Congenital dislocation of the patella

Congenital dislocation of the patella may occur as a persistent lateral dislocation of the patella that presents with a knee flexion contracture and the patella tethered lateral to the femoral condyles or as an intermittent dislocation of the patella. In the latter syndrome, the patella dislocates completely with each flexion and extension cycle of the knee and is best termed obligatory dislocation of the patella, because the patient has no control over the patella dislocating as he or she moves the knee. The first type of congenital dislocation, which is fixed, often is associated with syndromes such as arthrogryposis and should be corrected surgically by lateral release and realignment of the patella. Obligatory dislocation of the patella tends to be an isolated dysplastic anomaly and may be relatively well tolerated. Rebalancing of the patella usually is done at a later age because of less interference with function. The current author describes the natural history of patella femoral dysplasia, detailing the pathologic changes that are present, and recommends surgical techniques for correcting both types of congenital dislocation of the patella.

The success of closed reduction in the treatment of complex developmental dislocation of the hip

The purpose of our study was to determine the efficacy of closed reduction in the treatment of complex developmental dislocation of the hip. We identified two factors, the cone of stability and the limbus type, through the use of arthrography and gentle examination under anesthesia, which are useful guidelines in the management of complex developmental dislocation of the hip. We feel as a result of this study we can select those cases of complex developmental dislocation of the hip that are amenable to closed reduction and separate them from those other cases for which we recommend open reduction.

Fibular hemimelia: comparison of outcome measurments after amputation and lengthening

BACKGROUND

Treatment of fibular hemimelia includes either Syme or Boyd amputation with early prosthetic fitting or tibial lengthening. Numerous studies have documented the success of both procedures. The purpose of our study was to compare the outcome after amputation with that after tibial lengthening, specifically with regard to activity restrictions, pain, satisfaction, complications, number of procedures, and cost, in children with fibular hemimelia.

METHODS

Thirty limbs in twenty-five patients treated with either an amputation or a lengthening procedure and followed for at least two years were studied. Fifteen patients underwent amputation, and ten patients underwent lengthening of the tibia. The mean age was 1.2 years at the time of amputation and 9.7 years at the time of initial lengthening. The mean duration of follow-up was 6.9 years after the amputations and 7.1 years after the lengthening procedures.

RESULTS

The patients who underwent amputation were able to perform more activities than those who had a lengthening (mean activity score, 0 compared with 1.2 points; p<0.05), and they had less pain (mean pain score, 0.2 compared with 1.2 points; p = 0.091), were more satisfied and had a lower complication rate (0.37 compared with 1.91; p<0.05). The patients who underwent amputation also had fewer procedures (1.9 compared with 7.0; p<0.05), at a lower cost ($7016 compared with $26,900; p<0.05), than those who had a lengthening. Lengthening was successful in equalizing limb lengths; the mean limb-length discrepancy, assessed in nine of eleven limbs, was 0.7 centimeter.

CONCLUSIONS

This study demonstrated that children who undergo early amputation are more active, have less pain, are more satisfied, have fewer complications, undergo fewer procedures, and incur less cost than those who undergo lengthening. This was true even though good results were obtained with the lengthening procedures and most patients achieved limb-length equality, were able to walk, had minimal pain, and were quite active.

Children's and parents' visual perception of physicians

The purpose of this study is to evaluate the child's and parents' visual perception of physicians. To do this, 50 children and their parents were asked which physician they preferred, when shown eight pairs of photographs. Four characteristics were tested twice, white coat versus no white coat, smile versus stern face, cartoon posters versus no posters, and standing versus stooping. We found that both children and parents preferred the smiling physician and the physician with cartoon posters on the wall. Surprisingly 54% of children preferred the physician in the white coat, whereas only 35% of parents preferred the white coat. Sixty-eight percent of children also preferred the standing physician compared with only 41% of parents. There was little correlation between the parent's and child's answers. The results did not differ significantly with age, gender, or number of hospitalizations. In conclusion our study did not confirm the popular belief that children are afraid of physicians in white coats, although children did strongly prefer physicians who smiled and those with cartoon posters on the wall.

Posttraumatic genu valgum: operative versus nonoperative treatment

The purpose of this study was to compare the results of operative versus nonoperative treatment for posttraumatic genu valgum. It is a retrospective chart and radiograph review of all patients with the diagnosis of posttraumatic genu valgum from our institution and from data obtained in response to 389 letters sent to the members of the Pediatric Orthopaedic Society of North America (POSNA). The complementary physeal shaft (CPS) angle and the tibial femoral angle (TFA) were measured at the time of injury, at maximal deformity, and at latest follow-up. Fifteen patients were identified, 10 in the nonoperative group and five in the operative group. In both groups, the valgus deformity progressed over a 20-month span. In both groups, the valgus deformity improved at the time of follow-up. There was no significant difference in the CPS angle or TFA, between groups at the time of injury, at maximal deformity, or at follow-up.

Hemivertebral excision for congenital scoliosis

We retrospectively reviewed the cases of 10 consecutive patients treated with hemivertebral excision for congenital scoliosis at The Children's Hospital, Denver, CO, between 1982 and 1992. Follow-up consisted of physical and radiographic examination and averaged 54 months (range, 4-111). Age at surgery ranged from 9 months to 10 years, 5 months (average, 3 years, 11 months). Hemivertebra levels were between T12 and L3. The average preoperative curve measured 40 degrees (range, 20-55 degrees); the average at latest follow-up was 16 degrees (range, 3-37 degrees). We found hemivertebral excision for congenital scoliosis to be a safe and effective means of treatment. Curve correction averaged 67% and seemed to be greatest in those less than 4 years of age at the time of surgery.

Evaluation of the biomechanics of the hip following a triple osteotomy of the innominate bone

The biomechanics of the hip joint were evaluated in seventeen patients (twenty-two hips), twelve to forty-one years old (mean, twenty-four years old), who had a triple osteotomy of the innominate bone for treatment of symptomatic dysplasia of the hip. The duration of follow-up ranged from 2.2 to 13.8 years (mean, 6.8 years). Hip load, the area of the weight-bearing surface, and stress were determined from measurements on pelvic radiographs that were made preoperatively, postoperatively, and at the time of the latest follow-up; the values were compared with those in twenty-one hips from control subjects. The Harris hip-rating system was used for clinical assessment. According to the biomechanical analysis, there was significantly less relative stress on the hip after the triple osteotomy and at the time of the latest follow-up (p < 0.001 for both) than there had been preoperatively. The decrease in stress was a direct result of a significant increase in the area of the weight-bearing surface of the hip (p < 0.001). The load on the hip was not altered significantly, with the numbers available. The functional outcome was improved substantially when the biomechanical goals were achieved. Through the application of basic biomechanical principles, we were able to demonstrate the biomechanical efficacy of a triple osteotomy of the innominate bone. We recommend the use of biomechanical analysis as an adjunct to the clinical decision-making process in the treatment of a dysplastic hip.

Results of the Wagner and Ilizarov methods of limb-lengthening

We compared the results of the Wagner method of limb-lengthening in twenty extremities (nineteen patients) with those of the Ilizarov method in twenty-one extremities (eighteen patients). The Wagner external fixator was used in all twenty procedures in which the Wagner lengthening method was performed and in fourteen procedures in which the Ilizarov lengthening method was performed. The Ilizarov external fixator was used in the remaining seven procedures in which the Ilizarov method was performed. The average increase in length was 5.4 centimeters (range, 2.8 to 8.0 centimeters) with the Wagner technique and 5.9 centimeters (range, 1.0 to 16.8 centimeters) with the Ilizarov technique. The rate for the lengthening phase was nine days for one centimeter of length with the Wagner technique and twelve days for one centimeter with the Ilizarov technique. The rate for the consolidation phase was forty-four days for one centimeter with the Wagner technique and twenty-six days for one centimeter with the Ilizarov technique. The group of patients who were managed with the Wagner technique had thirty major complications, and the group of patients who were managed with the Ilizarov technique had only thirteen major complications. Forth complications were associated with the use of the uniaxial Wagner external apparatus and sixteen, with the use of the multiaxial Ilizarov external fixator.

Osteogenic sarcoma arising from bony regenerate following Ilizarov femoral lengthening through fibrous dysplasia

Sarcomatous degeneration of fibrous dysplasia has been previously documented in rare cases, often in association with prior radiation therapy. This case report describes the occurrence of osteosarcoma arising in the distal femur of a 15-year-old male with previous biopsy-proven fibrous dysplasia, who had undergone limb lengthening through a distal femoral corticotomy using the technique described by Ilizarov. In addition, distraction osteogenesis through an area of fibrous dysplasia in the proximal tibia produced a new area of fibrous dysplasia in the regenerate tissue as shown by histopathologic examination. This case raises two questions: (a) whether the biologic stimulus of distraction osteogenesis through abnormal metaplastic bone increases the risk of malignant neoplasia, and (b) whether distraction osteogenesis through dysplastic bone is contraindicated, since the regenerate tissue does not form normal bone.

Intraoperative blood salvage in children and young adults undergoing spinal surgery with predeposited autologous blood: efficacy and cost effectiveness

We conducted a retrospective review of 155 spinal operations at our institution to determine the efficacy of intraoperative salvage. Addition of intraoperative salvage had little effect on the success of a preoperative autologous donation program. Only patients with operative blood loss > 2,000 ml (12% of patients) benefited from this expensive source of autologous blood. The technique tended to be most effective in children aged 16-18 years. Use of intraoperative salvage for all pediatric spinal procedures is neither necessary nor cost effective.

Disruption of the anterior cruciate ligament in a 4-year-old child

Anterior cruciate ligament (ACL) injuries in children are rare. Thus, the natural history of ACL injuries in skeletally immature patients is unknown. This case represents the longest follow-up (11 years) reported in the literature of an ACL injury in a child of less than 5 years old.

Effect of chemotherapy on human growth plate

Histologic specimens of the distal femoral growth plates of 10 patients treated surgically for osteosarcoma were examined retrospectively. Eight of the patients received preoperative chemotherapy. None of the specimens showed complete growth arrest. The gross thickness of the plates was preserved. Columnar arrangement of the cells was minimally disrupted. The number of proliferative cells in each column was decreased, and the number of hypertrophic cells, was increased slightly. The metaphysis showed longitudinal trabeculations with a high chondroid content. Growth arrest lines were evidenced by transverse trabeculations with a high osteoid content. Our findings provide histologic support for previous clinical studies. Absence of complete growth arrest and evidence of a resumption of growth are relevant in planning limb salvage procedures in patients receiving pre- and postoperative chemotherapy for skeletal malignancy.

Effects of inhibitory casts and orthoses on bony alignment of foot and ankle during weight-bearing in children with spasticity

One theory about the improvements in gait seen in children with CP who use inhibitory casts holds that they are a result of better posture of the foot. To examine this theory, the authors used x-rays to document the position of the foot both before and during inhibitory casting to see whether there were measurable changes in foot posture that could be ascribed to the casts. The bony alignment of the ankle and foot was compared during weight-bearing with the children in and out of inhibitory casts (N = 12), static ankle-foot orthoses (N = 7) and articulated ankle-foot orthoses (N = 8). The only angle change which was significant was calcaneal inclination in the articulated AFOs versus out of the orthoses. There was no significant difference in any of the other angles in any of the groups.

Hip flexion contracture in cerebral palsy. The association between clinical and radiologic measurement methods

Hip flexion contracture was examined in 51 spastic cerebral palsy patients by three clinical methods and two radiologic methods. An extremely low association was found between the clinical and radiologic methods with no particular method, clinical or radiologic, showing a higher association. The method of clinical examination should be chosen by convenience. Radiologic measurements by the methods used did not add useful information.

Autologous transfusions for orthopaedic procedures at a children's hospital

We conducted a critical review of the use of autologous transfusions in orthopaedics at a tertiary-care children's hospital. The cases of 198 children who deposited blood before an orthopaedic operation were analyzed. There were 175 children who were enrolled in the program of preoperative deposit of autologous blood who later needed transfusion of blood; 73 per cent of them received only autologous blood. Seventy patients also had intraoperative salvage. We were unable to document a proved benefit of intraoperative salvage of blood in this group of patients. Forty patients had some difficulty donating autologous blood preoperatively, but these problems were rarely serious. Major human errors occurred in thirteen patients and resulted in some patients receiving homologous transfusions while autologous blood components were still available. Fifty-five (40 per cent) of all of the transfusions were administered in clinical circumstances that failed to meet generally accepted criteria for transfusion, and fifty-four (38 per cent) of the postoperative transfusions also failed to meet these criteria. This was true of the homologous transfusions in the study as well. Although an autologous blood transfusion is a generally safe procedure, it is not without risk, and human errors can occur. In light of the potential complications, surgeons should adhere to the standard indications for transfusion when administering autologous blood.

Fluoroscopic technique versus Phemister technique for epiphysiodesis

Seventy patients were followed after epiphysiodesis for limb length discrepancy. The Phemister technique was used on 44 and the fluoroscopic technique on 26 patients. Both techniques achieved growth plate arrest in 100% of patients. The average hospital stay was 1.8 days for the fluoroscopic technique and 3.5 days for the Phemister technique. Of the Phemister technique patients, 40% required formal postoperative physical therapy compared to only 8% of the fluoroscopic technique patients. The complication rate was two of 44 (4.5%) for the Phemister technique and one of 26 (4%) for the fluoroscopic technique. The advantages of the fluoroscopic technique are a much smaller scar, less postoperative knee stiffness, and a shorter hospital stay. Because of the similar results, the fluoroscopic technique is recommended.

Fracture through the stalk of pedunculated osteochondromas. A report of three cases

Although fracture through the base of an osteochondroma is a well-recognized clinical entity, the fate of such fractures has never been documented. Recommendations concerning the treatment of these fractures are contradictory. Of the three cases of fracture through the base of a pedunculated osteochondroma observed in the last 12 years, two healed without problem, one in a patient with a solitary osteochondroma, the other in a patient with multiple osteochondromas. The third patient remained symptomatic one year after injury, and histologic evaluation of the specimen after surgical excision confirmed the diagnosis of fibrous nonunion of the fracture. Experience with fractures through the base of a pedunculated osteochondroma suggests that the majority of these fractures will heal without complication, regardless of whether they involve solitary or multiple osteochondromas. However, symptomatic fibrous nonunion of such a fracture may occur particularly when an osteochondroma is located near large, mobile tendons.

Autograft versus allograft for benign lesions in children

Benign bone lesions in children are often so large in size that there is not an adequate amount of bone available for an autograft to fill the resultant cavity after surgical curettage. This study compared autografts and allografts with respect to the time required and the success of graft incorporation. Fifty-four patients with 61 lesions were studied. Lesions were classified as small volume (less than 60 cc) or large volume (more than 60 cc) and were separated into four groups: small-volume autograft, large-volume autograft, small-volume allograft, and large-volume allograft. Allografts appeared comparable to autografts when small-volume lesions were treated. The healing time was slightly longer for allografts with an average period of 21 months versus 27 months for autografts. Autografts were superior to allografts in rate and completeness of healing for solitary large lesions. This increased efficacy presumes a somewhat older child in which an adequate amount of bone is available for an autograft. A young child with multicentric or polyostotic lesions can still achieve successful incorporation with allografts. In this study, 38% healed completely and 29% healed partially. Allografts have a distinct place in the treatment of benign bone lesions in children.

Orthopaedic aspects of fragile-X syndrome

Fragile-X syndrome is one of the most common inherited forms of mental retardation. An associated connective-tissue disorder involving elastin accounts for the most frequent musculoskeletal manifestations, which include severe flexible flat feet, excessive laxity of the joints, and scoliosis. At our institution, seventy-five (50 per cent) of the 150 male patients who had fragile-X syndrome had flat feet, eighty-five (57 per cent) had excessive laxity of the joints, and ten had scoliosis. Twenty-nine of the patients who had flat feet had been evaluated or treated, or both, by an orthopaedic surgeon before the diagnosis of fragile-X syndrome had been made. Only one of these patients had been referred for developmental and genetic evaluation, which suggests that the orthopaedic community is not familiar with this syndrome. The orthopaedist should consider the diagnosis of fragile-X syndrome in the evaluation of a mentally retarded boy or man who has a family history of mental retardation. The presence of flat feet and excessive laxity of the joints, associated with the characteristic facies, macro-orchidism, and behavior, justifies a referral for developmental and genetic evaluation. Early diagnosis is important for several reasons, including genetic counseling for the family, more efficacious medical treatment, and specialized education.

Operative lengthening of the lower extremity and associated psychological aspects: the Children's Hospital experience

Twenty-two patients underwent 23 femoral and tibial lengthenings by the Wagner technique from 1977 to 1987. Average length gained was 5.8 and 5.2 cm, respectively. Long hospitalization in addition to multiple operative procedures and a high complication rate created a significant psychological impact. Fourteen of 22 patients experienced psychological problems, primarily adjustment disorders, all of which resolved without long-term sequelae. Parental/family and nursing staff support were identified as the most important during the lengthening process. Advances in limb lengthening techniques may lessen the overall impact of this procedure, but preoperative psychological preparation is important.

Congenital pseudarthrosis of the ulna: a report of two cases and a review of the literature

Two cases of congenital pseudarthrosis of the ulna in patients with neurofibromatosis were followed up for 15 and 8 years, respectively. In both cases conventional bone grafting failed. The solution in one case was production of a one-bone forearm. In the other, osteotomy of the radius, resection of the ulnar pseudarthrosis, and stabilization of the distal radioulnar joint achieved a good result. The literature suggests that free vascularized bone grafting, electrical stimulation, formation of a one-bone forearm, or osteotomy of the uninvolved bone with or without resection of the pseudarthrosis should be considered as treatment alternatives.

Cavus foot in cerebral palsy

In the child between 4 and 12 years of age presenting with cavus deformity associated with spastic cerebral palsy, symptomatic feet may be improved by soft tissue release of plantar structures followed by appropriate tendon lengthenings or transfers and good cast correction. It is more common for the deformity to present in teenage patients, however, with a more rigid foot usually complicated by some degree of varus and equinus. In these situations, triple arthrodesis is often necessary and is a predictable procedure for correction and stabilization of the deformity.

Protonmotive force in muscle mitochondria

The protonmotive force (delta p) of muscle mitochondria was measured by estimating the distribution of 14C-labeled TPMP (trimethylphenylphosphonium iodide) and 14C-labeled acetate across the inner membrane of muscle mitochondria. The matrix volume was simultaneously determined using 3H-labeled H2O and 3H-labeled mannitol and repeated drying to distinguish the label in these 2 compounds. Rapid separation of mitochondria from the incubation medium by centrifugation through silicone oil avoids the problems of potential anaerobic conditions associated with conventional centrifugation and large volumes of trapped media associated with filtration. The value for delta p (mean +/- SD) was 192+/- 26 mV in 30 determinations with rat muscle mitochondria during state 4. Measurement of oxygen consumption allowed calculation of membrane conductance (Cm,H+) which was 0.49 +/- 0.18 nmol of H+/min/mg protein/mV. The values for delta p and Cm,H+ are reported for a variety of experimental conditions and are consistent with Mitchell's chemiosmotic theory. Biopsy specimens obtained from human muscle gave state-4 delta p values of 197+/- 30 mV (n =5) and Cm,H+ values of 0.52 +/- 0.12 nmol of H+/min/mg/mV (n = 4). This delta p assay is the first described for coupled mammalian muscle mitochondria and will be useful in assessing membrane function.

Fibular transfer for congenital absence of the tibia

In patients with congenital absence of the tibia, construction of a knee joint by transferring the fibula under the femoral condyle gives satisfactory results, provided a strong quadriceps is present. In the rare patient with an associated proximal focal femoral deficiency on the same side, even in the absence of a strong quadriceps, this procedure with a fibulofemoral fusion will give a longer stump, allowing better prosthetic fitting. The procedure is performed as early as the first year of life.

Varus derotational osteotomy of the femur in cerebral palsy

Varus derotational osteotomy of the femur is designed to correct coxa valga and femoral anteversion which contribute to progressive hip subluxation and dislocation in certain cases of cerebral palsy. By the application of a careful preoperative evaluation, vigorous postoperative rehabilitation and treatment of complications, satisfactory results were obtained in 17 of 20 patients followed for one to 17 years after osteotomy. No hip subsequently dislocated and dysplastic acetabulae were predictably remodeled in those patients less than 8 years of age.

Boyd and Syme ankle amputations in children

The Syme and Boyd amputations at the ankle were compared in thirty-four children followed for three to sixteen years. Good results were found with both techniques. The best results occurred when the heel pad was aligned in the plantigrade position, which produced almost normal function of the heel pad. The Boyd technique was a surer method of obtaining such alignment but was technically more difficult. Both the Boyd and Syme techniques are recommended for ankle amputation in children, but a distinct advantage of one technique over the other could not be defined.