Introduction

Several hexapod external fixator devices are used in the treatment of bone fracture and deformity corrections. One characteristic of all of them is the requirement for manual adjustment of the fixator struts. The purpose of this study was to introduce a novel robotic system that executes automatic adjustment of the struts.

Introduction

Patient-specific instruments (PSI) and surgical-guiding templates are gaining popularity as a tool for enhancing surgical accuracy in the correction of oblique bone deformities Three-dimensional virtual surgical planning technology has advanced applications in the correction of deformities of long bones and enables the production of 3D stereolithographic models and PSI based upon a patient's specific deformity. We describe the implementation of this technology in young patients who required a corrective osteotomy for a complex three-plane (oblique plane) lower-limb deformity.

Background: Congenital dislocation of the patella can cause significant functional disability and is often associated with limb deformity in childhood. Two types or clinical manifestations of this condition have been previously described, namely the fixed lateral dislocation and the habitual or obligatory dislocation of the patella. Few surgical procedures have been suggested for the treatment of the complex condition.

Objective: We reviewed our surgical approach in ten knees (seven children) with both types of patellar dislocation, and evaluated the clinical and functional outcomes.

Methods: All our patients underwent an extensive sub-periosteal mobilization of the extensor mechanism from the lateral side of the thigh combined anteriorly with plication of the medial patellar retinaculum. This procedure was supplemented by medialization of half of patellar tendon in the skeletally immature patients, and by tibial tuberosity transfer that was performed in one skeletally mature patient.

Results: In six children, patellar dislocation was a part of a diagnosed syndrome, namely Down (3 patients), Larsen (1 patient), Rubinstein-Taybi (1 patient) and fibular hemimelia (1 patient). Six knees had fixed type and four (all Down syndrome) had obligatory type of patellar dislocation. Average age at surgery was 9.5 years (range 3.5–14) and the mean follow-up period was 19 months (range 7–33). There was no recurrence during the follow-up period. Two children with Down syndrome, who had flexion contraction and were non-ambulatory, began to walk three months and five months after the surgery. A significant resolution of the valgus deformities was obtained in the operated knees. Two complications were recorded, an undisplaced supracondylar fracture following removal of plastic cast and transitory peroneal nerve palsy.

Conclusions: Abnormal anatomical muscular and bony changes, soft tissue structural changes and limb alignment contribute to patellar dislocation and to subsequent clinical deterioration and deformity progression. Our surgical intervention aimed to realign the extensor mechanism and was effective in treating both types of congenital dislocation of the patella. Based on our experience, the long-standing habitual dislocation is accompanied by changes in the extensor mechanism of the knee that are similar to those occurring in the fixed patellar dislocation and therefore should be addressed surgically in a similar manner.

Background: The treatment of extensive soft tissue injury with bony involvement due to orthopaedic trauma or other pathologic conditions has undergone great improvement in the last decade.

The main fields that assisted with that progress are: the ability to transfer autogenous vascularized soft and/or bony tissues to the injured areas and the possibility to apply external fixation either statistically for acute stabilization of a limb or using dynamic frames to correct late occurring contractures or deformities.

Objectives: To present our experience in treating young patients with severe, post traumatic or tumor resection soft tissue and bony injuries including bone loss and late joint contractures. That was treated by a combination of free vascularized flaps and static or dynamic circular external fixation with special emphasis on preplanning and technical issues critical for the success of such complex procedures.

Methods: Seven patients were included in the study; six post traumatic patients who received free vascularized myocutaneous latissimum dorsi or fasciocutaneous anterolateral thigh flaps to the calf and foot. All six patients had an Ilizarov frame for initial stabilization; two of them needed late dynamic correction of equines with the frame. The seventh patient had surgery for removal of osteosarcoma and received a vascularized osteocutaneous fibula flap with fixation by Ilizarov frame, this patient also needed late dynamic frame application for equines correction.

Results: The mean age at surgery was 11.6 years (range 7–14 years); mean follow up was 1.8 years (range 2 months – 3.4 years).

All microvascular flaps but one survived where the patient with the failed latissimus dorsi flap had the second muscle transferred at the next day. One patient needed 2 vascular revisions. All bone flap showed solid union at 3 months post operatively. Four patients achieved plantigrade foot initially. The three patients with dynamic correction achieved plantigrade foot at frame removal.

Complications: Equinus contracture of the ankle in three patients, injury to the vascular anastomosis in one patient. Pin tract infection in all patients that responded well to antibiotics.

Conclusions: The circular external fixator is a reliable method for initial fixation of injured limb. It is advised to apply the fixator before the transfer of the free flap. Position of the fixation pins should be discussed before hand with the plastic surgeons to allow free access to the microvascular anastomosis site. Free flaps allow the coverage of large soft tissue defects while the external fixators maintain anatomical position of the limb. Late occurring contractures after the incorporation of the flap can be safely corrected gradually with the circular frame. It is of paramount importance to include the foot in the frame and maintain neutral position of the ankle joint to prevent equines contractures.

A congenital, unilateral, fixed flexion deformity in a neonate was diagnosed as a congenital absence of the knee. A single cartilage mass, with fusion of the lower femoral and upper tibial ossification centres, was demonstrated by imaging studies. This condition has been reported in the literature only once before. Surgery on our patient, which was performed at the age of two years, consisted of separation of the fused cartilaginous anlage and gradual correction of the deformity using an Ilizarov frame.

We believe that soft tissue release and articulated hip distraction distinguishes itself in the short term as a good salvage procedure for late onset severe Perthes disease of the hip.

Our series is made of 10 patients with late onset Perthes disease. All 10 patients were above 9 years of age at diagnosis (average = 11 years). There were 7 boys and 3 girls in the series. All patients had significant limp and pain with positive Trendelenburg sign. All patients used crutches or wheelchairs and had symptoms for a period of 0.5 to 3 years before the operation; all hips had limited ROM. Two patients had previous soft tissue release. There were 2 children with Down syndrome and 1 child had Gleophysic Dysplasia. On preoperative radiographs, 8 patients had a saddle shape subluxating femoral head with hinge abduction and 2 subluxations only. Nine hips were graded Catterall IV and Herring C and 1 hip Catterall III Herring B. There were at least 3 and mostly 4 Catterall prognostic risk signs for these hips. All patients had a broken Shenton line, increased medial joint distance and low Epiphyseal index before surgery.

After adductor and ileopsoas release an orthofix hinged apparatus for distraction is applied to the hip. The distraction continues until overcorrecting of Shenton line achieved. The external fixator is left in place for 4–5 months while in the apparatus flexion and extension of the hip is possible and encouraged. The follow-up ranged from 0.5 to 3 years. At last follow-up all patients were walking freely with improved hip ROM. All patients resumed daily ambulatory status and 2 were involved in regular sports. Latest radiographs showed that the saddle shape disappeared in 7 of 8 hips, in all patients hip subluxation decreased as measured by medial joint distance and Shenton line was corrected to between 0.6 mm. The Epiphysis index and joint congruency improved in most cases.

The level of satisfaction from the operation was very high for all patients and their parents.

Drawing of final conclusion will be possible only after assessing the long-term results.

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot.

The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot.

The conventional osteotomies used to treat infantile tibia vara (Blount’s disease) may require internal fixation and its subsequent removal. These techniques, which carry the risk of traction injury, and potential problems of stability and consolidation, do not always succeed in correcting the rotational deformity which accompanies the angular deformity.

We have used a new surgical approach, the serrated W/M osteotomy of the proximal tibia, to correct infantile tibia vara in 15 knees of 11 patients. We present the results in 13 knees of nine patients who have been followed up for a mean of eight years. The mean angular correction achieved after operation was 18 ± 5.8°. The mean femorotibial shaft angle was corrected from 14.2 ± 3.7° of varus to 4.6 ± 4.4° of valgus. At the last follow-up, the mean angular correction had reduced to 1.3 ± 4.9° of valgus without compromising the rotational correction and the overall good clinical results. All the patients and parents were satisfied, rating the result as excellent or good. There were no major postoperative complications and no reoperations. Eight patients were free from pain and able to perform physical activities suitable for their age. One complained of occasional pain. This procedure has the advantage of allowing both angular and rotational correction with a high degree of success without the need for internal fixation.