Cuneiform osteotomy of the femoral neck in severe slipped capital femoral epiphysis

From 1978 through 1988, 27 severe slipped epiphyses (Grade III) in 23 adolescent patients were treated with a cuneiform osteotomy of the proximal neck of the femur. Average time of followup was 8 years 5 months. The results were graded by the criteria of Southwick, with emphasis on pain, function, range of motion, and radiographic appearance. Arbitrarily, no hips were rated excellent, because the authors thought that this rating should be reserved for normal hips that have not had any disease process nor surgical procedure. There were 19 good, 4 fair, and 4 poor results. The 4 poor results were in patients with avascular necrosis. The avascular necrosis rate was 15%. Eight hips had some joint space narrowing during the postoperative followup period. All joint space narrowing was resolved by 20 months postoperatively. All patients, including those with avascular necrosis, improved in joint flexion and joint internal rotation. Although the avascular necrosis rate of 15% is significant, the authors believe that the potential for restoring hip anatomy and providing a normally functioning hip in the adolescent patient makes this procedure a viable treatment option.

Progressive congenital scoliosis treatment using a transpedicular anterior and posterior convex hemiepiphysiodesis and hemiarthrodesis. A preliminary report

STUDY DESIGN

Patients treated with a transpedicular anterior and posterior convex hemiepiphysiodesis and hemiarthrodesis for progressive congenital scoliosis were followed to evaluate this treatment.

OBJECTIVE

To evaluate an alternative to a separate anterior approach for performing an anterior hemiepiphysiodesis for progressive congenital scoliosis.

SUMMARY OF BACKGROUND DATA

Previous investigators have reported a transpedicular anterior fusion combined with a bilateral posterior fusion. The authors are unaware of a previous report on a transpedicular anterior convex hemiepiphysiodesis and fusion combined with a unilateral convex posterior spinal fusion to treat progressive congenital scoliosis.

METHODS

Nineteen curves were fused in 16 patients who had a variety of congenital anomalies. The average age at surgery was 4.8 years (range, 11 months to 13 years) The average follow-up period was 4.8 years (range, 2 to 9.6 years).

RESULTS

The average preoperative and postoperative fused curves measured 36 degrees and 38 degrees, respectively. Of the 19 fused curves, seven curves (37%) improved, eight curves (42%) were unchanged or progressed less than 7 degrees, three curves (16%) progressed 10 degrees to 15 degrees, and one curve (5%) progressed more than 15 degrees.

CONCLUSIONS

This procedure appears to be most effective in arresting growth in the young patient who has an isolated hemivertebrae and no excessive kyphosis. The epiphysiodesis effect is less predictable.

Myositis (fasciitis) ossificans in an infant

Myositis (fasciitis) ossificans developed following minor trauma to the soft tissues of the posterior aspect of the right knee of a 5-month-old female infant. The clinical and pathological features of myositis ossificans are reviewed and the differential diagnosis of soft tissue ossification in early childhood is discussed.

Transporting children in body casts

Automotive restraint systems for children in body or hip spica casts, who cannot be accommodated by conventional child restraints or seat belts, were investigated. A car bed restraint and a harness vest restraint were subjected to simulated 30-miles/h crash tests to assess their effectiveness. The successful systems were then tried by patients and their families and found to be convenient as well. Details of the testing, potential limitations of the systems, and a subsequent actual crash experience are reported.

Computed tomography arthrography in traumatic hip dislocation. Intra-articular and capsular findings

The newer diagnostic modalities such as computed tomography and magnetic resonance imaging are becoming increasingly used in the evaluation of joint trauma. The combination of computed tomography and arthrography can also be of significant diagnostic value in certain specific situations. In our case report, we describe its use in post-traumatic recurrent hip dislocation and its value, not only in depicting a posterior capsular tear, but also in the diagnosis of an internal joint derangement which may contribute to incongruous reduction of the hip joint.

A new osteotomy for cubitus varus

From 1974 to 1986, a step-cut technique of distal humerus valgus osteotomy using one cortical screw for fixation was used to correct cubitus varus deformity in 11 patients. The results were graded as excellent, eight patients, good, two, and poor, one. The poor result was secondary to persistent varus. The average humeral-elbow-wrist angle in the ten patients with valgus correction roentgenographically measured 9.3 degrees. The average amount of correction was 28.4 degrees. All patients retained their preoperative level of elbow motion. There were no radial or ulnar nerve injuries, nonunions, infections, or hypertrophic scars. The osteotomy requires careful preoperative planning and special attention to surgical detail. Large amounts of deformity may be corrected safely with a low complication rate.

Chest wall resection and reconstruction for malignant conditions in childhood

This report evaluates the efficacy of extensive chest wall resection and prosthetic reconstruction in 15 children with chest wall malignancies. There were nine boys and six girls, with a mean age of 9.6 years. Eleven patients had primary chest wall tumors including Ewing's sarcoma (ES), six; rhabdomyosarcoma (RH), two; chondrosarcoma (CS), one; Askin's malignant neuroectodermal tumor, one; and mesenchymal sarcoma, one. Four children had metastases to chest wall and lung from Wilms' tumor (WT), two; osteogenic sarcoma (OS), one; and neuroblastoma (NB), one. Chest wall resection of two to six ribs and reconstruction with Marlex mesh (seven), lattisimus flap (two), prolene mesh (one), and more recently, a Gortex patch (five), was performed. Eight of the patients required concomitant en-bloc pulmonary resection (wedge, five; lobectomy, two; pneumonectomy, one) and two required resection of diaphragm. Fourteen received adjunctive therapy (chemotherapy, 14; irradiation, eight [preoperative, five; postoperative, three]. Six patients had second-look resections after chemotherapy. There was no operative mortality. Early pulmonary function was normal; however, pulmonary restrictive disease and scoliosis occurred with growth. One ES patient developed a radiation-induced second malignant tumor at age 10 and one ES child died at age 6 (no evidence of disease) of meningitis. Average survival length for ES patients was 77 months (range, 18 to 132 months.) Currently, eight patients are alive and five are free of disease. Extensive chest wall resection and reconstruction is useful in the treatment of primary chest wall tumors, but is palliative in metastatic cases. The Gortex patch is the current prosthetic of choice.

Treatment of congenital dislocation of the hip. Management before walking age

Neonatal infants with Ortolani-positive dislocated hips are easily managed by reduction and maintenance of the reduction using a divarication splint, cast, or Pavlik harness. Sixty-six patients with 85 complete, congenitally dislocated hips (Ortolani negative) unassociated with other neuromuscular disorders were examined to assess a method of prereduction traction in the treatment of congenital dislocation of the hip. Forty of the 66 patients were six months of age or younger at the beginning of traction treatment. The remaining 26 were younger than 12 months of age prior to the treatment protocol. Overhead traction with the hip flexed to 90 degrees was employed. Gradual hip abduction to 70 degrees (140 degrees combined abduction) was accomplished over the next ten to 14 days. If the dislocated hip was still in a station above Hilgenreiner's line, then cross traction was applied to add another vector of force to pull the femoral head distally. At an average of 18 days into the treatment protocol, an examination under anesthesia with closed reduction was performed and the patient immobilized in a double hip spica in the "human" position for six to eight weeks. This was followed by use of an Ilfeld divarication splint for nine months. This traction/reduction program was effective in 91% of these cases (60 of 66). Six patients (ten hips) required an open procedure because of persistent instability in spite of reducibility. To date, there is no incidence of avascular necrosis using the criteria of Salter for whole head avascular necrosis and the criteria of Kalamchi and MacEwen for partial head avascular necrosis.

Magnetic resonance evaluation of disease of the soft tissues in children

Magnetic resonance imaging was a sensitive modality for identifying pathology in the soft tissues of 32 children, and it consistently showed more abnormality than CT. Magnetic resonance images are not histology specific, but with careful attention to the location of the abnormality, to the definition of the margins, and to the evaluation of involvement of adjacent muscle, bone, subcutaneous fat, and skin, the correct diagnosis can be strongly predicted in most cases. The ability of magnetic resonance to image in multiple planes aids in the evaluation of the extent of lesions and their relationship to adjacent structures. With magnetic resonance imaging, one can accurately predict the extent of abnormality, and there is great potential for the study of disease of soft tissues.

MR imaging of osteogenic and Ewing's sarcoma

Twenty patients with biopsy-proven osteogenic (11 cases) or Ewing's (nine cases) sarcoma were evaluated by MR imaging on a 0.15-T resistive unit to determine the value of MR in the diagnosis and treatment of these two neoplasms and to develop the best protocol for MR imaging. In all 20 cases, MR identified tumor spread into bone marrow, and it was superior to CT in five cases. Extension of tumor into the soft tissues adjacent to bone was shown better by MR than CT in six cases. Improved anatomic information from MR is the result of the ability to image in the axial, coronal, and sagittal planes. Compared with CT, MR identifies cortical disease but has inferior spatial resolution and defines calcium poorly. MR can be used to monitor tumor response to chemotherapy, and the relationship of tumor to adjacent vasculature can be determined without the use of contrast agents. Two pulse sequences are necessary for maximum display of disease, since, in general, tumor involvement of the bone marrow is best assessed on T1-weighted sequences, and tumor involvement of the soft tissue is best seen on T2-weighted sequences. Additional information about bone-marrow involvement, soft-tissue tumor extent, and the relationship of tumor to blood vessels makes MR a valuable adjunct to CT in the evaluation of these neoplasms.

Coexistent Legg-Calvé-Perthes disease and slipped capital femoral epiphysis in the same child

Legg-Calvé-Perthes disease and slipped capital femoral epiphysis in the same child occurs rarely. Three cases from Indiana University Medical Center (Indianapolis, IN) are reported. The two disease entities appear to be unrelated. However, a child with Legg-Calvé-Perthes disease in one hip may develop a slipped capital femoral epiphysis in the contralateral hip.

Results of posteromedial release for the resistant clubfoot

Sixty-nine children with 99 resistant clubfeet were operated on between 1973 and 1979 at the James Whitcomb Riley Hospital for Children (Indianapolis, IN). Three groups of children according to age at the time of surgery were identified: Group I, less than 12 months of age; Group II, between 12 and 36 months of age; and Group III, greater than 36 months of age. Minimum follow-up was 30 months, with an average follow-up for the entire series of 58 months. The radiographic results based on the talocalcaneal index revealed 95 of the 99 feet to have good or acceptable results. The clinical assessment of pain and function mirrored these good results, although, on occasion, the appearance was somewhat less than optimal.

Progressive scoliosis following chest wall resection in children

The effect of partial chest wall resection on subsequent production of spinal deformity was studied in six pediatric patients. The following observations are made: Scoliosis secondary to chest wall resection in the pediatric age group is progressive. The degree of curvature is related to the number of ribs resected. Anterior resection of ribs does not produce significant scoliosis, whereas resection of the posterior aspect of the ribs promptly produces scoliosis. Scoliosis associated with marked pleural thickening secondary to recurrent tumor, irradiation scarring, and underlying pulmonary metastases is always convex toward the normal side. Scoliosis associated with empyema and chest wall osteomyelitis is likewise convex toward the normal side and may respond to removal of this thether in the growing child.

Segmental femur loss in children

Two children with segmental femoral shaft loss were treated by skeletal traction to maintain soft tissue length, followed by casting to allow the callus to solidify. Initial traction was used to preserve length and allow for the development of bridging callus. Callus formation in 3-6 weeks was a good indicator for sufficient remaining periosteal sleeve to support healing without the need for bone grafting or internal fixation. These cases demonstrate the regenerative ability of the periosteum in healing pediatric fractures.

Congenital vertical talus: the Riley experience

This is a retrospective study of seven patients with 10 feet displaying nonparalytic congenital vertical talus treated at Riley Children's Hospital in Indianapolis by open reduction without naviculectomy. Each of the 10 feet underwent an operation for open reduction of congenital vertical talus. The procedure included a peritalar soft tissue release, posterior release of the hindfoot with Achilles tendon lengthening, and transfer of the tibialis anterior tendon into the talar neck. Length of follow-up ranged between 2 and 11 years. Average follow-up time was 6 years and 9 months. Age at time of open reduction ranged from 8 months to 3 years. The clinical follow-up evaluation revealed three excellent, three good, and four fair results. Only one patient underwent a subsequent surgical procedure.

Jejuno-renal injury following traumatic hyperextension

A 4-year-old boy suffered hyperextension injury with small-bowel obstruction and renal injuries. This unusual constellation of findings is discussed in light of the pathophysiologic mechanisms of the injury. Hyperextension of the spine resulted in rupture of the anterior longitudinal ligament and avulsion of the L1-L2 disc; a loop of bowel was then drawn into the disc space. There also was an internal tear of the renal artery. Two years after uretero-ureterostomy with nephrostomy tube, the child is normotensive with adequate renal function and with normal growth and development.

Sodium etidronate in the treatment of Paget's disease of bone. A study of long-term results

Subjects (109) with symptomatic Paget's disease of bone were treated with 5, 10, or 20 mg of sodium etidronate (EHDP)/kg body weight - day for 6 to 24 months. Significant decreases in serum alkaline phosphatase and urinary hydroxyproline were noted after 6 months of therapy; no significant further improvement resulted after prolonged therapy. Some patients maintained biochemical remission after withdrawal of EHDP but others showed a relapse, related primarily to the pretreatment severity. Clinical improvement was noted in 61% of the patients. Similar findings were seen after a second course of EHDP. No side-effects were noted in patients treated with 5 mg of EHDP/kg body weight - day. In patients treated with 10 or 20 mg of EHDP/kg body weight - day, severe diarrhea, bone pain, and nontraumatic fractures were noted in 3, 13, and 12 patients respectively. Quantitative histomorphometry showed mineralization delay in patients receiving 10 or 20 mg of EHDP/kg body weight - day but not in those receiving 5 mg/kg body weight - day. Five milligrams of EHDP/kg body weight - day was effective and appears to be safer than the higher doses.

Aggressive chondroblastoma. Report of a case with multiple bone and soft tissue involvement

A 14-year-old male had a recurrent chondroblastoma in his right talus which involved the right calcaneus and the soft tissue of that ankle. While the initial lesion had a typical, benign appearance, the recurrent lesion and the soft tissue nodules showed a significantly elevated mitotic rate. Although some extraosseous involvement by chondroblastomas may be secondary to soft tissue or hematogeneous seeding at the time of surgery, and aggressive variant of chondroblastoma appears to exist. Previous reports of these aggressive cases show a poor correlation between histologic appearance and biologic behavior. When objective quantitation of cytologic features such as mitotic rate are made, we believe that these features may serve as a marker for identification of those cases of chondroblastoma which have a propensity for aggressive behavior.

Tibial torsion?

A longitudinal study evaluating the degree of rotation of the bimalleolar axis of tibia and fibula at birth, 6 month, 12 months and 24 months revealed a gradual statistically significant external rotation from a mean of 4 degrees at birth to a mean of 11 degrees at 24 months. There was no correlation with the sex or race of the child or with the age at which the child began independent walking. It is concluded that this external rotation is a part of normal growth and development of the infants' lower extremities.

Correction of equinus in cerebral palsy by the Murphy procedure of tendo calcaneus advancement: a preliminary communication

The biomechanics of the Murphy procedure for correction of equinus in cerebral palsy are presented. A series of 79 surgical procedures on 48 patients, with a follow-up period of from one to four years, is reviewed. Correction of equinus was succeswful in 89-9 per cent of the procedures. Using the Murphy procedure the following advantages over other methods of correction are anticipated: (1) no loss on 'push-off' in gait; (2) no loss of correction (recurrence) during longitudinal growth of the child, necessitating repeated surgery; and (3) no need for continual night bracing during the growth period.