Reconsidering the Gold Standard for the Assessment of Spastic Equinus Foot

INTRODUCTION

To determine whether differences exist in the measured range of motion (ROM) by the goniometer, equinometer, and 3-dimensional (3D) gait analysis in different settings (under general anesthesia (GA) or in the clinic) among patients with cerebral palsy.

METHODS

A prospective comparative cohort study was conducted at our orthopaedics center, where 15 patients with diplegic cerebral palsy (30 limbs) were evaluated, all of whom had Gross Motor Function Classification System (GMFCS) level I and II. ROM was measured by (1) goniometer under GA (benchmark), (2) goniometer analysis during clinical examination, (3) equinometer under GA, (4) equinometer in the clinic, and (5) 3D gait analysis. ROM was measured during both knee flexion and extension. Subgroup analysis based on the GMFCS level was performed.

RESULTS

Nine patients were male with GMFCS level I and a mean age of 14.3 (SD=7.2) years. Statistically significant differences were noted between all studied measurement techniques in terms of ROM, dorsiflexion, and plantarflexion during both knee flexion and extension. The GMFCS level was an effect modifier of ROM measurements.

DISCUSSION

The ROM parameters during both knee flexion and extension differed from one measurement device/technique to another. The GMFCS level played a notable effect-modifying role on the ROM parameters.

Dermatofibrosarcoma Protuberans Arising From a Chronic Wound in the Left Shoulder: A Case Report

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing soft tissue sarcoma, typically presenting as a cutaneous lesion. However, its occurrence in chronic wounds is infrequently documented, posing diagnostic and therapeutic challenges. This report details the case of a 59-year-old female with no significant medical history, presenting with a chronic, non-healing wound on the left shoulder, persisting for three years. Initially a small nodule, it progressed into an ulcerating lesion. Physical examination revealed a contracted scar with restricted shoulder mobility. After obtaining informed consent, a surgical excision of the lesion was performed by an electrocautery. Histopathology confirmed DFSP, characterized by spindle fibrous cells, with skin ulceration and deep dermal infiltration. A split-thickness skin graft achieved successful closure. This case underscores the importance of considering DFSP in chronic, non-healing wounds. Timely intervention and appropriate surgical management are crucial for favorable outcomes.

The Impact of Operative Correction of Equinus in Cerebral Palsy on Gait Patterns

BACKGROUND

This study aimed to evaluate gait outcomes and strength following the surgical correction of equinus in cerebral palsy (CP) based on different surgical procedures. We included the Baumann and Strayer procedures, as well as the Achilles tendon lengthening (ATL).

METHODS

A retrospective analysis was performed in patients with infantile, bilateral CP who received instrumental 3D gait analysis before and after surgical correction (18.66 months postoperatively). Patients were divided into 3 groups: Strayer surgery, Baumann surgery, and ATL. Gait performance and muscle strengths were compared between studied surgeries.

RESULTS

A total population of 204 patients (15.43 years) with 341 operated lower limbs (LLs) was analyzed. Dorsiflexion in swing and stance phases significantly improved in all groups postoperatively. The Strayer and the ATL group showed higher postoperative dorsiflexion than the Baumann group. However, no loss of strength was observed with the Baumann method. Maximum power improved in this group postoperatively. An 8.2% loss in calf muscle strength was recorded in the Strayer group.

CONCLUSION

Operative pes equinus treatment successfully improved the gait of children and adults with CP postoperatively. There were differences in postoperative results between studied operative techniques regarding range of motion and power.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The comparative efficacy of nerve transfer versus tendon transfer in the management of radial palsy: A systematic review and meta-analysis

Background

There is no clear census as to which operative technique provides better recovery for radial nerve injuries. Therefore, in this systematic review, we examined the functional recovery, patient-reported outcomes, and complications of tendon transfer (TT) and nerve transfer (NT).

Methods

Five electronic databases were searched for studies (>10 cases per study) comparing NT and TT regardless of the study design (observational or experimental). Manual search was also conducted. The quality was assessed by the NIH tool. Outcomes included functional recovery, patient-reported outcomes (DASH score, satisfaction, and inability to return to work), and complications. The prevalence was pooled across studies using STATA software, and then, a subgroup analysis based on the intervention type.

Results

Twenty-one studies (542 patients) were analyzed. Excellent recovery, assessed by the Bincaz scale, was higher in the TT group (29 % vs. 11 %) as well as failure to extend the fingers (49 % vs. 9 %). No significant difference was noted between both groups regarding DASH score (mean difference = -2.76; 95 % CI: -12.66: 6.93). Satisfaction was great in the TT group (89 %) with a limited proportion of patients unable to return to work (7 %). Complications were slightly higher in the TT group (8 % vs. 7 %) while 18 % of patients undergoing TT requiring revision surgery. Radial deviation was encountered in 18 % of patients in the TT group and 0 % in the NT group. The quality was good, fair, and poor in 2, 13, and 6, respectively.

Conclusions

In radial nerve injuries, although tendon transfer may seem to provide better functional motor recovery than nerve transfer, it is associated with a higher rate of failure to extend the finger. Given the large confidence interval, the accuracy of this finding is questioned. However, a great proportion of those patients require revision surgery afterward. Additionally, tendon transfer is associated with a greater complication rate than nerve transfer, particularly radial deviation.

Palmar Trans-scaphoid Perilunar Dislocation: A Case Report and a Literature Review of Clinicodemographic Characteristics and Management Options

Palmar trans-scaphoid perilunar dislocation is a rare finding in clinical practice. Herein, we report a case of a young right-handed male hairdresser brought to the emergency room after a heavy blow to his right hand. An X-ray showed a palmar dislocation of the capitate, carpus, and distal scaphoid relative to the lunate, which remains in normal alignment with the radius, with the proximal scaphoid maintaining attachment to the lunate. Open reduction and internal fixation were done in the first week after trauma.

Clinicodemographic characteristics of extraosseous ewing sarcoma: A comparative meta-analysis of pediatric and adult patients

Background

Evidence suggests different presentation patterns and prognosis of extraosseous Ewing Sarcoma (EES) based on age. Thus, we carried out this study to test the difference between children and adult EES cases regarding clinicodemographic characteristics and prognosis.

Methods

A total of 4 databases were explored yielding 18 relevant studies for data synthesis. Outcomes included the comparison of demographic and clinical characteristics as well as prognosis between children and adults with EES. Log odds ratio (logOR) and its 95% confidence interval (CI) were pooled across studies. Statistical models/methods were selected based on heterogeneity.

Results

Our analysis included a total of 1261 children and 1256 adults. When we compared these two age categories, we did not observe a significant difference in the risk of developing EES [logOR = -0.13; 95% CI: -0.65: 0.39; I2 = 88.42%]. No significant differences regarding gender, tumor location, and size (≤5 vs. >5 cm), EWSR1 positivity, or management modality. We did not observe significant difference regarding clinical outcomes, such as 5-year overall survival and event-free survival, recurrence, mortality, no evidence of disease, and secondary metastasis.

Conclusions

Our findings highlight the absence of an association between the age category of patients and the incidence of EES, as well as its clinical outcomes.

Research trends in the orthopedic surgical management of cerebral palsy: a cross-analytical study of publications in the past decade

Little is known about the trends in orthopedic surgical management of cerebral palsy (CP). In this cross-analytical study we examined alterations in research publications in this field in the past 10 years through four databases. Thus, we divided publications into old (2012-2017) and recent (2018-2022). To determine if the focus of research in this field has changed, we compared both periods based on publication's (authors' number, journal, country, design), patients' (number, gender, age, CP type), and surgery-related (indication, number, category, type) characteristics. Publications showed a positive trend over the past 10 years with a peak in 2020. The number of publications was similar between old and recent ones (47.58% vs. 52.42%). Most research outputs were from the United States and Germany. Differences were noted between recent and old publications regarding journals (p = 0.0001), journal category (p = 0.023), authors' number (p = 0.006), and patients' age (p = 0.02). The impact factor was also different (p = 0.0001). However, no differences were noted regarding other characteristics (p > 0.05). The research output regarding surgical orthopedic management in CP has increased in the past decade with no difference between 2012-2017 and 2018-2022. Except for the number of authors, journal name, and patients' age, no significant differences were noted between both periods.

Management of Medication-Related Osteonecrosis of the Jaw with Photobiomodulation and Minimal Surgical Intervention

Medication-related osteonecrosis of the jaw (MRONJ) is a relatively common pathology occurring in around 5% of patients taking bisphosphate and other antiresorptive or anti-angiogenic medications. Despite the efforts, as of today there is still no consensus on its management. In this case report, the successful management of stage II MRONJ was performed for an eighty-three-year-old female patient suffering from pain and alteration in her normal oral functions (swallowing and phonation). The treatment consisted of three sessions of photobiomodulation therapy (PBM), followed by minimal surgical intervention and three other sessions of PBM. PBM was applied on the sites of osteonecrosis with the follow parameters: 4 J/cm²; a power of 50 mW; 8 mm applicator diameter; a continuous contact mode. Irradiation was performed on three points, including the vestibular, occlusal and lingual parts of each of the bone exposure areas. Each point was irradiated for 40 s, and, in total, nine points were made per session, and nine sessions were conducted. To assess the pain, a visual analogue scale was used in which zero represented no pain at all and ten represented the greatest pain. At the first session and before any intervention, the patient stated that her pain was 8 out of 10. At the end of the treatment, a significant reduction in VAS was noted (2/10) and, clinically, a healing of the soft tissue in the previously exposed bone was observed. This case report suggests that the combination of PBM with surgical intervention is promising in the management of MRONJ.

Orthopedics and Trauma in Children: Key Problems and Future Insights

Orthopedic disorders among children are frequently encountered in clinical practice [...].

Extraosseous Ewing Sarcoma in Children: A Systematic Review and Meta-Analysis of Clinicodemographic Characteristics

Background: We conducted this systematic review to provide comprehensive evidence on the prevalence, clinical features and outcomes of young extraosseous Ewing sarcoma (EES) cases. Methods: PubMed, Scopus, Web of Science, and Google Scholar were searched for articles reporting the occurrence of EES among children and adolescents (<21 years). The primary outcome included the rate of occurrence of EES among children and adolescents, while the secondary outcomes included the descriptive analyses of the demographic characteristics, tumor characteristics, and clinical outcomes of the affected cases. The data are reported as the effect size (ES) and its corresponding 95% confidence interval (CI). Results: A total of 29 studies were included. Twenty-four reported instances of childhood disease among all the EES cases [ES = 30%; 95%CI: 29−31%], while five studies reported extraosseous cases among the pediatric EES cases [ES = 22%; 95%CI: 13−31%]. The thorax is the most common location of childhood EES [33%; 95%CI: 20−46%] followed by the extremities [31%; 95%CI: 22−40%]. Concurrent chemotherapy and radiotherapy [57%; 95%CI: 25−84%] was the most commonly implemented management protocol in the pediatric EES cases. The rate of no evidence of disease and 5-year overall survival was 69% for both outcomes. Mortality occurred in 29% of cases, while recurrence and secondary metastasis occurred in 35% and 16% of cases, respectively. Conclusions: Our findings provide insight into the clinical features and outcomes of EES among children and adolescents.

Facial Aesthetic Laser-Assisted Protocol for the Management of Acne and Pigmentation: A Case Report

The demand for aesthetic procedures is significantly increasing worldwide. In this case report, an in-office laser-assisted protocol coupled with rejuvenating concentrate serum (Gluage, TEBISKIN Gluage, SkinMed, Italy) was made. A 24-year-old female patient presented with a chief complaint of abundant facial acne and localized pigmentation. Clinical examination revealed the presence of abundant acne on the forehead and cheeks and the presence of localized pigmentation. Laser-assisted protocol coupled with rejuvenating concentrate serum was suggested. The protocol consisted of a thorough cleansing of the face followed by irradiation with a 980 nm diode laser (Smart M, Lasotronix, Poland), followed by a 405 nm diode laser (Smart M, Lasotronix, Poland), the application of rejuvenating concentrate serum (Gluage, TEBISKIN Gluage, SkinMed, Italy), and irradiation with the 635 nm diode laser (Smart M, Lasotronix, Poland). The protocol was made once per week for three weeks (three sessions in total), and a three-month follow-up was made after the end of the last session to confirm the effectiveness of the treatment. Stomatology 1 diode laser (Smart M, Lasotronix, Poland) was used in this case report as a 980 nm, 405 nm, and 635 nm diode laser (Smart M, Lasotronix, Poland). During the follow-up period, an almost total reduction of the acne was observed with the total disappearance of the localized pigmentation. This case report confirms the effectiveness of the proposed laser-assisted facial aesthetic treatment. We invite further studies to be made within the same suggested promising protocol.

Lower-Limb Amputation in Children and Adolescents—A Rare Encounter with Unique and Special Challenges

Background/Aim: The pattern of lower-limb amputation, indications, complications, and revision in pediatric cases differs globally. Therefore, we conducted this study to describe the patterns of lower-limb amputation at our institution. Methods: During a set period between 2010 and 2020, adolescent patients undergoing lower-limb amputation within the orthopedic department of Heidelberg University Hospital were retrospectively collected and analyzed. The retrieved dataset included two parts: data on lower-limb amputations and data on subsequent complications and revision surgeries at the same time. Besides patients’ general information (age, gender), the dataset included data regarding amputation patterns (number, indications, and level of amputation, complications, and revision surgeries and their indications). Results: Twenty-two patients undergoing lower-limb amputation were examined, of which the majority were males (63.6%) with a mean age of 12 (5.1) years. Tumor was the most common indication for amputation (72.7%), and transfemoral amputation was the most frequent level (68.2%). Complications occurred in 10 patients, mostly due to stump impalement or bony overgrowth. Of all recorded patients requiring revision, nine were regarding bone and one case regarding soft tissue. Conclusions: Lower-limb amputation in adolescents is a rare encounter and it is commonly indicated due to bone tumors. The thigh is the most common level of amputation. Postoperative complications are frequent, mainly secondary to bony overgrowth, and often require revision surgery.

Validation of a new Equinometer device for measuring ankle range of motion in patients with cerebral palsy: An observational study

The goniometer is the gold-standard measurement tool of ankle range of motion (ROM). However, several studies have questioned its inter- and intra-rater reliability. Therefore, we conducted this validation study to assess the reliability of a different tool, named Equinometer, as a measurement device of ankle ROM in addition to comparing the reproducibility of their results.Sixteen healthy individuals were included. They underwent both goniometer and Equinometer measurements in knee extension and 90° knee flexion (Silfverskjöld Test). Three raters reported the values of dorsiflexion (DF) and plantarflexion (PF) in each session using both measurement tools. Intra-rater reliability was assessed between 2 raters on another study group of 24 participants. Intraclass correlation coefficients were used to determine the reliability of the used device.The age of study subjects ranged from 22 to 85 years. Fifty percent were males, and the right ankle joint was the most examined side (68.75%). In terms of DF and PF during knee extension and flexion, our analysis revealed that the measurements recorded by the Equinometer were equivalent to the goniometer. Of note, the intra-rater reliability of the Equinometer was excellent for both DF and PF assessment during both knee flexion and extension (Intraclass correlation coefficient ranged from 0.90 to 0.98), with minimal mean differences from goniometer measurements. Subgroup analysis based on age did not reveal any significant differences (P > .05).Given the high intra-rater correlations of the Equinometer, we suggest that it is reliable and precise in recording ankle ROM in outpatient clinics, particularly to obtain reproductive, comparable and unbiased data from different observers.

Radiological Outcomes of Femoral Head Resection in Patients with Cerebral Palsy: A Retrospective Comparative Study of Two Surgical Procedures

Background: We conducted this study to compare postoperative radiological outcomes of two surgical procedures (femoral head resection (FHR) and femoral head cap plastic surgery (FCP)) in patients with CP and hip dislocation. Methods: CP patients with Gross Motor Function Classification Score (GMFCS) IV or V, who underwent either FHR or FCP between 2007 and 2018 at Heidelberg University Hospital in Germany, were included. Most participants underwent postoperative traction in an attempt to prevent telescoping. Besides the above-mentioned objectives, we examined the association between telescoping and spasmolytic use, traction weight, and traction duration. Results: Thirty-eight CP patients were included, of whom 15 (25 hips) underwent FHR and 23 (30 hips) underwent FCP. Heterotopic ossification (grades I, II, and III) occurred in 80% and 83.3% of patients in the FHR and FCP groups, respectively. Telescoping occurred in 18.68 and 31.99% of patients in the FHR and FCP groups, respectively (p = 0.999). Other complications were similar between both groups. Conclusions: The postoperative outcomes of FHR and FCP are similar in terms of telescoping, heterotopic ossification, and complications. Although telescoping was encountered more in the FCP group, no significant difference from the FHR group was found. We noted that the weight of traction could reduce the development of telescoping.

The effect of television-mediated aggression and real-life aggression on the behavior of Lebanese children

This study investigated the effect of television-mediated aggression and real-life aggression on the behavior of Lebanese children. The sample consisted of 48 boys and 48 girls of Lebanese origin who were students in an elementary school in Beirut, Lebanon. After controlling for pre-experimental aggression, the subjects were randomly assigned to one of the following treatment conditions: human-film aggression, cartoon-film aggression, neutral film, or real-life (act of war) aggression. The results indicated that boys as a group were more aggressive than girls and exhibited more imitative aggression after viewing both violent film and real-life violence. Girls were not more violent after viewing filmed aggression but were affected by the real-life violence. Comparisons of Bandura's work within the Lebanese culture are made.

Tru-cut needle biopsy of abdominal tumors in children: a safe and diagnostic procedure

Fifteen children with inoperable abdominal malignancies underwent percutaneous biopsy. Both fine needle aspiration (FNA) and core biopsies using a cutting needle were obtained. In 5 of the 15 specimens obtained by FNA, the material obtained showed malignant cells but did not allow a precise diagnosis to be made. In a sixth case, the diagnosis made on a FNA specimen proved to be incorrect. In contrast, all 15 specimens obtained with a cutting needle were diagnostic. No complications were observed following these procedures. Core biopsies appear to be a safe and reliable means of obtaining tissue for diagnosis in children with inoperable solid abdominal masses.

Johanson-Blizzard syndrome in a large inbred kindred with three involved members

An infant with aplastic alae nasi, imperforate anus, focal aplasia cutis over the fontanels, microcephaly, and mental retardation is presented as an example of the Johanson-Blizzard syndrome. The infant failed to thrive and had evidence of malabsorption. He died at 4 months of age. The occurrence of extensive consanguinity in his family and the occurrence of two other members of the kindred with a similar syndrome indicate that this disorder is transmitted by an autosomal recessive gene.

[Variation in serum nonesterified fatty acids during glucose tolerance test in undernourished patients with anorexia nervosa and in obese patients]

Intravenous glucose tolerance tests (0,33 g glucose per kg body weight) are performed in 11 self starved women suffering from anorexia nervosa, 10 obese and 8 normal women. They have no genetic or chemical diabetes and belong to the same age group. Plasma concentrations of immuno-reactive insuline (IRI) and non esterified fatty acids (NEFA) are determined during these tests. The basal concentrations of NEFA are very high in the obese patients. In the starved women the elevation of the basal plasma NEFA concentration is less striking and statistically not significant. The plasma level of NEFA is reduced in all subjects by hyperinsulinism secondary to hyperglycemia. This drop in NEFA concentration is significantly reduced in the obese patients and markedly inhibited in the starved women. This observation points toward an increased resistance to the antilipolytic action of insulin in anorexia nervosa because, in these patients, the glucose load determines a normal increase in plasma IRI but the fall in plasma NEFA concentration is severely impaired.