Publications by authors named "Sebastian Farr"

65 Publications

Autologous replacement of the head of the radius-proximal fibula versus second metatarsal base: an anatomic feasibility study.

Arch Orthop Trauma Surg 2022 May 9. Epub 2022 May 9.

Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.

Introduction: This study investigated the anatomic feasibility of a new surgical therapy option for radial head arthrosis using an autologous vascularized bone graft of the second metatarsal and proximal fibula to recreate the proximal radiohumeral joint.

Materials And Methods: Upper and lower extremities of eleven body donors were evaluated using CT prior to anatomic dissection. Several distinct anatomic parameters were measured on the ipsi- and contralateral radial and fibular head and the second metatarsal base: bone diameter, articular surface diameter, head height, metaphyseal (neck) diameter, articular surface radius, total articular surface area, and angulation of the articular surfaces (facet). Each dissection phase was photographed in a standardized fashion and all measurements were repeated by direct caliper-measurements.

Results: When comparing the proximal radius and fibula to search for anatomic similarities, similar values were found in the maximum articular surface diameter and minimum and maximum measures of the neck diameter. Comparing the proximal radius and the second metatarsal, statistically similar values were found in the maximum neck diameter performing direct measurements and CT evaluation, the maximum head diameter in CT evaluation and the articular facet angulation.

Conclusions: Neither the proximal fibula nor the base of the second metatarsal are ideal bone grafts for replacement of the head of the radius. The base of the second metatarsal might be a bit more suitable as a potential donor since the angulation of the proximal articular facet is similar to that of the radius.

Level Of Evidence: Level IV, anatomic study.
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http://dx.doi.org/10.1007/s00402-022-04460-yDOI Listing
May 2022

Outcomes of soft tissue distraction prior to radialization of the hand in children with severe radial longitudinal deficiency.

J Hand Surg Eur Vol 2022 Apr 26:17531934221095380. Epub 2022 Apr 26.

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria.

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http://dx.doi.org/10.1177/17531934221095380DOI Listing
April 2022

The Hand in Distal Arthrogryposis.

J Hand Surg Am 2022 05 10;47(5):460-469. Epub 2022 Feb 10.

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria. Electronic address:

Distal arthrogryposis is the second most common type of arthrogryposis after amyoplasia and is defined as arthrogryposis that affects hands and feet; it is mostly inherited in an autosomal-dominant fashion. This review discusses up-to-date background information, clinical features, and treatment of distal arthrogryposis in hands concentrating on camptodactyly, thumb-in-palm deformity, and windblown hand deformity, which are the most common and functionally limiting deformities. Treating these deformities should be individualized and follow a multidisciplinary approach. Most deformities can be initially treated nonoperatively, and if not responsive, operative treatment may be pursued to improve function. Surgery primarily aims to release soft-tissue contractures, rebalance muscle forces, and may need bony correction based on the deficits of each case. Current literature suggests that early treatment leads to better outcomes. However, reported cases are scarce, and no consensus or gold standard for treatment exists. Therefore, long-term (multicenter) studies are needed to assess outcomes and standardize the treatment of such deformities whenever possible.
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http://dx.doi.org/10.1016/j.jhsa.2021.10.027DOI Listing
May 2022

Does the way of weight-bearing matter? Single-leg and both-leg standing radiographic and pedobarographic differences in pediatric flatfoot.

Gait Posture 2022 03 14;93:135-141. Epub 2022 Jan 14.

From the Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria.

Background: An exact definition is lacking for the term "weight-bearing" or different standing modalities when implementing foot radiographs for children and adults; moreover, only few studies have investigated the relationship between radiographic and pedobarographic measurements.

Research Question: We hypothesized that the method of weight-bearing in single-leg and both-leg standing positions could influence the measurement results in radiographs and the distribution of foot pressure.

Methods: This prospective study evaluated 33 children (66 feet) with flexible flatfoot deformities scheduled for subtalar screw arthroereisis surgery. Radiographs in the lateral and anteroposterior (AP) views were assessed independently in the single-leg and both-leg standing positions. Static pedobarography was performed as that for measuring weight-bearing. Standardized radiographic angles and pedobarographic data were analysed and correlated.

Results: There were differences in radiographic measurements between the single-leg and both-leg standing positions, including the AP talocalcaneal angle (p = 0.032), AP talus-first metatarsal base angle (p = 0.003), AP talus-first metatarsal angle (p = 0.003), lateral calcaneal pitch angle (p = 0.001), talus-first metatarsal index (p = 0.004), and talocalcaneal index (p = 0.029). Moreover, differences between these two standing modalities were found in most of the static pedobarographic data, including the contact area (p = 0001), maximal force (p = 0.001), and peak pressure (p = 0.007). Overall, medial foot pressure increased more in both-leg standing than in the single-leg standing position, whereas radiographic measurements showed a more pronounced flatfoot deformity in the single-leg standing position. The AP talus-first metatarsal angle was the only angle or index with a significant association to some pedobarographic measurements in both standing modalities.

Significance: As there are significant differences between single-leg standing and both-leg standing radiographic and static pedobarographic values, observers have to be precise in the definition of "weight-bearing" to gain reproducible and comparable study values in children and adults. We recommend acquiring both-leg standing foot radiographs because children with flexible flatfeet can stand more steadily in this position than in the single-leg standing position.
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http://dx.doi.org/10.1016/j.gaitpost.2022.01.009DOI Listing
March 2022

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases.

J Pediatr Orthop 2022 Feb;42(2):e181-e187

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria.

Background: The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures.

Methods: This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score.

Results: This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes.

Conclusions: Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration.

Level Of Evidence: Level IV-retrospective case series.
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http://dx.doi.org/10.1097/BPO.0000000000002013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8740600PMC
February 2022

The Effects of Preterm Birth on Musculoskeletal Health-Related Disorders.

J Clin Med 2021 Oct 29;10(21). Epub 2021 Oct 29.

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Speisingerstrasse 109, A-1130 Vienna, Austria.

Preterm birth is associated with various diseases and conditions which demand multidisciplinary medical care. Approximately 10% of all neonates are born prematurely with an increasing survival rate in almost all Western countries. This ongoing, yet desirable trend is creating new challenges for sufficient medical treatment regimens, which should be upheld throughout the patients' lives. Orthopedic surgeons are focused on musculoskeletal disorders and the improvement of patients' ability to cope with the challenges of everyday life. The most common conditions associated with preterm birth are cerebral palsy and a dysregulation of the calcium/phosphorus metabolism, which may lead to fractures. These diseases may vary greatly in their organic manifestation and clinical presentation. This demands multidisciplinary cooperation and parental support. Clinical management is aimed on the early enhancement of a patient's physical, as well as neurological condition, and to prevent the development of secondary musculoskeletal disorders. In this article, we give an overview of the current literature on the most common musculoskeletal disorders associated with preterm birth and critically discuss state of the art diagnostic standards and treatment algorithms.
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http://dx.doi.org/10.3390/jcm10215082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8584797PMC
October 2021

Splinting for the treatment of pediatric trigger thumbs: a pilot study.

Wien Med Wochenschr 2021 Aug 12. Epub 2021 Aug 12.

Department of Physical Medicine and Rehabilitation, Orthopaedic Hospital Speising, Vienna, Austria.

Controversy still exists whether conservative treatment may be a useful option for the treatment of pediatric trigger thumbs. We reviewed a random sample patient cohort with regard to success rates depending on whether flexible or fixed trigger thumbs were present. We performed a pilot study of 13 children (15 thumbs), who received a standardized treatment protocol including a custom-made thermoplastic splint for use during sleeping hours for a minimum of 3 months. Splinting was of only minor value for moderate and severe cases was but was beneficial for the majority of patients showing triggering symptoms only. It may thus be a reasonable option to delay surgery in infants with mild/flexible cases.
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http://dx.doi.org/10.1007/s10354-021-00860-8DOI Listing
August 2021

The Molding Hands of Time: Remodeling of Sagittal Plane Malunion After Pediatric Supracondylar Humerus Fractures.

J Pediatr Orthop 2021 Sep;41(8):e700

Department of Orthopedics and Trauma Surgery, Medical University Vienna Austria.

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http://dx.doi.org/10.1097/BPO.0000000000001895DOI Listing
September 2021

Editorial Commentary: The Hook Test Is More Accurate for Detecting Foveal Triangular Fibrocartilage Complex Tears but Not More Important Than the Trampoline Test.

Authors:
Sebastian Farr

Arthroscopy 2021 06;37(6):1808-1810

Wrist arthroscopy is a successful tool to diagnose and treat several intra-articular wrist pathologies. To assess the stability and integrity of the triangular fibrocartilage complex (TFCC), the most commonly injured structure in the ulnocarpal compartment, the trampoline and hook tests are frequently used in daily practice. However, their arthroscopic performance measures have not been well elucidated to date. While the hook test may primarily be seen as a sensitive tool to detect foveal TFCC tears, the trampoline test is of equal importance for the clinician because it can detect frequently occurring superficial (distal) tears in the peripheral TFCC area. As opposed to the hook test, however, the trampoline test might more easily lead to interrater disagreement since the rebound after probing is rather a continuum than a binary measure and might be related to a different severity of peripheral TFCC disruption. The combination of both tests should thus be pursued since they complement each other very well. Proper interpretation of the tests needs sufficient experience and should be done in concordance with the clinical evaluation (ie, fovea sign, distal radioulnar joint ballottement test). Hence, the hook test may be more accurate to detect foveal TFCC tears but all together not more important than the trampoline test to establish the correct diagnosis. For once, Captain Hook has won!
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http://dx.doi.org/10.1016/j.arthro.2021.04.011DOI Listing
June 2021

Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review.

J Clin Med 2021 May 27;10(11). Epub 2021 May 27.

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Speisingertrasse 109, A-1130 Vienna, Austria.

Introduction: Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents.

Materials And Methods: A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed.

Results: The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7-19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain ( = 31) and temporary paresthesia ( = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation.

Conclusion: Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.
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http://dx.doi.org/10.3390/jcm10112363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8199377PMC
May 2021

Current concepts in diagnosis and management of common upper limb nerve injuries in children.

J Child Orthop 2021 Apr;15(2):89-96

Orthopedic Hospital Speising, Department of Pediatric Orthopedics and Foot and Ankle Surgery, Vienna, Austria.

Peripheral nerve injuries (PNI) of the upper limb are a common event in the paediatric population, following both fractures and soft tissues injuries. Open injuries should in theory be easier to identify and the repair of injured structures performed as soon as possible in order to obtain a satisfying outcome. Conversely, due to the reduced compliance of younger children during clinical assessment, the diagnosis of a closed nerve injury may sometimes be delayed. As the compliance of patients is influenced by pain, anxiety and stress, the execution of the clinical manoeuvres intended to identify a loss of motor function or sensibility, can be impaired. Although the majority of PNI are neuroapraxias resulting in spontaneous recovery, there are open questions regarding certain aspects of closed PNI, e.g. when to ask for electrophysiological exams, when and how long to wait for a spontaneous recovery and when a surgical approach becomes mandatory. The aim of the article is therefore to analyse the main aspects of the different closed PNI of the upper limb in order to provide recommendations for timely and correct management, and to determine differences in the PNI treatment between children and adults.
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http://dx.doi.org/10.1302/1863-2548.15.200203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138792PMC
April 2021

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus-Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months.

Foot Ankle Surg 2022 Jul 17;28(5):557-563. Epub 2021 May 17.

Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising, Speisingerstraße 109, 1130 Vienna, Austria. Electronic address:

Background: This study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence.

Methods: 32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration.

Results: After a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction.

Conclusions: Advanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.
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http://dx.doi.org/10.1016/j.fas.2021.05.007DOI Listing
July 2022

Treatment of advanced stage osteochondrosis dissecans in the adolescent elbow using a hyaloronic acid-based scaffold: a case series of 5 patients.

Arch Orthop Trauma Surg 2021 Sep 4;141(9):1541-1549. Epub 2021 Feb 4.

Orthopedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Medical University Vienna, Speisingerstrasse 109, 1130, Vienna, Austria.

Introduction: Osteochondrosis dissecans (OCD) is considered to be one of the main causes for pain, discomfort and morbidity in the pediatric elbow joint. Few treatment options, such as microfracture or autologous transplantation, of osteochondral bone grafts have been described to address advanced OCD. The aim of this retrospective case series is to present preliminary clinical and radiologic findings following advanced stage OCD repair using a novel combination of a hyaluronic acid-based scaffold with autologous iliac crest bone grafting.

Materials And Methods: Five adolescents, who underwent treatment of OCD (grade 3 or 4 according to Nelson) using a combination technique of defect debridement, transplantation of cancellous iliac crest bone and application of a HYALOFAST® membrane (Anika Therapeutics S.r.L., Italy), were re-assessed using clinical and radiologic examinations (defect diameter, depth, sclerosis, congruency, fragmentation, dissection, radiolucency, growth plate status; MRI) after a minimum of 2 years (mean, 34 months; range, 24-45) postoperatively. Dedicated outcome scores (Numeric Rating Scale [NRS], Pediatric Outcome Data Collection Instrument [PODCI], Mayo Elbow Performance Score [MEPS], and Timmerman-Andrews Score [TIMM] were collected.

Results: All patients reported a NRS score of 0. The mean total TIMM, MEPS and PODCI (Global Functioning Scale) scores were 189 (range 165-200), 94 (range, 70-100), and 92 (range 83-98; normative score 47; range 35-55), respectively, indicating good to excellent clinical outcomes. The radiographic analysis showed overall improvements with regard to OCD width and depth reduction (35%, - 27-100%; 52%, 4-100%), but full resolution in only 2 of 5 cases. Elbow motion improved slightly after surgery. No complications were noted.

Conclusion: This study showed promising clinical short- to mid-term results in adolescent patients with advanced OCD using a novel surgical treatment combination. Radiographic results showed partial healing; hence, residual changes should be monitored over a longer period.
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http://dx.doi.org/10.1007/s00402-021-03773-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354908PMC
September 2021

Brachymetacarpia and brachymetatarsia: do we need to operate?

EFORT Open Rev 2021 Jan 4;6(1):15-23. Epub 2021 Jan 4.

Orthopedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Vienna, Austria.

Brachymetacarpia and brachymetatarsia are rare congenital presentations denoted by shortening of metacarpals and metatarsals respectively, in which the deformity usually presents around childhood/early adolescence.The aetiology is usually congenital besides several other syndromic or endocrinologic associations.Cosmetic issues such as absence of a normal-looking knuckle while making a fist or disruption of finger-tip curvature besides functional issues are the main indications for surgical intervention in brachymetacarpia.In the foot, apart from cosmetic issues, pain due to transfer metatarsalgia as well as callosities along with toe deformities which lead to difficulty of using footwear are the main indications for intervention.Lengthening of the affected bone, either acute with grafting or gradual, is the mainstay of treatment. Gradual lengthening can be either single-stage as in callotasis, or two-stage where the primary procedure is followed by bone grafting after the length has been achieved.Adolescence, specifically between 12 and 15 years, is the preferred period for surgical intervention in these cases. Cite this article: 2021;6:15-23. DOI: 10.1302/2058-5241.6.200087.
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http://dx.doi.org/10.1302/2058-5241.6.200087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845563PMC
January 2021

Mid-term foot function and pedobarographic analysis of 52 feet after polydactyly resection in childhood.

Bone Joint J 2021 Feb;103-B(2):415-420

Orthopaedic Hospital Speising, Laboratory for Gait and Movement Analysis, Vienna, Austria.

Aims: The aims of this study is to report the clinical and radiological outcomes after pre-, central-, and postaxial polydactyly resection in children from a tertiary referral centre.

Methods: All children who underwent resection of a supernumerary toe between 2001 and 2013 were prospectively enrolled and invited for a single re-assessment. Clinical parameters and several dedicated outcome scores (visual analogue scale (VAS), Paediatric Outcomes Data Collection Instrument (PODCI), Activities Scale for Kids (ASK), and American Orthopaedic Foot and Ankle Society Score (AOFAS)) were obtained, as were radiographs of the operated and non-operated feet along with pedobarographs.

Results: In all, 39 children (52 feet) with a mean follow-up of 7.2 years (3.1 to 13.0) were included in the study. Resection of a duplicated great toe was performed in ten children, central polydactyly in four, and postaxial polydactyly in 26. The mean postoperative VAS (0.7; 0 to 7), ASK (93.7; 64.2 to 100), and AOFAS range (85.9 to 89.0) indicated excellent outcomes among this cohort and the PODCI global functioning scale (95.7; 75.5 to 100) was satisfactory. No significant differences were found regarding outcomes of pre- versus postaxial patients, nor radiological toe alignment between the operated and non-operated sides. Minor complications were observed in six children (15%). There were seven surgical revisions (18%), six of whom were in preaxial patients. In both groups, below the operation area, a reduced mean and maximum force was observed. Changes in the hindfoot region were detected based on the prolonged contact time and reduced force in the preaxial group.

Conclusion: Excellent mid-term results can be expected after foot polydactyly resection in childhood. However, parents and those who care for these children need to be counselled regarding the higher risk of subsequent revision surgery in the preaxial patients. Also, within the study period, the plantar pressure distribution below the operated part of the foot did not return to completely normal. Cite this article: 2021;103-B(2):415-420.
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http://dx.doi.org/10.1302/0301-620X.103B2.BJJ-2020-1341.R2DOI Listing
February 2021

The prevalence of Vickers' ligament in Madelung's deformity: a retrospective multicentre study of 75 surgical cases.

J Hand Surg Eur Vol 2021 May 17;46(4):384-390. Epub 2021 Jan 17.

Shriners Hospitals for Children, Philadelphia Hand to Shoulder Center, Philadelphia, PA, USA.

In a retrospective multicentre study, we aimed to correlate clinical factors and findings on plain radiographs and MRI with the intraoperative presence of Vickers' ligament in Madelung's deformity. We screened the records, in which the absence or presence of Vickers' ligament was affirmatively indicated, of 75 consecutive operated extremities in 58 patients. In 83% a Vickers' ligament was observed intraoperatively. The whole bone Madelung type (as opposed to the distal type) and a distal radial notch were independent, significant predictors for the presence of the ligament. The correct Vickers detection rate using MRI was 85% of the 27 cases for which MRI was available. Thus, the MRI was a good but not perfectly reliable modality. We conclude that Vickers' ligament is present in the majority but not all cases with Madelung deformity. We advise that patients with a more severe type of Madelung's deformity and a distal radial notch should be monitored closely. IV.
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http://dx.doi.org/10.1177/1753193420981522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056710PMC
May 2021

Severe Pediatric Wrist Joint Sequelae following Blunt Trauma in the Presence of Chronic Regional Pain Syndrome.

J Hand Microsurg 2020 Dec 22;12(3):212-214. Epub 2019 Jun 22.

Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria.

The pediatric chronic regional pain syndrome (CRPS) type I is a recognized syndrome that follows a preliminary event (e.g., trauma, fracture) with amplified spontaneous or stimuli-induced extremity pain that differs from its adult form with rather favorable outcomes. Conservative treatment is usually indicated for CRPS treatment. We present a unique case of an adolescent girl who revealed severe wrist joint sequelae following a blunt trauma, complicated by a challenging CRPS resistant to treatment. Diagnostic wrist arthroscopy eventually revealed a massive cartilage degeneration and scapholunate tear as underlying causes for the pain and CRPS. It was decided to proceed with radioscapholunate wrist fusion, which promptly led to pain relief and disappearance of the CRPS. The relevance of this report is therefore to emphasize the possibility, against earlier thoughts, that well-indicated surgeries in pediatric CRPS patients may lead to prompt symptom improvement and may not be uniformly predicted to fail. With the clinical probability of a presence of an uncontrolled, symptomatic causative factor such as cartilage degeneration and chondrolysis, further early diagnostic and therapeutic interventions may be indicated to control the disease.
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http://dx.doi.org/10.1055/s-0039-1692324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773500PMC
December 2020

Results after treatment of congenital radioulnar synostosis: a systematic review and pooled data analysis.

J Pediatr Orthop B 2021 Nov;30(6):593-600

Department of Pediatrics Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.

Congenital radioulnar synostosis (CRUS) is one of the most common congenital disorders affecting the elbow and forearm, with the forearm being fixed in a range of positions usually varying from neutral rotation to severe pronation. The aim of this study, apart from a systematic review of all surgical procedures described for CRUS, is to derive any correlation between various influencing factors, outcomes and complications. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format by an electronic literature search of Ovid, MEDLINE and the Cochrane Library databases. Grading was according to the Newcastle-Ottawa scale and the Modified Coleman Methodology Score. Demographic data, surgical procedures, outcomes and complications were analyzed. Outcome data were pooled to establish means and ranges across all studies. Spearman correlations were performed. A total of 23 articles, showing a poor overall study quality (all Level of Evidence IV), met the inclusion criteria. A total of 374 forearms with a mean age of 6.7 years (2.0-18.8) were analyzed. Derotational surgeries were more commonly performed (91%) than motion-preserving surgeries (9%). The mean deformity improved from 64.8° pronation (-75° to 110°) to a mean of 2.8° pronation (-50° to 80°). In total, 17.9% of patients presented with complications. A significant correlation was noted between age and major complications, proximal osteotomies and complications, and postoperative loss of reduction and double level osteotomies as the primary treatment modality. Most of the complications occurred above the threshold of 65-70° of correction and in children 7 years and above. Surgery is essential to improve the quality of life of children with CRUS. However, each type of surgery is associated with complications, along with the respective hardware being used in rotation osteotomies. Caution is, nevertheless, warranted in interpreting these results in view of the inherent limitations of the included studies.
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http://dx.doi.org/10.1097/BPB.0000000000000841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8480519PMC
November 2021

Is the Apert foot an overlooked aspect of this rare genetic disease? Clinical findings and treatment options for foot deformities in Apert syndrome.

BMC Musculoskelet Disord 2020 Nov 28;21(1):788. Epub 2020 Nov 28.

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising, Speisingerstrasse 109, 1130, Vienna, Austria.

Background: Apert syndrome is characterised by the presence of craniosynostosis, midface retrusion and syndactyly of hands and feet, thus, synonymously referred to as acrocephalosyndactyly type I. Considering these multidisciplinary issues, frequently requiring surgical interventions at an early age, deformities of the feet have often been neglected and seem to be underestimated in the management of Apert syndrome. Typical Apert foot features range from complete fusion of the toes and a central nail mass to syndactyly of the second to fifth toe with a medially deviated great toe; however, no clear treatment algorithms were presented so far. This article reviews the current existing literature regarding the treatment approach of foot deformities in Apert syndrome.

State-of-the-art Topic Review: Overall, the main focus in the literature seems to be on the surgical approach to syndactyly separation of the toes and the management of the great toe deformity (hallux varus). Although the functional benefit of syndactyly separation in the foot has yet to be determined, some authors perform syndactyly separation usually in a staged procedure. Realignment of the great toe and first ray can be performed by multiple means including but not limited to second ray deletion, resection of the proximal phalanx delta bone on one side, corrective open wedge osteotomy, osteotomy of the osseous fusion between metatarsals I and II, and metatarsal I lengthening using gradual osteodistraction. Tarsal fusions and other anatomical variants may be present and have to be corrected on an individual basis. Shoe fitting problems are frequently mentioned as indication for surgery while insole support may be helpful to alleviate abnormal plantar pressures.

Conclusion: There is a particular need for multicenter studies to better elaborate surgical indications and treatment plans for this rare entity. Plantar pressure measurements using pedobarography should be enforced in order to document the biomechanical foot development and abnormalities during growth, and to help with indication setting. Treatment options may include conservative means (i.e. insoles, orthopedic shoes) or surgery to improve biomechanics and normalize plantar pressures.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1186/s12891-020-03812-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700708PMC
November 2020

Treatment of Mild Ulnar Longitudinal Deficiency with a Z-Shaped Ulna Lengthening Osteotomy: A Report of 2 Cases.

JBJS Case Connect 2020 Jul-Sep;10(3):e2000080

1Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria.

Case: Two adolescent patients with therapy-refractory ulnocarpal wrist pain because of mild ulnar longitudinal deficiency (ULD; ulna hypoplasia type I according to Bayne) underwent surgical treatment with a Z-shaped ulna lengthening osteotomy and interposition of the iliac crest bone graft. Long-term ULD correction and pain-free motion were maintained in both patients.

Conclusion: Pediatric patients with symptomatic mild ULD are often mistaken for ulnar negative variance with radioulnar impingement and may be successfully treated using this newly described technique. The ulnar malangulation is corrected at the apex of the deformity, and the clinical and radiographic outcomes have been successful.
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http://dx.doi.org/10.2106/JBJS.CC.20.00080DOI Listing
April 2021

Temporary epiphysiodesis in adolescent patients with ulnocarpal impaction syndrome: a preliminary case series of seven wrists.

J Pediatr Orthop B 2021 Nov;30(6):601-604

Orthopaedic Hospital Speising, Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Vienna, Austria.

Adolescents with ulnar positive variance can develop ulnocarpal symptoms due to ulnocarpal impaction syndrome. Common treatment methods are conservative therapy, distal ulna epiphysiodesis or eventually ulnar shortening osteotomy. The aim of this preliminary case series was to investigate a recently described, new therapeutic approach using a reversible, temporary epiphysiodesis technique, following the principles of guided growth. Seven cases with the diagnosis of a painful ulnar positive variance, which underwent a temporary epiphysiodesis, were retrospectively evaluated. These cases consisted of four individual patients who received an intraoperatively customized plate fixation to slow down growth. The following parameters were collected: diagnosis, age at surgery, age at explantation, growth plate status at explantation, ulnar variance before and after surgery, complications and any clinical and radiological abnormalities. The radiological measurements of ulnar variance were performed according to the Gelbermann method. The seven investigated cases (average age at surgery 12.4 years; average age at explantation 14.7 years), in which a temporary epiphysiodesis was performed, showed an average ulnar variance of +3.9 mm (range: from +1.9 mm to +6.1 mm) before the start of therapy. After explantation, an average ulnar variance of +0.1 mm (range: from -3.2 mm to +5.0 mm) was observed, which corresponds to an average reduction/improvement of -3.8 mm (range: from -0.5 mm to -9.3 mm). The ulnocarpal wrist complaints were significantly reduced after the intervention. One case needed a secondary ulnar shortening osteotomy. The described method of a temporary, reversible epiphysiodesis is an elegant, less invasive technique to correct the ulnar positive variance without irreversibly closing the growth plate. In case of therapy failure, a secondary ulna shortening osteotomy is still possible.
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http://dx.doi.org/10.1097/BPB.0000000000000805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8480517PMC
November 2021

Peripheral Nerve Compression Syndromes in Children.

J Hand Surg Am 2020 Sep 6;45(9):857-863. Epub 2020 Jul 6.

Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria. Electronic address:

Nontraumatic neuropathies of the upper limb are rare in children. In this paper, we present the latest updates in this field and also critically review the diagnosis and treatment of nerve compression syndromes in children. This review describes the most common manifestations including idiopathic carpal tunnel syndrome (CTS), CTS occurring as a component of lysosomal storage diseases (mucopolysaccharidosis) and hereditary neuropathies, ulnar nerve neuropathy, and atraumatic radial nerve neuropathies.
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http://dx.doi.org/10.1016/j.jhsa.2020.04.028DOI Listing
September 2020

Evaluation of radiological instability signs in the distal radioulnar joint in children and adolescents with arthroscopically-verified TFCC tears.

Arch Orthop Trauma Surg 2020 Jul 7;140(7):993-999. Epub 2020 May 7.

Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising, Medical University Vienna, Speisingerstrasse 109, 1130, Vienna, Austria.

Introduction: Recent reports in the adult literature reported the use of standardized radiographic measurement techniques to determine distal radioulnar joint (DRUJ) instability. The aim of this study was to evaluate the efficacy and accuracy of (1) the MRI-based modified radioulnar ratio technique and (2) the pisoscaphoid (PiSca) and radioulnar (RaUl) distances in true lateral radiographs in children and adolescents with arthroscopically-verified TFCC tears.

Materials And Methods: We retrospectively assessed lateral wrist radiographs and axial MRI sequences of 18 adolescent patients (22 wrists) who had arthroscopically-confirmed TFCC tears and compared them to similar imaging of a control group of 28 healthy patients (28 wrists). Three raters assessed the images twice in a 2-week interval. Intraclass correlation coefficients (ICCs), unifactorial ANOVA, and ROC analysis were performed with regards to the different radiographic variables.

Results: The interrater ICCs were almost perfect for all measurements except RaUl1, which showed a substantial agreement (0.751) among the three observers. The intrarater ICCs were almost perfect when measuring PiSca and MRI, and substantial to almost perfect for RaUl. Pearson's correlation showed a moderate, positive correlation between PiSca and RaUl distances (r = 0.608; p < 0.001), and a moderate, negative correlation between RaUl distance and MRI shift (r = - 0.486; p = 0.010). When the three core groups (peripheral, central tear, controls) were compared to each other regarding the radiographic instability parameters, only the MRI shift revealed a statistically significant difference (p = 0.003). Comparisons revealed significant differences between patients and controls (p = 0.004) and peripheral tears vs. controls (p = 0.001 and p = 0.010). The ROC analysis revealed a significant AUC only for the MRI (AuC 0.787 and p = 0.002).

Conclusions: Children and adolescents with peripheral TFCC tears showed significantly increased instability parameters in MRI compared to controls. These measurement techniques are no replacement for a thorough clinical examination but may be helpful for indicating diagnostic wrist arthroscopy in ambiguous cases.

Level Of Evidence: Level III; Diagnostic.
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http://dx.doi.org/10.1007/s00402-020-03470-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295725PMC
July 2020

Letter to the Editor regarding "Does overcorrection cause any negative effect on pediatric missed Monteggia lesion?"

Eur J Orthop Surg Traumatol 2020 08 25;30(6):1025-1026. Epub 2020 Apr 25.

Department of Pediatric Orthopedics and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy.

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http://dx.doi.org/10.1007/s00590-020-02673-8DOI Listing
August 2020

Complications of hardware removal in pediatric upper limb surgery: A retrospective single-center study of 317 patients.

Medicine (Baltimore) 2020 Jan;99(5):e19010

Orthopedic Hospital Speising, Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Vienna, Austria.

Previous studies indicated that hardware removal may lead to increased morbidity and therefore, at least in adults, remains questionable for certain indications. However, risks such as corrosion or local reactions may be less likely in younger patients with current, improved hardware materials. We sought to retrospectively determine complication rates of hardware removal in pediatric upper limb surgery, and establish potential risk factors for increased morbidity.All children and adolescents who underwent inpatient hardware removal under anesthesia after previous upper limb surgery between 2002 and 2016 were retrospectively evaluated. The following details were extracted at the latest follow-up: demographics, implant location, hardware material, duration of surgery, duration of hardware in situ, and any complications graded according to Goslings et al (grade 0-5) and Sink et al (grade 1-5), respectively. Correlations were calculated to establish potential relationships between specific outcome parameters (e.g., location, duration of surgery etc.) and complication grades.A total of 2089 children were evaluated of whom 317 patients with 449 interventions (mean age 9.4 years) fulfilled the inclusion criteria for this study. Overall, 203 K-wires (46%), 97 plates (22%), 102 external fixators (23%), 32 intramedullary nails (7%), 6 screws (1%), 4 cerclages (1%) and 1 pin (0.2%) were removed; most common locations were the forearm (34%) and humerus (24%). The mean duration of surgery was 40 minutes (± 50.9), mean time in situ was 194 days (± 319.6). Complication rates were low overall, with most being grade 0 (n = 372; 83%) or 1 (n = 60; 13%) according to Goslings et al and grade 1 (n = 386; 86%) and 2 (n = 42; 9%) according to Sink et al. No severe complications were observed. The following predictors were related to the severity of the complications in linear regression analysis: more distal localizations, external fixators, longer duration of surgery and female sex.Hardware removal under anesthesia in the pediatric upper extremity has produced a low complication rate with no severe complications and can thus be considered to be safe. Increased morbidity occurred in more distal localizations, external fixators, longer surgeries and females.Level of Evidence: Therapeutic, Level IV.
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http://dx.doi.org/10.1097/MD.0000000000019010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004601PMC
January 2020

Perinatal outcomes of infants with congenital limb malformations: an observational study from a tertiary referral center in Central Europe.

BMC Pregnancy Childbirth 2020 Jan 13;20(1):35. Epub 2020 Jan 13.

Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria.

Background: Congenital limb malformations are rare, and their perinatal outcomes are not well described. This study analyzed the perinatal outcomes of infants with congenital limb malformations.

Methods: All infants with congenital limb malformations who underwent prenatal assessment and delivery at our tertiary referral center from 2004 through 2017 were retrospectively identified. Neonatal outcome parameters were assessed, and the predictors of worse perinatal outcomes were determined.

Results: One hundred twenty-four cases of congenital limb malformations were identified, of which 104 (83.9%) were analyzed. The upper limb was affected in 15 patients (14.4%), the lower limb in 49 (47.1%), and both limbs in 40 (38.5%) patients. A fetal syndrome was identified in 66 patients (63.5%); clubfoot and longitudinal reduction defects were the most frequent malformations. In total, 38 patients (36.5%) underwent termination, seven (6.7%) had stillbirth, and 59 (56.7%) had live-born delivery. Rates of preterm delivery and transfer to the Neonatal Intensive Care Unit were 42.4 and 25.4%, respectively. Localization of the malformation was a determinant of perinatal outcome (P = .006) and preterm delivery (P = .046).

Conclusions: Congenital limb malformations frequently occur bilaterally and are associated with poor perinatal outcomes, including high rates of stillbirth and preterm delivery. Multidisciplinary care and referral to a perinatal center are warranted.
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http://dx.doi.org/10.1186/s12884-020-2720-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958570PMC
January 2020

Outcomes after thumb carpometacarpal joint stabilization with an abductor pollicis longus tendon strip for the treatment of chronic instability.

Arch Orthop Trauma Surg 2020 Feb 6;140(2):275-282. Epub 2019 Nov 6.

Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Vienna-Speising; Affiliated to Medical University Vienna, Speisingerstrasse 109, 1130, Vienna, Austria.

Introduction: Instabilities of the thumb carpometacarpal (CMC) joint, caused by idiopathic ligamentous hyperlaxity, trauma or other conditions may lead to pain, functional impairment and eventually osteoarthritis. Several techniques have been described to enhance stability of the CMC 1. The aim of this study was to evaluate postoperative outcomes after CMC 1 joint stabilization using a soft-tissue procedure in patients with chronic instability.

Materials And Methods: This study was designed as a retrospective study with a single follow-up visit after a minimum of 1 year postoperatively. All patients who underwent stabilization of the CMC 1 with an abductor pollicis longus (APL) tendon strip for chronic, habitual instability were re-assessed using clinical examination, dedicated outcome scores [Visual Analogue Scale (VAS); The Disability of the Arm, Shoulder and Hand (DASH) score; Nelson score; Kapandji opposition score], grip and pinch strength measurements, and radiographic examination.

Results: 12 patients (15 operated thumbs) with a mean age at surgery of 23.2 (± 9.3) years were included after a mean follow-up period of 3.5 (± 1.3) years. The postoperative outcomes indicated excellent results, with a mean DASH score of 13.3 (± 11.3), VAS 1.1 at rest (and 2.8 during stress) and Nelson score of 87.7 (± 11.3). Postoperative grip, pinch strength and passive stability were not significantly different between operated and non-operated sides (p = 0.852; p = 0.923 and p = 0.428, respectively). We observed one case of recurrent instability besides no other complications. However, patients with trapezium hypoplasia (5 of 12) were more prone to signs of radiographic instability during stress testing.

Conclusions: Thumb carpometacarpal stabilization with an APL tendon strip yielded excellent clinical outcomes and low morbidity in the mid-term. However, long-term follow-up is needed to assess specifically whether patients with trapezium hypoplasia may be more prone to clinical symptom recurrence than those with normal anatomy.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s00402-019-03302-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989670PMC
February 2020

A 3-Dimensional Model of Zonally Organized Extracellular Matrix.

Cartilage 2021 12 2;13(2_suppl):336S-345S. Epub 2019 Aug 2.

Karl Chiari Lab for Orthopaedic Biology, Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria.

Objective: Functional cartilage repair requires the new formation of organized hyaline cartilaginous matrix to avoid the generation of fibrous repair tissue. The potential of mesenchymal progenitors was used to assemble a 3-dimensional structure in vitro, reflecting the zonation of collagen matrix in hyaline articular cartilage.

Design: The 3-dimensional architecture of collagen alignment in pellet cultures of chondroprogenitors (CPs) was assessed with Picrosirius red staining analyzed under polarized light. In parallel assays, the trilineage capability was confirmed by calcium deposition during osteogenesis by alizarin S staining and alkaline phosphatase staining. Using reverse transcription-quantitative polymerase chain reaction (RT-qPCR), mRNA levels of ALP, RUNX2, and BGLAP were assessed after 21 days of osteoinduction. Lipid droplets were stained with oil red O and adipogenic differentiation was confirmed by RT-qPCR analysis of PPARG and LPL gene expression.

Results: Under conditions promoting the chondrogenic signature in self-assembling constructs, CPs formed an aligned extracellular matrix, positive for glycosaminoglycans and collagen type II, showing developing zonation of birefringent collagen fibers along the cross section of pellets, which reflect the distribution of collagen fibers in hyaline cartilage. Induced osteogenic and adipogenic differentiation confirmed the trilineage potential of CPs.

Conclusion: This model promotes the differentiation and self-organization of postnatal chondroprogenitors, resulting in the formation of zonally organized engineered hyaline cartilage comparable to the 3 zones of native cartilage.
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http://dx.doi.org/10.1177/1947603519865320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8804753PMC
December 2021
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