Orthopaedic Sequelae Research Articles

Estudio y valoración de los cambios introducidos en el nuevo baremo relativos a las secuelas traumatológicas en los cuatro miembros

The orthopaedic sequelae affecting any of the members of the sections are of more prevalence and interest in the valuation of bodily harm. They are usually present in any multisystem trauma patients as well in any kind of aggression in both the aggressor and the aggrieved. These aftereffects result from any damage or injury either osteo-articular soft tissue either of the aforementioned members. Whatever the damaged structure the result will be a deficit or limitation in mobility in this segment with the consequent loss of function. When we use the word ‘deficit’ we are referring to any type of residual state (amputation, joint limitation, stiffness, deviation, pains, etc.) altering and impairing the functionality of that member. The purpose of this scale is none other than to serve the coroner to frame and weigh any sequel with the sole purpose of ‘trying’ to financially compensate the injured. This scale object of this study has been able to improve the above in certain respects. It has been rearranged and has added different effects that did not exist in the previous one, and improved their score in both the average value and the limits of each range to avoid any overlaps. However, there is no uniformity in the joint sequels, the burden of some of them is not adequately assessed and there are gaps in relation to certain deficits and deformities that are not included in this new scale.

Functional outcome in traumatic brain injury in Tunisia

Traumatic brain injury (TBI) occurs mainly in young adults in full swing. The objective of this work is to specify the functional outcome of patients with TBI sequelae. We included adult patients who were hospitalised between January 2009 and December 2013 for the management of TBI sequelae. We excluded patients with a history of neurological or psychiatric disorders before the TBI. We contacted these patients in an attempt to clarify their current functional status. For each patient we stated: the functional independence measurement (FIM), the severity of disability based on the Glasgow Outcome Scale (GOS). The motor part of the Canadian neurological scale was used to evaluate motor impairments. 27 patients were included. 89.3% of our patients were male. The mean age was 34.6 (range: 19 to 66 years). The TBI was severe in 19 cases and moderate in 8 patients. The average duration of post-traumatic coma was 38.7 days. Initial FIM was 66.4/126. The overall assessment of disability by the GOS found two vegetative states; 9 patients had moderate disability and 16 patients had severe disability. A motor impairment was found in all these patients. Only one patient had resumed his previous occupation; 2 had resumed a professional activity with adaptation of the workplace; and 3 others were following appropriate training. The socio-professional reintegration remains a difficult goal to achieve, due to neuropsychological disorders in addition to orthopaedic sequelae which often causes neuro dependency and disability. However, it should optimise the residual functional capacity whenever the possibility of a life plan is offered to the patient.

Spina bifida.

Spina bifida is a birth defect in which the vertebral column is open, often with spinal cord involvement. The most clinically significant subtype is myelomeningocele (open spina bifida), which is a condition characterized by failure of the lumbosacral spinal neural tube to close during embryonic development. The exposed neural tissue degenerates in utero, resulting in neurological deficit that varies with the level of the lesion. Occurring in approximately 1 per 1,000 births worldwide, myelomeningocele is one of the most common congenital malformations, but its cause is largely unknown. The genetic component is estimated at 60-70%, but few causative genes have been identified to date, despite much information from mouse models. Non-genetic maternal risk factors include reduced folate intake, anticonvulsant therapy, diabetes mellitus and obesity. Primary prevention by periconceptional supplementation with folic acid has been demonstrated in clinical trials, leading to food fortification programmes in many countries. Prenatal diagnosis is achieved by ultrasonography, enabling women to seek termination of pregnancy. Individuals who survive to birth have their lesions closed surgically, with subsequent management of associated defects, including the Chiari II brain malformation, hydrocephalus, and urological and orthopaedic sequelae. Fetal surgical repair of myelomeningocele has been associated with improved early neurological outcome compared with postnatal operation. Myelomeningocele affects quality of life during childhood, adolescence and adulthood, posing a challenge for individuals, families and society as a whole. For an illustrated summary of this Primer, visit: http://go.nature.com/fK9XNa.

Analysis of Orthopaedic Sequelae of Special Treatment of Malignant Tumors in Children

Ninety five patients (mean age 13.72±4.2) with complaints on loco-motor system disorders after special treatment for malignant tumors were under observation of orthopaedic surgeon. The most common sequelae of treatment were muscular hypotrophy (66 children), I-III degree scoliosis (75), rigidity (61), bone metabolism disorder and osteopenia (47), one limb shortening even in presence of “growing” endoprosthesis (46). Individual rehabilitation course was performed in 43 (45.3%) children and resulted in increase of joint movement range, improvement of posture, and increase in muscular tension. Timely performed complex of rehabilitation measures enabled to correct sequelae of special treatment at early terms that significantly decreased disability of children, increases their social adaptation and quality of life.

Analysis of Orthopaedic Sequelae of Special Treatment of Malignant Tumors in Children

Ninety five patients (mean age 13.72±4.2) with complaints on loco-motor system disorders after special treatment for malignant tumors were under observation of orthopaedic surgeon. The most common sequelae of treatment were muscular hypotrophy (66 children), I-III degree scoliosis (75), rigidity (61), bone metabolism disorder and osteopenia (47), one limb shortening even in presence of “growing” endoprosthesis (46). Individual rehabilitation course was performed in 43 (45.3%) children and resulted in increase of joint movement range, improvement of posture, and increase in muscular tension. Timely performed complex of rehabilitation measures enabled to correct sequelae of special treatment at early terms that significantly decreased disability of children, increases their social adaptation and quality of life.

Spondylodiscitis After Ingestion of a Lithium Button Battery: A Case Report.

Ingestion of a foreign body is a common problem in the pediatric population. Disc or button batteries represent an important category of foreign body ingestion because of the potential for serious complications if they are not removed promptly. Although the incidence of ingestions involving button batteries has leveled off, the frequency of serious complications from these ingestions has continued to rise1. Orthopaedic sequelae, however, remain rare1. We present the case of a nineteen-month-old girl who developed spondylodiscitis after ingesting a lithium button battery. The patient’s family was informed that data concerning the case would be submitted for publication, and they provided consent. A nineteen-month-old girl presented to the emergency department as a transfer from another hospital after chest radiographs showed a 20-mm disc-shaped foreign body lodged in the esophagus (Figs. 1-A and 1-B). The parents reported that the child had decreased oral intake and increased salivation over the twenty-four hours before presentation. The patient was urgently taken to the operating room and underwent the uncomplicated removal of a lithium button battery under direct visualization with a rigid esophagoscope. During the procedure, it was noted that there was substantial coagulative necrosis around the esophagus and around the foreign body, suggesting that it had been present for a prolonged period of time. The area of necrosis appeared to be less than full thickness in extent. On the first postoperative day, the patient underwent an esophagogram that was consistent with esophageal inflammation; there was no leakage of contrast. She was slowly advanced from a clear liquid diet, as recommended by the National Battery Ingestion Hotline of the National Capital Poison Center, and was discharged to home uneventfully. Fig. 1 Anteroposterior ( Fig. 1-A ) and lateral ( Fig. 1-B ) radiographs at initial presentation showing the button battery lodged in the esophagus. The patient initially …

Perioperative Management of an Adolescent With Friedreich’s Ataxia and Hypertrophic Cardiomyopathy

Friedreich’s ataxia (FA) is an autosomal recessive neurodegenerative disorder with an incidence of 1 : 50,000 which usually presents during adolescents. Given the progressive neurologic involvement, surgical intervention is frequently required for correction of orthopedic sequelae including scoliosis. Associated co-morbid conditions including hypertrophic cardiomyopathy, restrictive lung disease, and diabetes mellitus may impact the perioperative care of such patients. We present a 14-year-old girl with FA presenting for posterior spinal fusion for the treatment of scoliosis. The perioperative management of such patients is discussed. J Med Cases. 2014;5(9):473-477 doi: http://dx.doi.org/ 10.14740 / jmc1900w

Perioperative Management of an Adolescent With Friedreich’s Ataxia and Hypertrophic Cardiomyopathy

Friedreich’s ataxia (FA) is an autosomal recessive neurodegenerative disorder with an incidence of 1:50,000 which usually presents during adolescents. Given the progressive neurologic involvement, surgical intervention is frequently required for correction of orthopedic sequelae including scoliosis. Associated co-morbid conditions including hypertrophic cardiomyopathy, restrictive lung disease, and diabetes mellitus may impact the perioperative care of such patients. We present a 14-year-old girl with FA presenting for posterior spinal fusion for the treatment of scoliosis. The perioperative management of such patients is discussed. J Med Cases. 2014;5(9):473-477 doi: https://doi.org/10.14740/jmc1900w

Intrathecal Baclofen (ITB) Treatment in a Rodent Model of TBI-induced Spasticity

Intrathecal Baclofen (ITB) Treatment in a Rodent Model of TBI-induced Spasticity

Unusual locations of osteoarticular tuberculosis in children: A report of 12 cases

Unusual locations of osteoarticular tuberculosis (OA-TB) raise diagnostic issues due to their untypical and non-suggestive clinical and radiological presentation. The present retrospective study analyzed the various clinical, radiological and therapeutic aspects. A retrospective series included 12 children (mean age, 7 years 4 months; sex-ratio, 0.7), treated in our department between 1980 and 2010. Knee, hip and spine locations were excluded. Mean time to diagnosis was 32 months. Active TB infection was identified in 42% of cases. Pain was the presenting symptom in 83% of cases, with a preponderance of osteitis. Bone loss was the main radiological sign. Phemister's triad was found in two cases of combined articular and bone infection. Diagnosis was confirmed on histology in 92% of cases. All patients were managed according to the Moroccan national TB protocol. Surgery was indicated in five cases, comprising abscess drainage with or without bone surgery (notably for joint dislocation). Four patients showed orthopedic sequelae, including two with associated spinal locations. Rare osteoarticular tuberculosis locations often cause diagnostic problems. Any chronic clinical presentation or suspected atypical bone lesion should suggest a diagnosis of osteoarticular tuberculosis. Level IV. Retrospective study.

Le handicap comme paradoxe et paradigme de la guérison Vivre après une tumeur osseuse traitée pendant l’enfance ou l’adolescence

For children and adolescents treated for a bone tumor, the orthopedic sequelae related to surgeries practised to save the life will, after the completion of oncologic treatment, force them to chronic disability. Thanks to the transversal approach of the author, who works in two experts centers (pediatric oncology and orthopedic surgery), the young patients have a psychological support in the continuity. After the first step, which is the struggle for life, an endless time of handicap occurs. It sets to work on the issue of identification and shakes up the narcissistic foundations, in particular the physical ones. Disability appears as both a paradox and a paradigm of curing a bone tumor. Children and adolescents have to achieve a difficult work of somatopsychic reorganization in a different and postponed time, which goes far beyond the end of the oncologic treatments.

Late adverse events in long-term dumbbell neuroblastoma survivors

s ingediend voor het Amsterdam Kindersymposium 2013 71 Late adverse events in long-term dumbbell neuroblastoma survivors KCJM Kraal (1), AJ Blom (1), GAM Tytgat (1), HN Caron (1) and HJH van der Pal (2). (1) Dept. Pediatrics, division of Oncology. Emma Children’s Hospital – AMC Amsterdan (2) Dept. of Internal medicine, division of Oncology. AMC Amsterdam INTRODUCTION Neuroblastoma (NBL) is a malignant neoplasm of the sympathetic nervous system. There are 2025 newly diagnosed NBL patients/ year in The Netherlands of which 1-2/ year have a dumbbell variant. The dumbbell NBL originates from any neural crest element of the sympathetic nervous system, the tumor grows through the foramen intervertebrale into the spinal canal. This leads to neurological symptoms due to spinal cord compression, which may be permanent. Treatment can be accompanied by a heavy burden of morbidity: extensive laminectomies at a young age can lead to serious orthopedic sequelae. Purpose: to evaluate the prevalence of late adverse events in long-term dumbbell NBL survivors. METHODS Single center study (AMC. Dumbbell NBL patients who have survived longer than 5 years after treatment (0-17 years of age), diagnosed between January 1980January 2007, will be selected from the database Outpatient Clinic for Late Eff ects. RESULTS N=19, 75% female. Median age (range): 14,9 months (7-130 months). Tumor genetics: NMyc amplifi cation 0/8 and loss of chromosome 1P 0/4. Hundred percent survival. Neurological symptoms at diagnosis: ranging from mild to severe. The majority of the tumors were localised in the thoraco-lumbar region. Most of the patients have received a combination of treatment modalities, including: neuro-(surgery), radiotherapy, 131I-MIBG therapy and/or chemotherapy. Late sequelae found are neurological and orthopaedic. Other late sequelae data are yet to be analysed. CONCLUSION There are a signifi cant amount of late sequelae found in these patients.

The management of the orthopaedic sequelae of meningococcal septicaemia

Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients. Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.

Neonatal Osteomyelitis and Complex Nephro-Ureteral Duplication

This report presents a case of femoral osteomyelitis secondary to urinary tract infection in a female neonate with bilateral urinary duplication and right ectopic ureterocele. A female neonate with a history of late perinatal sepsis presented to the emergency department and was found to have left distal femoral osteomyelitis. A complex urological malformation was diagnosed (bilateral renal duplication with right ectopic ureterocele associated with nonfunctional superior pole of the ipsilateral kidney). The baby was submitted to prolonged antibiotic therapy and upper pole nephrectomy of the right kidney. The pathology report confirmed chronic pyelonephritis and dysplasia in the resected specimen. After 1.5 years the patient is asymptomatic and developing normally, with no apparent deformity, but manifests asymptomatic vesicoureteral reflux. Urinary tract infections must always be excluded as the primary infection focus in neonates with sepsis. Perinatal osteomyelitis is almost always a complication of neonatal sepsis and is associated with orthopedic sequelae. This is the first report in literature of a case of osteomyelitis complicating complex urinary duplication and urinary tract infection.

Meningococcal purpura fulminans in children. II: Late orthopedic sequelae management

Purpura fulminans is a rare and extremely severe infection, mostly due to Neisseria meningitidis. Nineteen patients were followed up immediately after the initial multivisceral failure in order to diagnose late-onset orthopedic sequelae. We report our experience with these 19 patients, in light of our medical follow-up protocol and surgical management. Nineteen patients were referred for acute purpura fulminans between 1987 and 2005 to our institution and followed up prospectively until the present. We collected information on all diagnosed orthopedic sequelae, all surgical procedures performed, and the actual orthopedic outcome. Fourteen patients developed at least one orthopedic sequel after a mean of 2years delay, with a mean of 8.65years follow-up (range 3-22years). The most common presentation was lower limb physeal growth plate arrest in eight patients involving 18 growth plates, leading to five limb length discrepancies and 12 significant knee and/or ankle deviations. Patients were treated by completing epiphysiodesis in addition to limb lengthening and/or reaxation osteotomies, except for two patients, in which epiphysiolysis was performed. All outcomes are, to date, satisfactory, with both knee and ankle axes within the physiological range. Among the seven patients who underwent below-knee amputation, six needed stump revision because of skin conflict (4) or prosthetics misadaptation due to upper tibial varus (2). Regarding the upper limb, three patients presented with four cicatricial scar bands, one located on a ring finger, two at the first commissure, and one at the wrist (all were successfully treated by enlargement Z-plasties). Two patients developed hip avascular necrosis. It is important for children diagnosed with meningococcal purpura fulminans to be followed up closely starting from the very beginning by a pediatric orthopedic surgeon. It ensures that late-onset orthopedic sequelae will be diagnosed early. In accordance to the literature, this study highlights the high rate of lower limb epiphysiodesis, above all other types of sequelae. This study reports a possible link between purpura fulminans and avascular necrosis of the hip.

Orthopaedic Sequelae of Childhood Meningococcemia: Management Considerations and Outcome

Patients who survive the initial acute phase of fulminant meningococcemia are at increased risk for serious orthopaedic complications. This report describes our experience with purpura fulminans related to meningococcemia, with emphasis on musculoskeletal sequelae and their treatment. We retrospectively reviewed the cases of forty-eight patients (twenty-two boys and twenty-six girls) who survived the acute phase of meningococcal septicemia and developed musculoskeletal sequelae. Early sequelae required surgical treatment within six months after the onset of sepsis and were primarily amputations. Late sequelae required surgical management six months or more following the initial infection and included growth disturbances, stump overgrowth, scar contractures, and soft-tissue and bone infections. The mean age at the onset of sepsis (and standard deviation) was 2.6 ± 3.0 years, and the mean duration of follow-up was 11.7 ± 5.1 years. The mean number of surgical procedures required was 4.4 ± 2.9 per patient. Early sequelae included amputations at a variety of levels. Upper-extremity amputations were less frequent than lower-extremity amputations. Growth disturbances in the upper extremities were less frequent than growth disturbances in the lower extremities. Stump overgrowth occurred in only eleven patients (23%) with a lower-extremity amputation. The prevalence of scar contractures in the upper extremities was similar to that in the lower extremities. Eight patients (17%) acquired soft-tissue and bone infections at the distal portion of the amputation stump, at a mean of 7.2 ± 5.4 years after the initial sepsis. Thirteen patients (27%) were found to have developmental delay at the time of follow-up, and it was severe in seven of them. All patients who survive meningococcal septicemia should be followed by an orthopaedic surgeon who is experienced in pediatric limb deformities and amputations. Children requiring surgery for purpura fulminans are often limited by physical disability due to amputation, scarring, and abnormal bone growth. Despite advances in orthopaedic management, children are still at risk of developing physical and developmental limitations.

Surviving meningococcal septic shock in childhood: long-term overall outcome and the effect on health-related quality of life

IntroductionThe purpose of this study was to evaluate associations between long-term physical and psychological outcome variables in patients who survived meningococcal septic shock (MSS) in childhood.MethodsThe study population was made up of all MSS patients requiring intensive care treatment between 1988 and 2001.ResultsA total of 120 patients visited the follow-up clinic (age at paediatric intensive care unit (PICU) admission 3.1 years; follow-up interval 9.8 years; age at follow-up 14.5 years (all medians)). Four major outcomes were considered: 1) major physical sequelae (defined as major scars and/or orthopaedic sequelae) (29/120), 2) mild neurological impairments (39/120), 3) problem behaviour (defined as a total score above the 90th percentile of the reference groups on questionnaires to screen for psychopathology) (16/114) and 4) total intelligence quotient < 85 (18/115). No differences were found between patients with major physical sequelae and patients without major physical sequelae as to the presence of problem behaviour or total IQ < 85. Also, no differences were found between patients with mild neurological impairments and patients without as to the presence of problem behaviour or total IQ < 85. Finally, no differences were found between patients with major physical sequelae and patients without as to the presence of mild neurological sequelae. Less favourable scores on behavioural and emotional problems were significantly associated with poorer health-related quality of life (HR-QoL). HR-QoL scores were to a lesser amount predicted by severity of illness at time of PICU admission or by adverse physical outcome.ConclusionsLong-term adverse physical and psychological outcomes in survivors of MSS did not seem to be associated. Poorer HR-QoL was mainly predicted by problem behaviour.

Application of the vacuum-assisted closure in pediatric patients with orthopedic sequelae of meningococcemia: report of a case successfully treated

Patients who survive the initial acute phase of fulminant meningococcemia are at an increased risk for serious complications as a result of poor tissue perfusion. It is rare that early surgical intervention is required, as it is relatively difficult to determine the degree of tissue loss early on. Once the patient is stable, debridement of all necrotic tissue is essential and may necessitate extensive removal of skin, subcutaneous tissue, and muscle. Widespread use of the vacuum-assisted closure for complex soft tissue injuries has generally showed accelerated wound healing compared with traditional methods. We report a new possible application of the vacuum-assisted closure system in very young patients with loss of tissue as a result of purpura fulminans secondary to meningococcemia.

Management of Orthopaedic Sequelae of Congenital Spinal Disorders

Management of Orthopaedic Sequelae of Congenital Spinal Disorders

Survival and functional outcome of childhood spinal cord low-grade gliomas

Intramedullary spinal cord low-grade gliomas (LGGs) are rare CNS neoplasms in pediatric patients, and there is little information on therapy for and outcome of these tumors in this population. Furthermore, most patient series combine adult and pediatric patients or high- and low-grade tumors, resulting in controversial data regarding optimal treatment of these children. To clarify these issues, the authors performed a regional population-based study of spinal cord LGGs in pediatric patients. All pediatric patients with LGGs treated during the MR imaging era (1985-2007) were identified in the comprehensive database of the Hospital for Sick Children in Toronto. Data on demographics, pathology, treatment details, and outcomes were collected. Spinal cord LGGs in pediatric patients constituted 29 (4.6%) of 635 LGGs. Epidemiological and clinical data in this cohort were different than in patients with other spinal tumors and strikingly similar to data from pediatric patients with intracranial LGGs. The authors observed an age peak at 2 years and a male predominance in patients with these tumors. Histological testing revealed a Grade I astrocytoma in 86% of tumors. Although 5-year progression-free survival for the entire group was 48 +/- 9%, all patients were alive at a median follow-up of 8.2 years. Five-year progression-free survival was 88 +/- 13% for patients undergoing gross-total resection and 34 +/- 11% for those undergoing all other therapies, respectively (p = 0.02). Chemotherapy and radiation therapy showed similar efficacy, achieving sustained tumor control in most patients. However, this excellent survival rate was associated with an 83% rate of significant neurological and orthopedic sequelae. This study provides basic data on the incidence, clinical course, and outcome of spinal cord LGGs in pediatric patients. The similarities between spinal and intracranial LGGs in pediatric patients showing excellent survival but high morbidity suggest that a less aggressive approach may be the preferable treatment option for these patients.