Blog Elements - International Journal of Paediatric Orthopaedics

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

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 […]

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 […]

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

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

Full Sized Blog Element (Big Preview Pic)

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).

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.

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.

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: Comparison of preoperative and postoperative clinical 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.

(Abstract) (Full Text HTML) (Download PDF)

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.

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

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

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

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

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

Full Sized Blog Element (Big Preview Pic)

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

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

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

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

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

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

License

Publisher