Femoral varus derotational osteotomy in cerebral palsy

The records concerning 64 hips in 36 cerebral palsy patients treated with varus derotational osteotomy (VDO) alone (2 hips), VDO with muscle releases (adductors, iliopsoas, hamstrings; 46 hips), and VDO, soft-tissue release, and innominate bone osteotomy (16 hips) were reviewed. There were 23 quadriplegic and 13 diplegic patients. Average age at surgery was 7 years. Average follow-up period was 3.8 years. All hips that had VDO, soft-tissue release, and innominate osteotomy were stable at follow-up. Nine hips of the 44 treated with VDO and muscle release alone dislocated, and required second osteotomies.

Fever as the presenting complaint of travellers returning from the tropics

We investigated prospectively the cause of fever in patients requiring hospitalization after returning from the tropics. All consecutive admissions (n = 195) with oral temperature > 37.0 degrees C at the time of admission were enrolled. Final diagnosis as recorded on the discharge summary by the attending physician and results of any relevant laboratory or radiological investigations were recorded on standard proforma. Malaria accounted for 42% of admissions; two patients had returned to Britain more than 6 months before presentation. The second largest group was assumed to have a non-specific viral infection (25%). Cosmopolitan infections (urinary tract infection, community-acquired pneumonia, streptococcal sore throat, etc.) accounted for 9%. Coincidental infections (schistosomiasis, filariasis, intestinal helminths) were found in 16%. Serology was positive for HIV infection in 3%. The most useful investigation was a malaria film, which was positive in 45% of cases in which it was performed. The combination of thrombocytopaenia (platelet count < 100 x 10(9)) and hyperbilirubinaemia (bilirubin > 18 IU/ml) were useful predictive markers of malaria: all 23 patients with both abnormalities had positive malaria films. Malaria must be excluded in any febrile patient returning from the tropics. In the absence of a positive malaria film, the combination of a low platelet count and raised bilirubin may suggest the need for an empirical course of therapy.

Combined hip surgery in cerebral palsy patients

Seventeen cases of dislocated/subluxated hips in 14 cerebral palsy patients that were relocated by the combined hip procedure were reviewed. The combined hip procedure includes varus derotation osteotomy, open reduction, innominate bone osteotomy, adductor releases, and iliopsoas recession, all done at one stage. Eleven patients were spastic quadriplegic, 1 was spastic diplegic; and 2 were spastic hemiplegic. Average age at operation was 10 years. Average follow-up was 3 years. A total of 16 hips (94%) remained stable at follow-up with almost no change in center edge angle and the migration percentage, although the neck shaft angle remodeled over time. We conclude that the combined hip procedure is effective in maintaining hip reduction in cerebral palsy patients.

Minor knee trauma as a possible cause of asymmetrical proximal tibial physis closure. A case report

An unusual case is presented in which minor soft tissue injury may have caused premature asymmetrical closure of the proximal tibial physis resulting in a 30 degrees genu recurvatum that necessitated corrective osteotomy. Awareness of the possibility of a hidden physeal injury in the presence of soft tissue injury and a normal radiograph may lead to its early recognition and treatment.

Histological and radiographic determination of the age of physeal closure of the distal femur, proximal tibia, and proximal fibula of the New Zealand white rabbit

A longitudinal study was performed in a series of 124 New Zealand White rabbits to determine the radiographic versus the histologic age of closure of the growth plates of the distal femur, proximal tibia, and proximal fibula. Periodic assessment was made by standard radiographs and histological studies. Histologically, growth plates in the distal femur closed at 19-24 weeks; growth plates in the proximal tibia, at 25-32 weeks; and growth plates in the proximal fibula, at 26-32 weeks. Radiographically, evidence of closure of growth plates in the distal femur occurred at 20-23 weeks; in the proximal tibia, at 22-27 weeks; and in the proximal fibula, at 23-31 weeks. A discrepancy in age between radiographic and histologic closure of the growth plate occurred in 3.6% of the femora, 10.9% of the tibias, and 16% of the fibulas.

Diagnosis of osteoid osteoma in the child

Fifty-two cases of osteoid osteoma in children under 5 years of age were collected from the English literature and reviewed, along with seven cases from the Hospital for Joint Diseases. Analytic emphasis was placed on the clinical and radiologic difficulties encountered in the diagnosis of osteoid osteoma in children. Diagnosis is especially challenging in patients that are just beginning to walk. Osteoid osteoma is often confused with many other entities. Although pain was the most frequent clinical manifestation, it was absent in 12% of cases; limp tenderness, swelling, and atrophy were the next most frequent findings. When standard radiographic findings proved negative for this condition, technetium bone scans were of considerable efficacy in identifying the tumor. When used, computerized tomograms permitted visualization and precise localization of the tumors in all cases. Bone deformities and leg-length discrepancies were found in more than 25% of the cases. Mini-block excision is recommended at diagnosis.

Osteoid osteoma under the age of five years. The difficulty of diagnosis

Ninety-one cases of histologically confirmed osteoid osteoma were collected during an 11-year period; of them, seven (7.6%) had onset of symptoms while younger than five years of age. Special diagnostic difficulties were found in this specific age group: most cases were misdiagnosed or diagnosed incorrectly. The time between the onset of symptoms and the diagnosis varied from three months to five years. Although pain was present in six patients, in four cases, other concomitant signs and symptoms attracted more attention and led to a misdiagnosis and unnecessary invasive procedures. Gait disturbance (limp) was the second most frequent sign and was always present when the lower extremity was affected. In five cases, initial radiographs were not conclusive. Bone scans were very sensitive and conclusive in three cases where radiographs were atypical. Computerized tomograms always located the tumor.

Tarsal navicular position after complete soft-tissue clubfoot release

The navicular position was evaluated (according to Simons' criteria) on anteroposterior and lateral roentgenograms of 45 clubfeet that were treated with complete soft-tissue release without internal fixation. The evaluation was performed an average of 28 months after surgery. Position of the navicular correlates well with the functional rating score system. Navicular position can be viewed as an indicator for clubfoot correction. Internal fixation of the talonavicular joint was correlated with favorable correction of deformity.

Complete soft-tissue clubfoot release with and without internal fixation

Two groups of patients who underwent soft-tissue release of clubfoot are compared. In group I, internal fixation (two Kirschner wires) was used for 6 weeks to retain correction of clubfoot. In group II, no internal fixation was used. Patients from the two groups were operated on by one surgeon using the same procedure. Because there was no statistically significant difference in functional result between the two treatment groups (P = .08; Mann-Whitney Test), the authors recommend avoiding internal fixation (with all the associated problems) in cases of uncomplicated clubfoot, and encourage early removal of the cast and frequent manipulations to prevent stiffness of the joints and reduce the recurrence rate.

Avascular necrosis of the femoral head as sequela of fracture of the greater trochanter. A case report and review of the literature

After a fall from a tree, a 12-year-old boy sustained a fracture of the greater trochanter and was subsequently treated by open reduction. Twenty months after surgery, the hip developed to a flexion contracture, limb-length discrepancy, a collapsed, irregular-shaped femoral head with sclerotic areas, and a metaphyseal cyst. A growing child with avascular necrosis of the femoral head after fracture of the greater trochanter seems not to have been reported in the English language literature.

Detection of varicella-zoster virus DNA using the polymerase chain reaction in an immunocompromised patient with transverse myelitis secondary to herpes zoster

A case of herpes zoster transverse myelitis is described in which the clinical diagnosis was confirmed by demonstrating the presence of varicella-zoster virus (VZV) DNA in the cerebrospinal fluid (CSF) by amplification using the polymerase chain reaction. This case illustrates the potential role of the selective amplification of VZV DNA from CSF in contributing to the diagnosis of neurological complications associated with VZV infection.

Application of information technology to the laboratory reporting of communicable disease in England and Wales

The transmission of laboratory reports from diagnostic medical microbiology laboratories to the PHLS Communicable Disease Surveillance Centre (CDSC) is a major component of surveillance of communicable disease in England and Wales. Information on more than 3800 types of organism is held on the CDSC database (labBASE). The volume of reporting has risen steadily during the last 17 years and electronic reporting via epiBASE is beginning to replace postal reporting. Computers are used extensively to collate and analyse data for surveillance reports which are disseminated via the Communicable Disease Report, Epinet and other means. Recent developments include the computer-aided detection of temporal clusters and the establishment of an electronic library of surveillance data.

Pavlik harness versus Frejka splint in treatment of developmental dysplasia of the hip: bicenter study

A bicenter study was conducted to compare the results of treatment in developmental dysplasia of the hip (DDH) with Frejka splint versus Pavlik harness. Eighty-four dislocated hips were treated by the Frejka splint, and 48 dislocated hips were treated by the Pavlik harness. Failure of reduction was 10% with the Frejka splint and 12% with the Pavlik harness. Avascular necrosis (AVN, mostly type 1) was detected in 7% of Frejka patients versus 6% in Pavlik patients. The Frejka splint is simpler to use and if properly applied may be as safe as the Pavlik harness for DDH treatment.

Changing patterns of respiratory disease in HIV positive patients in a referral centre in the United Kingdom between 1986-7 and 1990-1

BACKGROUND

Respiratory illness is a significant contributor to morbidity and mortality in patients with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS). It has been suggested that Pneumocystis carinii pneumonia is no longer the most frequent cause of respiratory disease in this group because of widespread use of prophylaxis and anti-retroviral drugs.

METHODS

A retrospective comparison of the diagnoses in HIV 1 antibody positive patients with respiratory illness admitted to a major UK centre in 1986-7 and 1990-1 was carried out to identify changes in patterns of respiratory disease.

RESULTS

In the 1986-7 period there were 73 patients, of whom none received zidovudine or prophylaxis for pneumocystis pneumonia while in the 1990-1 period there were 122 patients. One hundred and ninety patients (98%) were male homosexuals. Pneumocystis pneumonia remained the commonest respiratory disease, comprising 68% of all diagnoses in the 1986-7 period and 48% in the 1990-1 period. Bacterial infections (bronchitis and pneumonia) were seen more commonly in the 1990-1 period (23%) than in the 1986-7 period (14%), as was pulmonary Kaposi's sarcoma (12% in 1990-1 and 4% in 1986-7). Mycobacterial infection remained uncommon (4% in 1986-7 and 6.5% in 1990-1).

CONCLUSION

Despite widespread use of zidovudine and prophylaxis, pneumocystis pneumonia remains the commonest respiratory disease in homosexual men.

Use of tissue expansion in clubfoot surgery

Tissue expansion was used successfully to prepare adequate soft tissue for closure following a difficult clubfoot correction. The gradual expansion was done weekly at the outpatient clinics (average 3-4 months). The procedure proved to be useful in severe cases of clubfoot.

Excision of the posterior tibial tendon during clubfoot release

In 50 patients (72 clubfeet), the posterior tibial tendon was excised during complete soft tissue clubfoot release. The end results after an average of 3 years were graded as follows: 55.5% excellent, 29.3% good, 8.3% fair, and 6.9% poor. Heel varus and forefoot adduction were the main causes for recurrence. Heel valgus occurred in one foot. Excision of the posterior tibial tendon is safe, does not lead to overcorrection, and may prevent further scarring created when the tendon is lengthened.

Postpoliomyelitis syndrome problems of knee function: a review

Postpoliomyelitis syndrome describes a ¿new¿ weakness, unrelated to any other neurological or medical disorder. It appears 10 to 15 years or more after recovery from the initial paralysis. This new weakness interferes with activities of daily living. The management of postpoliomyelitis syndrome may include orthotics, special exercises, a change in their lifestyle, or a combination of these regimens. This article is especially concerned with knee joint stabilization in various deformities that are weakened by the postpoliomyelitis syndrome.

Tips of the trade. Computerized tomography--guided excision of osteoid osteoma

Excision of osteoid osteoma nidus utilizing a Kirschner wire for preoperative marking of the lesion and a CORB biopsy set for excision is described. The procedure is performed in a computed tomographic scan unit under local anesthesia and results in minimal postoperative discomfort.

Osgood-Schlatter lesion: fracture or tendinitis? Scintigraphic, CT, and MR imaging features

To determine whether the Osgood-Schlatter lesion (OS) is produced by avulsion fracture or injury to the patellar tendon, all images obtained in 28 cases of OS in 20 patients (16 scintigrams, 34 computed tomographic [CT] scans, and 27 magnetic resonance [MR] images) were retrospectively analyzed. In 21 cases, imaging was performed before and after treatment; in 20 cases, relief from pain was complete at the time of repeat examination. In all patients (100%), abnormal size of the tendon, decreased attenuation, and increase in signal intensity were compatible with the CT and MR imaging appearance of tendinitis. Distended deep infrapatellar bursa was a frequent finding, particularly on MR studies. These abnormalities had partially disappeared at follow-up examination. An ossicle was seen in only nine of 28 cases (32%); in three of seven cases with follow-up, the ossicle remained nonunited to the tibial tuberosity on follow-up studies despite relief from symptoms. This implies that healing of fracture is not essential for relief from symptoms. These results strengthen the argument that in most cases of OS, insult to the tendon and associated soft tissues, rather than avulsion fracture, causes OS.

Pelvic osteotomies in children

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New method of limb deformities correction in children

A new "bloodless" technique (Ilizarov) was used to correct 36 limb deformities in 29 children. There were six leg length discrepancies, five achondroplasias, four deformed feet, five joint contractures, one rotational deformity of tibia, and in three the apparatus was used as an external fixator after corrective osteotomy. Lengthening was accomplished in 15 of the 16 procedures (93%). Average increase in femur length was 10 cm (32%), in tibial length 7.5 cm (30%), in humerus 11 cm (40%). Bony union was achieved in two out of five pseudoarthroses. Four deformed feet were fully corrected. Joint contractures were corrected in four out of five. The complication rate is as high as in other methods but with the Ilizarov apparatus, longer segments of bone were lengthened and more complex deformities were treated. Complications lessened as experience was gained.

Revision surgery in clubfeet

The reoperated clubfeet of 29 children aged one to 12 years were reviewed. The surgical procedure most often used in revision surgery was recomplete soft-tissue release alone or combined with plantar release, calcaneocuboid fusion, and capsulotomies of the navicular-first cuneiform-first metatarsal joint. In 27 of 29 feet, acceptable results were achieved. Nineteen were excellent and good results. An algorithm that suggests surgical solutions to a variety of clubfoot deformities in different age groups has been developed, as well as an objective rating system, to evaluate the long-term results of revision surgery of clubfeet.

Discitis in children

Discitis is usually a benign, self-limiting disease that is frequently misdiagnosed. The disease usually leads to spontaneous disc-space narrowing and end-plate irregularity, which require no treatment and rarely cause morbidity.

The Ilizarov apparatus for treatment of melorheostosis. Case report and review of the literature

Traditional conservative and surgical methods of treatment of melorheostosis, such as manipulations, plaster casts, soft-tissue releases, capsulotomies, and osteotomies cause a high recurrence rate. In a 12-year-old girl, flexion contracture of a knee with limb inequality caused by melorheostosis was corrected successfully with the Ilizarov distraction apparatus.

The Ilizarov technique in correction of complex foot deformities

The Ilizarov technique allows new histogenesis of soft tissue as well as bone. This process, extended to the foot, has allowed correction of complex three-dimensional deformities. The method is described and demonstrated to illustrate the action and limitations as well as the complications of the method.

Ilizarov technique in treatment of congenital hand anomalies. Two case reports

An Ilizarov apparatus was successfully used in the treatment of a six-year-old child with a radially deviated hand caused by congenital pseudoarthrosis of the distal radius after previous traditional surgery failed. The limb length was restored, the pseudoarthrosis healed, and the deviated hand corrected. A second child, five years old, with Poland's syndrome, had a 90 degrees flexion contracture of the wrist that was treated with the Ilizarov apparatus. The flexion contracture was gradually corrected. It seems that the Ilizarov apparatus can be an important tool in the treatment of complex limb deformities.

Preventing and overcoming equinus contractures during lengthening of the tibia

The new technique of leg lengthening and deformity correction with different types of external fixators has given the orthopedic surgeon a tool that allows correction of very difficult deformities and leg length discrepancies of the lower extremity. Dissemination of this knowledge has demonstrated that there are many associated problems with these techniques: one of which is resulting equinus deformity after correcting the tibia. The shortened soleus-gastrocnemius-achilles tendon complex is the cause of this deformity. Several techniques are suggested on avoiding this complication and how to correct it once it has occurred.

Treatment of complex limb deformities in children with the Ilizarov technique

Twenty-nine children underwent 36 Ilizarov procedures for a variety of limb deformities. We present the results in 11 patients, six with leg length discrepancies and five with achondroplasia, who underwent lengthening procedures using the Ilizarov method. Lengthening was accomplished in 15 of the 16 procedures (93%). Average increase in femur length was 10 cm (32%), in tibial length 7.5 cm (30%), in humerus length 11 cm (40%). Eleven complications occurred. The most common were pin tract infections (4), joint contractures (2), transient nerve injury (4), premature consolidation (5), and three fractures of the regenerated bone. The complication rate was as high as in other methods, but with the Ilizarov apparatus longer segments of bone were lengthened and more complex deformities were treated. The number of complications were lessened as experience was gained.

Pavlik harness pathology

Several complications following Pavlik harness splintage for congenital dislocated hips have been described. Two cases are reported where prolonged Pavlik splintage without concentric hip reduction caused posterior acetabular deficiency. Open reductions were required in both cases to correct deformity.

Fractional lengthening of the flexor tendons in clubfoot surgery

Massive scarring of the Z-lengthened flexor digitorum and flexor hallucis longus is a constant finding in clubfoot surgery. A method of fractional lengthening of the tendons is described. This method has been proven effective in preventing this complication.

Complications in clubfoot surgery

Thirty percent to 50% of clubfeet will not respond to conservative treatment and will require surgery. The average failure rate in clubfoot surgery is 25% (range, 13% to 50%). Many complications can occur during surgery and postoperatively. Preoperative planning of the appropriate skin incision and special attention to wound closure may prevent some of these complications. Awareness of the multiple complications that can occur such as cavus, persistent adductus, overcorrection of the hindfoot, and recurrent deformity allows the surgeon to prepare and plan for these often unavoidable problems.

Growing pains

Growing pains are leg pains that appear in a significant number of children 3 to 12 years of age and cease with maturity. They occur at the end of the day or may awaken the child from sleep. Their pathogenesis is unknown. The diagnosis should be one of exclusion only, and treatment is supportive.

Cannulated blade plate for proximal femoral varus osteotomy

Fixation of the osteotomy site in the proximal femur is technically demanding. A new system, which includes cannulated chisels and a cannulated one-piece plate that can be inserted over a guide wire, is suggested. The new system simplifies the procedure and provides stable fixation.

Ilizarov technique in correction of foot deformities: a preliminary report

Four deformed feet in three patients were corrected completely using the new limited intervention technique of Ilizarov. One foot in the younger patient was corrected by soft tissue distraction only. In three feet in the older patients V osteotomies were needed to initiate the distraction. Two complications occurred: herpes simplex infected two of the osteotomy sites, which were treated successfully with local treatment. The detailed method and indications are outlined.

Pediatric update #14. Functional rating system for evaluating the results of clubfoot surgery

The results obtained in a study of 32 patients with 45 idiopathic clubfoot deformities treated by complete soft-tissue release between 1985 and 1986 were investigated retrospectively. The evaluation was based on a specifically designed functional rating system. The results were graded as follows: 51% excellent, 25% good, 18% fair, and 6% poor.

The use of a tissue expander in club-foot surgery. A case report and review

Primary skin closure after the surgical correction of severe club-foot may be difficult. We describe the use of a tissue expander to provide sufficient skin, and review some aspects of the use of the method.

Pediatric update #12. A simplified method for percutaneous epiphysiodesis

Nine patients have undergone percutaneous epiphysiodesis using a 4.5-mm drill and image intensification fluoroscopy. The minimal surgical exposure resulted in minimal postoperative discomfort, excellent cosmesis, and complete closure of the physis in all patients in three to five months. No complications were encountered. The procedure is easy to perform and reliable.

Re-do clubfoot: surgical approach and long-term results

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Neck metaphyseal angle guidance in proximal femoral varus osteotomy

An angle within the femoral arch is defined, and its line is described in selecting the osteotomy site and the position of the fixation device in performing a femoral varus osteotomy. This neck metaphyseal angle was measured with varying degrees of rotation on seven pediatric femurs; it was also studied on 283 randomly selected hip radiographs. The angle varied 25-40 degrees in 90% of the patients and was not age related. The angle is stable within 5 degrees as long as the landmarks, base of the great trochanter, and medial metaphysis of the femoral neck are definable (0-30 degrees of rotation).

Equinus deformity in cerebral palsy: a retrospective analysis of treatment and function in 39 cases

Equinus deformity, due to a contracture of the triceps surae, is a frequent problem in cerebral palsy. The authors present a retrospective analysis of the functional status of 27 patients (39 feet) of equinus deformity seen in a 10-year follow-up study. When either a Hoke or White tendo Achillis surgical lengthening procedure was combined with a postoperative management program of night-bracing, the recurrence of equinus deformity was significantly reduced.

Template specificity of DNA binding by nogalamycin and its analogs utilizing competitive fluorescence polarization

Nogalamycin, an anthracycline antibiotic, interacts with DNA. This interaction is measured by a competitive fluorescence polarization assay in which nogalamycin displaces acridine orange. The amount of acridine orange displaced is dependent upon the concentration and DNA-binding capability of the drug. The relative DNA-binding capacities of several nogalamycin analogs are also determined by this method. A comparison of these results with circular dichroism and thermal denaturation yields a positive correlation. The base-pair specificities of these compounds are also evaluated by competitive fluorescence polarization using DNA's of differing base composition. These results indicate that compounds containing the nogalose moiety generally prefer adenine and thymine. On the other hand, some of the 7-O-alkyl analogs appear to interact similarly with DNA's of differing base composition, and others show a preference for DNA's with high guanine and cytosine content. Specificities obtained with this method are compared with DNA thermal denaturation and polymerase inhibition studies. The potential value of this relatively new competitive method for the study of DNA-reactive antitumor compounds is discussed.

Metal mutagens and carcinogens effectively displace acridine orange from DNA as measured by fluorescence polarization

Several metals are known mutagens and carcinogens. These metals effectively displace acridine orange from DNA when measured by fluorescence polarization. Displacement of 50% of the acridine orange is obtained with less than 0.5 mM concentrations of lead, manganese, cobalt, zinc, cadmium, nickel, iron, copper, and cis-platinum. In contrast, greater than 80 mM concentrations of lithium, sodium, and potassium are required to displace an equivalent amount of acridine orange from calf thymus DNA. Although cis-platinum shows the best DNA reactivity in this assay, the interaction between this metal and DNA does not occur immediately, as it does for the other metals tested. These results indicate the acridine orange displacement assay provides a relative measure of the interaction of metals with DNA, and this DNA reactivity shows a positive correlation with mutagenic/carcinogenic potential.