotation. Capitellar entry provides for better stiffness of the construct compared to direct lateral entry by engaging sufficient bone and providing enough separation between the wires.
-Authors concluded that a capitellar entry should be used for one of the k wires.

7. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study [7].

Salient Features
-Authors encountered a radial nerve palsy while using a lateral proximal pin entry for the cross K wire fixation for supra-condylar fracture of humerus.
-They did a cadaveric study in a pediatric humeri and noted that radial nerve is farthest from the wire in the postero lateral plane.
-Authers concluded that direction of the pin should be posterolateral within 2 cm of the lateral epicondyle.

8. Safe Zone for Superolateral Entry Pin Into the Distal Humerus in Children: An MRI Analysis [8]

Salient features
To determine the course of the radial nerve at the lateral distal humerus, authors reviewed 23 elbow radiographs and MRIs of 22 children and mapped radial nerve course.
-They concluded that Percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.

9. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures [9].

Salient features
-18% patients had loss of reduction. Technical errors were noted to be higher in those patients were reduction was lost.

10. Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons [10].

Salient features
-A short survey was sent to Pediatric Orthopaedic Society of North America (POSNA) members using an online survey and questionnaire service. The purpose of the survey was to establish an overview of current practices in the United States concerning treatment of type III supracondylar humerus fractures and the influence of the recent literature on the management of these injuries. — A total of 309 members, representing a wide range of locations and years in practice, responded to the survey
They reported 3 lateral pins (37%), 2 lateral pins (33%), and cross pins (30%) as the preferred method of fixation among respondents. This does show that two thirds of survey participants were using lateral pins primarily.
-However, many of those responding noted that they will add a medial pin to a lateral pin construct if they feel like more stability is needed intraoperatively. Some said that medial cortex comminution is one instance where a medial pin may be needed.
-The respondents that do place a medial pin regularly, advise placement of the lateral pin first for stability, followed by extension of the elbow for placement of the medial pin. This plus opening the medial side and exposing the medial epicondyle has been shown as a reliable technique to assist in protecting the ulnar nerve during medial pin placement. Overall, the sense was that ulnar nerve injury is not a common occurrence if proper precautions are taken.

Authors Comments and recommendations
1. The battle between lateral pinning and cross pinning is a battle between safety and stability
2. The supracondylar fractures are of different configurations and hence pin configurations have to be customized to the specific fracture geometry
3. Most cases of transverse and lateral oblique variety can be well treated by two or three lateral parallel or divergent pins. The stability of lateral pins can be improved in these cases by following measures
a. Capitellar entry point for one of the pins
b. Divergent pin configuration
c. Using wires more than 2 mm diameters
d. Pass pins from anterior to posterior direction at 15-300 to shaft of humerus to have maximum purchase in the distal humerus which is inclined 45 to shaft of humerus
e. Avoid multiple attempts. Multiple attempts weaken the pin bone interphase and weakens the hold of the K wire
4.In some situations medial pin may be added in addition to lateral pins These indications are
a. Intraoperative instability after passing lateral pins
b. Medial comminution
c. Medial oblique fracture
d. Adolescent supracondylar fracture
e. Low supracondular fractures
f. Obliquity in coronal plane which signifies instability
5. Some medial oblique fractures may need only medial pinning
6. The safety of medial pinning can be improved in these cases by
a. Pinning in relative extension The elbow should not be flexed more than 60
b. Pinning from anterior to epicondyle to posterior
c. Feeling the medial epicondyle and pushing ulnar nerve manually with a thumb pressure
d. In doubt or whenever there is a swelling using a mini opening on medial side to make sure the pin is well away from the nerve and does not entangle it
e. Use of a K wire protecting sleeve to prevent entanglement of ulnar nerve sheath.

B] Timing of surgery Emergency v/s Elective
Traditionally supracondylar fractures have been treated as emergency cases. The delay in management of supracondylar fracture may be because of delay in presentation of patient to the hospital or delay after the patient pesents to the hospital. If the patient presents in the morning hours the emergency management is not an issue but when the patient presents to hospital the emergency management poses issues of availability of senor consultant, anaesthesia risk, support staff and cost. The main concerns associated with delayed treatment are as follows:
1. the failure of closed reduction due to swelling
2. the need to convert to open reduction
3. the complications of neurovascular compromise and compartment syndrome.
One study found that children who underwent later surgery after injury (more than 8 h) were more likely to require an open reduction as compared with those who underwent earlier surgery after injury (8 h or less)[3], whereas other studies found no such statistically significant association [4,5]. One of the issues in the management of displaced supracondylar fracture is to manage the patient as emergency or do the surgery the next morning on a routine list. We have again explored recent literature to show some guidelines for treating orthopedic surgeons on this issue.

1. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children [11].

Salient features
-Using medline and Cochrane database 156 publications were scrutinized. Only 7 studies were identified were the effect of early versus delayed treatment were studied. Treatment given in all of them was closed reduction and percutaneous pinning. All the studies were non-randomized and retrospective.
-The authers concluded that chances of failure of closed reduction and conversion to open reduction were significantly high if surgery was delayed beyond 12 hours.

2. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre [12].

Salient features
-Authors reviewed charts of patients :115 children into those treated before 12 h (early surgery) and after 12 h (delayed surgery) .
-The results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis

3. Operative Treatment of Type II Supracondylar Humerus Fractures: Does Time to Surgery Affect Complications? [13]

Salient Features
-Retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury.
-Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children.

4. Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons [10].

Salient features
-An overwhelming majority of respondent to the survey (81%) noted that they do not treat type III supracondylar humerus fractures on an emergent basis if they present after normal work hours, assuming the patient has no obvious reason for emergent intervention, such as, impending compartment syndrome, open injury, vascular injury, or skin compromise
-NPO status and aspiration risk is a concern during emergency surgery. This is a complication that can potentially be avoided with delayed treatment.
– Some respondents treated these on an emergent basis if the fracture is severely displaced or that reduction has seemed more difficult as swelling increases. Other participants cite the lack of OR time the following morning as a reason to fix some of these fractures after normal work hours.
-However, the majority of respondents felt like delayed surgical fixation in this setting was appropriate.

Authors Comments and recommendations
1. We feel that every displaced supracondylar fracture is different and need to have different strategy
2. A displaced supracondylar fracture should be splinted in 60 flexion in an above elbow slab and note be made of neurovascular status, swelling, compartment syndrome, open injury, pucker sign, medial spike
3. Most who present in routine hours get fixed in routine list
4. Those who present in after routine hours are classified into two types
a. Those who can wait till next day
1. Those not fitting into emergency fixation check list
2. Those Presenting after 48 hours where delay of few hours will not make a difference
b. Those who need to be fixed immediately
1. Open injury
2. Compartment syndrome or impending compartment syndrome or even suspicion of compartment syndrome
3. Nerve palsy
4. Pulseles hand pink or pale
5. Difficult reductions due to swelling medial spike puckering etc as the difficulty will increase with increasing time
5. In borderline cases or when doubt exists the case is operated as emergency in presence of senior consultant
6. Even in emergency situation make sure that facilities for open reduction if required are available.

C] Radiation Exposure – What is the risk?

The use of fluoroscopy facilitates the accurate placement of K wires while fixing supracondylar fractures. One negative side effect of fluoroscopic imaging, however, is ionizing radiation. It is a practice to use image intensifier in inverted fashion while doing CRPP for SCFH in children. The issue is what are the factors affecting direct beam and scattered radiation exposure and how to minimize this.

1. The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus [14].

Salient features
-There is a concern that using image intensifier as operating table during surgery may lead to increased radiation exposure to the patient and to the surgeon. This study was done to determine radiation exposure from c-arm configurations.
-It was noted that there was 16% less scatter at waist level but 54% more scatter at the neck level when using c arm as operating table as compared to using an arm board.
-Although the statiscal difference was significant between the 2, yet neither of the 2 was safe.

2. Direct Beam Radiation Exposure to Surgeons During Pinning of Supracondylar Humerus Fractures: Does C-Arm Position and the Attending Surgeon Matter?

3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon’s body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded.
-They noted that fluoroscopy was significantly longer and surgeon’s exposure to direct beam radiation higher when the C-arm position was inverted when compared with the standard position.

Authors Comments and recommendations
1. Direct exposure delivers approximately 100 times more ionizing radiation to the surgeon compared with scatter radiation.
2. Standard radiation dosimeter badges are worn on the neck and waist of surgeons, which measure only scatter radiation unless the fluoroscopy beam directly hits the badge.
3. The surgeons’ hands are the most exposed part of the body during surgery, with the fingertips and the dominant index finger being at greatest risk.
4. Suggestions for minimizing the radiation exposure to both the patient and the surgeon.
a. Use of protective lead aprons, thyroid seals, leadlined eyeglasses, and lead-lined gloves.
b. Lead-lined gloves, however, may produce a false sense of security by providing little additional protection.
c. Being close to the radiation source side of the platform and reducing the fluoroscopy time is shorter.
d. Using a laser light guidance beam with the conventional C-arm.

D] Other issues

1. Can CRPP for supracondylar fractures be considered as being a day care procedure?
Answer : Yes. Provided fracfture is not open or associated with a neuro-vascular injury [16].

2. Does the Pin Size influence the stability of supracondylar fixation
Answer – Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. The commonly used 1.6-mm K-wire may be considered a “large” pin if used in a young or small patient, but also could be considered a “small” pin if used in an older or larger individual. The pin diameter should be similar to the thickness of the midshaft cortex. At the time of fracture reduction, the ratio of the diameter of the pin to the patient’s humeral midshaft cortical thickness can quickly and easily be determined by placing the pin over the arm during fluoroscopy. For a “large” pin, the ratio should be atleast 1 [17,18]

3. How long does it take for children supracondylar fractures to regain full range of motion after closed pinning?
Answer: By 6 weeks children gain 72% of elbow ROM of contralateral elbow and by 52 weeks 98% of elbow ROM of contralateral elbow [19].

References

1. Lee KM, Chung CY, Gwon DK, Sung KH, Kim TW, Choi IH, Cho TJ, Yoo WJ, Park MS. Medial and lateral crossed pinning versus lateral pinning for supracondylar fractures of the humerus in children: decision analysis. J Pediatr Orthop. 2012 Mar;32(2):131-8.
2. Zhao JG, Wang J, Zhang P. Is lateral pin fixation for displaced supracondylar fractures of the humerus better than crossed pins in children? Clin Orthop Relat Res. 2013 Sep;471(9):2942-53.
3. Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012 Jan;26(1):48-53.
4. Zamzam MM, Bakarman KA. Treatment of displaced supracondylar humeral fractures among children: crossed versus lateral pinning. Injury. 2009 Jun;40(6):625-30.
5. Krusche-Mandl I, Aldrian S, Köttstorfer J, Seis A, Thalhammer G, Egkher A. Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis. Int Orthop. 2012 Sep;36(9):1893-8.
6. Gottschalk HP, Sagoo D, Glaser D, Doan J, Edmonds EW, Schlechter J. Biomechanical analysis of pin placement for pediatric supracondylar humerus fractures: does starting point, pin size, and number matter? J Pediatr Orthop. 2012 Jul-Aug;32(5):445-51.
7. Gangadharan S, Rathinam B, Madhuri V. Radial nerve safety in Dorgan’s lateral cross-pinning of the supracondylar humeral fracture in children: a case report and cadaveric study. J Pediatr Orthop B. 2014 Nov;23(6):579-83.
8. Bloom T, Zhao C, Mehta A, Thakur U, Koerner J, Sabharwal S. Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis. Clin Orthop Relat Res. 2014 Dec;472(12):3779-88.
9. Balakumar B, Madhuri V. A retrospective analysis of loss of reduction in operated supracondylar humerus fractures. Indian J Orthop. 2012 Nov;46(6):690-7.
10. Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop. 2013 Oct-Nov;33(7):750-4.
11. Loizou CL, Simillis C, Hutchinson JR. A systematic review of early versus delayed treatment for type III supracondylar humeral fractures in children. Injury. 2009 Mar;40(3):245-8.
12. Mayne AI, Perry DC, Bruce CE. Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1107-10.
13. Larson AN, Garg S, Weller A, Fletcher ND, Schiller JR, Kwon M, Browne R, Copley LA, Ho CA. Operative treatment of type II supracondylar humerus fractures: does time to surgery affect complications? J Pediatr Orthop. 2014 Jun;34(4):382-7.
14. Hsu RY, Lareau CR, Kim JS, Koruprolu S, Born CT, Schiller JR. The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus. J Bone Joint Surg Am. 2014 Aug 6;96(15):e129.
15. Eismann EA, Wall EJ, Thomas EC, Little MA. Direct beam radiation exposure to surgeons during pinning of supracondylar humerus fractures: does C-arm position and the attending surgeon matter? J Pediatr Orthop. 2014 Mar;34(2):166-71.
16. Nayak AR, Natesh K, Bami M, Vinayak S. Is closed manipulative reduction and percutaneous Kirschner wiring of supracondylar humeral fracture in children as day-care surgery a safe procedure ? Malays Orthop J. 2013 Jul;7(2):1-5.
17. Srikumaran U, Tan EW, Erkula G, Leet AI, Ain MC, Sponseller PD. Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures. J Pediatr Orthop. 2010 Dec;30(8):792-8.
18. Srikumaran U, Tan EW, Belkoff SM, Marsland D, Ain MC, Leet AI, Sponseller PD, Tis JE. Enhanced biomechanical stiffness with large pins in the operative treatment of pediatric supracondylar humerus fractures. J Pediatr Orthop. 2012 Mar;32(2):201-5.
19. Zionts LE, Woodson CJ, Manjra N, Zalavras C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res. 2009 Aug;467(8):2007-10.

How to Cite this Article: Nagda T, Dhamele J, Pishin C. Controversial Issues in Closed Reduction and percutaneous pinning of Supracondylar Fractures of Humerus in children. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):11-15.          

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