RESUMEN
Stress fractures are uncommon in skeletally immature patients and usually affect adolescents involved in competitive sports, whereas they are very rare in young children. Involvement of the fourth metatarsal is very infrequent and has been associated with metatarsus adductus deformities. The authors describe a stress fracture of the proximal fourth metatarsal occurred in a 5.5-year-old child with a relapsed clubfoot. Operative correction of the deformity and cast immobilization provided consolidation of the fracture. Stress fractures of lateral metatarsals may represent a possible source of pain in recurrent clubfeet, even in young children. In these cases, early correction of the deformity is required.
Asunto(s)
Pie Equinovaro/complicaciones , Fracturas por Estrés/etiología , Huesos Metatarsianos/lesiones , Preescolar , Femenino , Humanos , RecurrenciaRESUMEN
Fibroblast growth factor 2 (FGF-2) plays an important role in the early phases of bone healing. In this study, we measured FGF-2 serum levels in 88 children undergoing surgical treatment for congenital (n = 49) or acquired (n = 39) orthopedic conditions, which were associated (n = 35) or not (n = 53) with bone lesions, to assess whether serum levels of FGF-2 varied according to the underlying disease and may predict clinical outcomes. FGF-2 serum levels were significantly lower in patients who did not heal after surgery (p = 0.008). Diagnostic accuracy was validated statistically, and the ROC curve provided a threshold value useful in discriminating good versus poor outcomes. The relationship between FGF-2 and bone healing was supported by in vitro experiments. A mineralization assay was performed on bone marrow stromal cells from three patients with congenital pseudarthrosis, who had low serum levels of FGF-2 and a poor clinical outcome after surgical treatment. Autologous serum alone was not sufficient to induce in vitro mineralization, but it did occur when cells were cultured with different sources of exogenous growth factors (GFs), including recombinant FGF-2 and homologous serum collected from children with fractures, high FGF-2 levels, and a good clinical outcome. In conclusion, our findings suggest that osteoinductive GFs are essential for bone repair, and that the amount of circulating FGF-2 may predict bone healing.
Asunto(s)
Factor 2 de Crecimiento de Fibroblastos/sangre , Adolescente , Remodelación Ósea , Calcificación Fisiológica/efectos de los fármacos , Niño , Preescolar , Femenino , Fracturas Óseas/cirugía , Humanos , Lactante , Masculino , Seudoartrosis/congénito , Seudoartrosis/cirugíaRESUMEN
Arthrogryposis includes heterogeneous disorders, characterized by congenital contractures of multiple joints. Knee involvement is very common (38-90 % of patients with amyoplasia) ranging from soft-tissue contractures (in flexion or hyperextension) to subluxation and dislocation. Flexion contractures are more common and disabling and show significant resistance to treatment and rate of recurrence. Surgical procedures vary with severity of contracture and patient age and include soft-tissue release, femoral shortening-extension osteotomy, gradual correction with Ilizarov, and femoral anterior epiphysiodesis. The presence of pterygium greatly complicates treatment, given the high rate of complications reported. Hyperextension deformities (recurvatum, anterior subluxation, and dislocation) have better prognosis for walking ability. Surgical options include percutaneous (or mini-open) quadriceps tenotomy, open quadricepsplasty, and femoral shortening osteotomy with limited arthrotomy. Knee dislocations usually require surgery and should be reduced early.
Asunto(s)
Artrogriposis/terapia , Articulación de la Rodilla/anomalías , Artrogriposis/cirugía , Alargamiento Óseo/métodos , Tirantes , Niño , Preescolar , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Terapia Combinada , Anomalías del Ojo/cirugía , Femenino , Dedos/anomalías , Dedos/cirugía , Deformidades Congénitas del Pie/cirugía , Humanos , Lactante , Recién Nacido , Articulación de la Rodilla/cirugía , Deformidades Congénitas de las Extremidades Inferiores/cirugía , Masculino , Modalidades de Fisioterapia , Recurrencia , Sindactilia/cirugía , Tenotomía , Anomalías Urogenitales/cirugíaRESUMEN
Arthrogryposis represents a group of heterogeneous disorders, characterized by contractures of multiple joints at birth. Involvement of the hip is very common (55-90% of patients) ranging from soft tissue contractures to subluxation and dislocation. Isolated contracture of the hip can usually be managed conservatively: compensative mechanisms and contractures of other joints should be evaluated before planning surgery. For unilateral dislocations, open reduction is indicated to provide a level pelvis, even though the risk of stiffness, avascular necrosis and redislocation is significant. Indications for surgical reduction of bilateral dislocations are more controversial: an adequate evaluation of ambulatory potential of the child (muscular weakness, involvement of upper extremities, etc.) and of stiffness of the hips is suggested. An extensive and long-lasting programme of bracing, physiotherapy and multiple surgery may lead to some measure of functional ambulation in most cases, but high need for surgery and considerable risk of complications must be considered. This paper summarizes problems and principles of treatment for hip contractures and dislocations in arthrogryposis and provides a review of the current literature.
Asunto(s)
Artrogriposis/complicaciones , Contractura de la Cadera/terapia , Luxación Congénita de la Cadera/terapia , Tirantes , Pie Equinovaro/cirugía , Necrosis de la Cabeza Femoral/etiología , Contractura de la Cadera/congénito , Contractura de la Cadera/etiología , Contractura de la Cadera/cirugía , Luxación Congénita de la Cadera/etiología , Luxación Congénita de la Cadera/cirugía , Humanos , Lactante , Recién Nacido , Modalidades de Fisioterapia , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Congenital pseudarthrosis of the tibia (CPT) is a rare orthopedic disease presenting spontaneous fractures that do not heal. The treatment of CPT is characterized by repeated surgical procedures that often fail, with the inevitable outcome of severe disability and amputation. We tested the hypothesis that CPT may benefit from regenerative strategies based on mesenchymal stromal cells (MSC) combined with platelet-rich fibrin (PRF) as a source of growth factors. The aim of the study was to verify whether laboratory testing to assess the osteogenic properties of MSC and the osteo-inductive activity of PRF correlated with the clinical outcome. METHODS: Ten patients affected by refractory CPT were treated by using MSC derived from the iliac crest (IC-MSC), PRF and lyophilized bone. In six patients, CPT was associated with type 1 neurofibromatosis (NF1). Biochemical, functional and molecular assays were performed to assess the intrinsic osteogenic potential of IC-MSC (cells cultured with fetal calf serum) and the osteo-inductive properties of PRF (cells cultured with autologous serum). RESULTS: Bone consolidation was obtained in three patients who had CPT and NF1. In these patients, the IC-MSC exposed to autologous serum were able to form mineral nodules in vitro, while the mineralizing ability was totally abrogated in patients with a poor clinical outcome. CONCLUSIONS: Cell therapy may be a useful tool for the treatment of refractory CPT because it increases the opportunity to achieve effective bone tissue regeneration. Our data suggest that the presence of pro-osteogenic growth factors is an essential requirement for bone healing.
Asunto(s)
Regeneración Ósea , Trasplante de Células Madre Mesenquimatosas , Osteogénesis , Seudoartrosis/congénito , Adolescente , Animales , Bovinos , Supervivencia Celular , Trasplante de Células , Células Cultivadas , Niño , Preescolar , Femenino , Fibrina/metabolismo , Humanos , Ilion/citología , Ilion/metabolismo , Lactante , Masculino , Células Madre Mesenquimatosas/metabolismo , Neurofibromatosis 1/complicaciones , Neurofibromatosis 1/patología , Seudoartrosis/complicaciones , Seudoartrosis/patología , Seudoartrosis/terapia , Suero/metabolismo , Tibia/anomalías , Tibia/patología , Trasplante Autólogo/métodos , Resultado del TratamientoRESUMEN
The authors report a series of 11 patients treated surgically by trochanteroplasty for septic arthritis of the hip at our institution from 1974 to 2010. Trochanteroplasty was indicated due to the absence of a valid alternative, and because it does not rule out the option of total hip arthroplasty at a later stage.
Asunto(s)
Artritis Infecciosa/cirugía , Artroplastia/métodos , Desviación Ósea/cirugía , Fémur/cirugía , Luxación de la Cadera/cirugía , Articulación de la Cadera/cirugía , Artritis Infecciosa/complicaciones , Desviación Ósea/etiología , Niño , Preescolar , Femenino , Luxación de la Cadera/etiología , Luxación Congénita de la Cadera/complicaciones , Luxación Congénita de la Cadera/cirugía , Articulación de la Cadera/patología , Humanos , Masculino , Osteotomía , Resultado del TratamientoRESUMEN
PURPOSE: The purpose of this study was to review the operative long-term results of a large cohort of children treated arthroscopically for a symptomatic discoid lateral meniscus. METHODS: We retrospectively reviewed the arthroscopic procedures performed on 104 knees (97 patients) between 1990 and 2006 to treat symptomatic discoid lateral meniscus in children. The median age at the time of surgery was 8 years (range 2.5-13.9 years). RESULTS: The follow-up was 8.5 ± 2.5 (mean ± SD) years (median 9, range 2-18.5 years). In this series, young children (2-7 years) usually presented complete discoid menisci with deficit in extension and little pain. The meniscal tissue was almost degenerated, and subtotal meniscectomy was performed. Children aged from 8 to 14 years referred to our institute typically presented a symptomatic tear (pain and swelling joint with snap) of a complete or incomplete discoid lateral meniscus, usually pursuant to a trauma. The treatment performed in this group was a partial meniscectomy. Clinical results at long-term follow-up show better results for subtotal meniscectomies than for partial ones. CONCLUSION: The results showed the long-term efficacy of arthroscopic treatment of a symptomatic discoid lateral meniscus. On the basis of this study, subtotal meniscectomies in younger patients are preferable when meniscal tissue is degenerated. In older children, we recommend to preserve meniscal tissue as much as possible. In younger patients submitted to subtotal meniscectomies, some adaptation of the knee to stress activity may occur. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.
Asunto(s)
Artroscopía/métodos , Articulación de la Rodilla/cirugía , Meniscos Tibiales/anomalías , Meniscos Tibiales/cirugía , Adolescente , Factores de Edad , Niño , Preescolar , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Artropatías/diagnóstico por imagen , Artropatías/cirugía , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Meniscos Tibiales/diagnóstico por imagen , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Radiografía , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Factores de Tiempo , Resultado del TratamientoRESUMEN
Osteoarthritis of the hip joint secondary to femoral head collapse may develop after curettage of lesions in the femoral head. We report the case of a patient with chondroblastoma of the femoral head who was treated with wide curettage of the lesion and implantation of an osteochondral allograft to prevent femoral head collapse.
Asunto(s)
Neoplasias Óseas/cirugía , Trasplante Óseo/métodos , Condroblastoma/cirugía , Cabeza Femoral/cirugía , Cabeza Femoral/trasplante , Adolescente , Legrado , Humanos , Masculino , Recuperación de la Función , Trasplante HomólogoRESUMEN
The study was designed to establish the biological basis for the use of autologous bone-marrow stromal cells (MSC) in order to improve the curing opportunities of congenital pseudarthrosis of the tibia (CPT). The investigation was planned by taking into account that the pathophysiology of bone healing mainly depends on the osteogenic potential of the resident cells, although several factors play a crucial role in restoring the normal bone structure. Bone marrow samples were collected from the lesion site (P) and the iliac crest (IC) of 7 patients affected by CPT and type 1 neurofibromatosis (NF1+) and 6 patients affected by CPT without NF1 (NF1-). Four patients without CPT served as control group. Biochemical, functional and molecular assays showed that the ability to generate bone-forming cells was higher in IC-MSC than in P-MSC, but lower in CPT patients than in control group. We evaluated whether host factors, such as autologous serum and the microenvironment surrounding the pseudarthrosis lesion, could impair the osteogenic differentiation of IC-MSC. Autologous serum was less effective than FBS in promoting the IC-MSC differentiation, but the damage was more evident in NF1- than in NF1+ patients. Additionally, the supernatant of osteoblast cultures obtained from bone fragments close to the lesion site favoured the differentiation of IC-MSC in NF1- patients. In summary, our results suggest that MSC transplantation could be a promising strategy for the therapy of CPT. Further studies are warranted to confirm the clinical effectiveness in comparison to standard surgical treatment.
Asunto(s)
Trasplante de Médula Ósea , Seudoartrosis/congénito , Seudoartrosis/cirugía , Tibia/anomalías , Tibia/cirugía , Adolescente , Médula Ósea/patología , Trasplante de Médula Ósea/patología , Células Cultivadas , Niño , Preescolar , Técnicas de Cocultivo , Femenino , Humanos , Lactante , Masculino , Seudoartrosis/diagnóstico por imagen , Radiografía , Células del Estroma/trasplante , Tibia/diagnóstico por imagen , Trasplante Autólogo/patología , Resultado del TratamientoRESUMEN
We report results of surgical treatment of ten knees affected by patellar dislocation in six children with Down syndrome. Four knees showed a dislocatable patella (grade III according to Dugdale), two a dislocated reducible patella (grade IV) and four a dislocated irreducible patella (grade V). Symptoms included frequent falls, limping and pain. In all the cases a Roux-Goldthwait-Campbell procedure was performed. Mean age at surgery was 10 years (range 6 years and 6 months to 13 years and 4 months). Patients were reviewed at an average follow-up of 8 years and 8 months (range 3 years and 6 months to 11 years and 5 months). None showed signs of recurrence of the dislocation. The median Lysholm score improved from 57.5 to 91/100. Statistical analysis showed a significant effectiveness of the procedure in improving function, and that surgery was significantly more effective in patients with more severe disability.
Asunto(s)
Síndrome de Down/complicaciones , Síndrome de Down/cirugía , Luxación de la Rótula/complicaciones , Luxación de la Rótula/cirugía , Adolescente , Niño , Femenino , Estudios de Seguimiento , Humanos , Inestabilidad de la Articulación/etiología , Inestabilidad de la Articulación/cirugía , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/cirugía , Masculino , Procedimientos Ortopédicos/métodos , Rótula/diagnóstico por imagen , Rótula/cirugía , Luxación de la Rótula/diagnóstico , Radiografía , Rango del Movimiento Articular , Recuperación de la Función , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Osteoid osteomas of the hand are uncommon. Particularly, location in the thumb and involvement of the distal phalanx are very rarely reported. Long diagnostic delay and inadequate treatment are typical, since clinical features may mimic other causes more frequently found in the same site (post-traumatic, infective, rheumatic, neoplastic conditions, regional pain syndrome) and even the nail morphology may be altered, as in the reported case (watch-glass deformity). A case of an osteoid osteoma of the distal thumb phalanx in a 27-year-old man is presented, along with its clinical, radiographic and CT findings. In the Authors' opinion, curettage should be considered the treatment of choice.
Asunto(s)
Neoplasias Óseas/diagnóstico por imagen , Osteoma Osteoide/diagnóstico por imagen , Pulgar , Adulto , Neoplasias Óseas/diagnóstico , Neoplasias Óseas/cirugía , Legrado , Humanos , Masculino , Osteoma Osteoide/diagnóstico , Osteoma Osteoide/cirugía , Radiografía , Pulgar/diagnóstico por imagen , Pulgar/cirugía , Resultado del TratamientoRESUMEN
Treatment of cases of congenital pseudarthrosis of the fibula presenting with severe or progressive valgus deformity in early childhood is challenging. The purpose of the study presented was to analyse the deforming mechanisms to get therapeutic recommendations for this condition. A 2.5-year-old child was treated by resection of pseudarthrosis and distal tibiofibular fusion (Langenskiold operation) with autogenous bone grafting, associated with subtalar arthroereisis: progressive correction of the deformity was achieved. A 21-month-old child was treated with resection of pseudarthrosis, homologous bone grafting and fibular osteosynthesis: after failure, Langenskiold operation with autogenous bone grafting was performed and stabilization of the deformity was achieved. In young children with congenital pseudarthrosis of the fibula and valgus deformity, early surgical treatment is advisable: fibular ostheosynthesis has limited indications; distal tibiofibular fusion remains the treatment of choice, providing correction that may exceed the simple stabilization of deformity expected. Radiographic findings lead the authors to suggest that part of the effectiveness of the procedure is due to abnormal growth patterns.
Asunto(s)
Articulación del Tobillo/anomalías , Peroné/anomalías , Seudoartrosis/congénito , Articulación del Tobillo/cirugía , Trasplante Óseo/métodos , Niño , Preescolar , Peroné/cirugía , Peroné/trasplante , Humanos , Masculino , Seudoartrosis/cirugía , Resultado del TratamientoRESUMEN
The Authors describe a case of Freeman-Sheldon Syndrome, a rare congenital autosomal dominant disorder (gene mapped on chromosome 11p15.5) characterized by microstomia with crinkled lips, camptodactyly with ulnar deviation of the fingers and equinus-varus-supine clubfoot. The autosomal recessive form, even rarer and difficult to recognize, has a more severe clinical manifestation. The symptomatology is worsened by breathing and swallowing disorders due to the small orifices of the mouth and nose, which sometimes require tracheotomy to avoid obstruction of the airways.
Asunto(s)
Anomalías Múltiples , Pie Equinovaro/genética , Cara/anomalías , Deformidades Congénitas de la Mano/genética , Anomalías Múltiples/genética , Anomalías Múltiples/patología , Anomalías Múltiples/cirugía , Artrogriposis/genética , Tirantes , Bronconeumonía/etiología , Preescolar , Pie Equinovaro/cirugía , Genes Recesivos , Luxación Congénita de la Cadera/genética , Luxación Congénita de la Cadera/cirugía , Humanos , Cifosis/congénito , Cifosis/genética , Cifosis/cirugía , Cifosis/terapia , Microstomía/genética , Microstomía/cirugía , Atrofia Muscular/genética , Reoperación , Insuficiencia Respiratoria/etiología , Escoliosis/congénito , Escoliosis/genética , Escoliosis/cirugía , Escoliosis/terapia , Síndrome , TraqueotomíaRESUMEN
Ninety-one children who had been treated for fractures of the proximal humerus (59 metaphyseal fractures; 32 epiphyseal fractures) from 1980 to 1992 at an average age of 10.7 years (range 3 to 14 years) were reviewed. In 82 cases a nonsurgical treatment (Desault bandage in 11 cases, hanging cast in nine cases, closed reduction and shoulder spica cast in 62 cases) was performed. At a mean time of 7.2 months (range 1 to 156 months), 96% of patients showed good/excellent clinical results. In 15 cases, radiographs were reviewed at a mean follow-up of 8 years (range 1 to 23.5 years): just a slight metaphyseal or meta-diaphyseal varus deformity was found in three cases. In nine cases surgery was required. Patients were reviewed by clinical examination at a mean time of 34.8 months (1-150 months), and in six cases radiographs were reviewed at a mean time of 5 years and 5 months (range 1 to 12.5 years) after surgery. In one case, a septic process occurred, that caused a severe deformity of the epiphysis and a noticeable functional deficit. Good/excellent clinical and radiographic results were achieved in the other patients. Conservative treatment of fractures of the proximal humerus in children is recommended. Surgery should be reserved for specific cases.
Asunto(s)
Fracturas del Hombro/epidemiología , Adolescente , Vendajes , Moldes Quirúrgicos , Niño , Preescolar , Epífisis/lesiones , Epífisis/cirugía , Femenino , Estudios de Seguimiento , Fijación Interna de Fracturas , Humanos , Masculino , Osteítis/etiología , Osteítis/prevención & control , Complicaciones Posoperatorias , Radiografía , Reoperación , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/cirugía , Fracturas del Hombro/terapiaRESUMEN
One thousand nine hundred and eighty-four children who had received conservative treatment for shaft (diaphyseal and metadiaphyseal) fractures of lower limbs (1162 femoral, 822 tibial fractures) at an average age of 8.5 years (range 0-14 years) were reviewed by clinical and radiographic investigations at an average follow-up of 6.6 years (1-15 years). Particularly, two main features were evaluated: remodelling of (angular and rotational) deformities and post-traumatic overgrowth. Mechanisms underlying these processes are discussed, based on a review of the literature, and parameters conditioning their evolution are analysed. Finally, criteria for an acceptable reduction (and limits for residual deformities that may be tolerated) at the time of conservative treatment are proposed.
Asunto(s)
Remodelación Ósea , Fracturas del Fémur/terapia , Fracturas de la Tibia/terapia , Adolescente , Factores de Edad , Moldes Quirúrgicos , Niño , Preescolar , Femenino , Fracturas del Fémur/diagnóstico por imagen , Fémur/crecimiento & desarrollo , Estudios de Seguimiento , Humanos , Inmovilización , Lactante , Recién Nacido , Masculino , Radiografía , Tibia/crecimiento & desarrollo , Fracturas de la Tibia/diagnóstico por imagen , Factores de Tiempo , Tracción , Resultado del TratamientoRESUMEN
We report a very rare association of a physeal fracture of the medial clavicular growth plate with a fracture of the adjacent clavicle in a 14-year-old boy who fell on his shoulder while playing football. Clinical, radiographic and computed tomographic (with three-dimensional reconstruction) features are described. Open reduction, internal fixation of the lateral fracture (with a reconstructive plate) and suture of the periosteum were performed.
Asunto(s)
Clavícula/lesiones , Fútbol Americano/lesiones , Fracturas Óseas/diagnóstico , Luxaciones Articulares/diagnóstico , Articulación Esternoclavicular/lesiones , Adolescente , Fracturas Óseas/etiología , Fracturas Óseas/cirugía , Humanos , Luxaciones Articulares/etiología , Luxaciones Articulares/cirugía , MasculinoRESUMEN
Septic arthritis of the shoulder in children is a rare condition. The diagnosis may present some difficulties and, consequently, appropriate treatment often is delayed. Main sequelae are humeral shortening, joint instability, premature arthritis and limited range of motion. We report a case of septic arthritis of the shoulder in a child who was treated by means of shoulder arthroscopy. A 6-year-old boy presented with a history of fever, pain and functional impairment of the shoulder that were lasting despite having undergone antibiotic therapy for 28 days (amoxicillin per os, and then teicoplanin intravenously combined with meropenem intravenously) and an arthrocentesis (no organisms were identified) in another hospital. Clinical examination (pain, swelling, warmness, functional impairment), laboratory tests (white blood cell count, 6.900/mm(3); C-reactive protein, 6.44 mg/dL; erythrocyte sedimentation rate, 119 mm), and imaging studies (radiographs, ultrasonography, computed tomography scan, magnetic resonance imaging, bone scan) performed in our department suggested the diagnosis of a stage IV (with osseous involvement) septic arthritis. Arthroscopic irrigation, debridement, synoviectomy and shaving of the osteochondral erosions were performed, in association with antibiotic therapy (teicoplanin and ceftriaxone disodium intravenously, and then amoxicillin/clavulanate per os). At 22-month follow-up, the patient was asymptomatic and showed a full range of motion. No limb length-discrepancy was found. Radiographs showed irregular profile of the humeral epiphysis without any physeal disturbances. Arthroscopic treatment for septic arthritis of the shoulder in children, though rarely reported, represents an adequate procedure for cases without bone involvement and may lead to good results, even in stage IV cases. Open arthrotomy should be reserved for cases with concomitant osseous infection after failure of arthroscopic treatment.