Automatic Cartilage Segmentation for Delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Hip Joint Cartilage: A Feasibility Study

OBJECTIVE

Automatic segmentation for biochemical cartilage evaluation holds promise for an efficient and reader-independent analysis. This pilot study aims to investigate the feasibility and to compare delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) hip joint assessment with manual segmentation of acetabular and femoral head cartilage and dGEMRIC hip joint assessment using automatic surface and volume processing software at 3 Tesla.

DESIGN

Three-dimensional (3D) dGEMRIC data sets of 6 patients with hip-related pathology were assessed (1) manually including multiplanar image reformatting and regions of interest (ROI) analysis and (2) automated by using a combined surface and volume processing software. For both techniques, T1_Gd values were obtained in acetabular and femoral head cartilage at 7 regions (anterior, anterior-superior, superior-anterior, superior, superior-posterior, posterior-superior, and posterior) in central and peripheral portions. Correlation between both techniques was calculated utilizing Spearman's rank correlation coefficient.

RESULTS

A high correlation between both techniques was observed for acetabular (ρ = 0.897; P < 0.001) and femoral head (ρ = 0.894; P < 0.001) cartilage in all analyzed regions of the hip joint (ρ between 0.755 and 0.955; P < 0.001).

CONCLUSIONS

Automatic cartilage segmentation with dGEMRIC assessment for hip joint cartilage evaluation seems feasible providing high to excellent correlation with manually performed ROI analysis. This technique is feasible for an objective, reader-independant and reliable assessment of biochemical cartilage status.

T2*-Mapping of Acetabular Cartilage in Patients With Femoroacetabular Impingement at 3 Tesla: Comparative Analysis with Arthroscopic Findings

Objective To evaluate the diagnostic accuracy of T2*-mapping for detecting acetabular cartilage damage in patients with symptomatic femoroacetabular impingement (FAI). Design A total of 29 patients (17 females, 12 males, mean age 35.6 ± 12.8 years, mean body mass index 25.1 ± 4.1 kg/m², 16 right hips) with symptomatic FAI underwent T2* MRI and subsequent hip arthroscopy. T2* values were obtained by region of interest analysis in seven radially reformatted planes around the femoral neck (anterior, anterior-superior, superior-anterior, superior, superior-posterior, posterior-superior, posterior). Intraoperatively, a modified Outerbridge classification was used for assessment of the cartilage status in each region. T2* values and intraoperative data were compared, and sensitivity, specificity, negative predictive values (NPV) and positive predictive values (PPV) as well as the correlation between T2*-mapping and intraoperative findings, were determined. The mean time interval between MRI and arthroscopy was 65.7 ± 48.0 days. Results Significantly higher T2* values were noted in arthroscopically normal evaluated cartilage than in regions with cartilage degeneration (mean T2* 25.6 ± 4.7 ms vs. 19.9 ± 4.5 ms; P < 0.001). With the intraoperative findings as a reference, sensitivity, specificity, NPV and PPV were 83.5%, 67.7%, 78.4% and 74.4%, respectively. The correlation between T2*-mapping and intraoperative cartilage status was moderate (ρ = -0.557; P < 0.001). Conclusions T2*-mapping enabled analysis of acetabular cartilage with appropriate correlation with intraoperative findings and promising results for sensitivity, specificity, PPV, and NPV in this cohort. Our results emphasize the value of T2*-mapping for the diagnosis of hip joint cartilage pathologies in symptomatic FAI.

Single Stem Cell Imaging and Analysis Reveals Telomere Length Differences in Diseased Human and Mouse Skeletal Muscles

Muscle stem cells (MuSCs) contribute to muscle regeneration following injury. In many muscle disorders, the repeated cycles of damage and repair lead to stem cell dysfunction. While telomere attrition may contribute to aberrant stem cell functions, methods to accurately measure telomere length in stem cells from skeletal muscles have not been demonstrated. Here, we have optimized and validated such a method, named MuQ-FISH, for analyzing telomere length in MuSCs from either mice or humans. Our analysis showed no differences in telomere length between young and aged MuSCs from uninjured wild-type mice, but MuSCs isolated from young dystrophic mice exhibited significantly shortened telomeres. In corroboration, we demonstrated that telomere attrition is present in human dystrophic MuSCs, which underscores its importance in diseased regenerative failure. The robust technique described herein provides analysis at a single-cell resolution and may be utilized for other cell types, especially rare populations of cells.

•

MuQ-FISH is a telomere analysis assay of mouse and human muscle stem cells

•

Highly sensitive telomere analysis on small numbers of cells

•

Detection of both telomere length and number of telomere foci with MuQ-FISH assay

•

Telomere analysis is now possible in quiescent and/or cycling stem cells

Lateral center-edge angle on conventional radiography and computed tomography

BACKGROUND

Lateral center-edge angle (LCEA), originally described and validated on AP radiographs, has been used increasingly in CT-based studies, but it is unclear whether the measure is reliable and whether it correlates with that on AP radiographs.

QUESTION/PURPOSES

We therefore determined: (1) the interobserver and intraobserver reliabilities of the LCEA measured on AP radiographs; (2) the interobserver and intraobserver reliabilities of the LCEA measured on CT scans; and (3) the intermodality correlation of the LCEA between CT and AP radiography.

METHODS

We reviewed the AP radiographs and CT scans of 22 patients treated for slipped capital femoral epiphyses. CT scans were reoriented to a neutral pelvic tilt and inclination. Three evaluators measured the LCEA on the unaffected hip on the AP and CT coronal images that corresponded to the center of the acetabulum on the axial slice.

RESULTS

We found an interobserver intraclass correlation (ICC) analysis of 0.84 for the AP radiographs and 0.88 for the CT scans. The intraobserver ICC for the AP radiographs was 0.96, and for the CT scans 0.98. The intermodality ICC for the CT scans and AP radiographs was 0.79, with a lower bound of 0.61 and an upper bound of 0.87.

CONCLUSIONS

Our data suggest the LCEA measured on a CT scan is reliable and correlates with the LCEA on AP radiographs.

What is the evidence supporting the prevention of osteoarthritis and improved femoral coverage after shelf procedure for Legg-Calvé-Perthes disease?

BACKGROUND

The evidence supporting continued use of shelf acetabuloplasty in Legg-Calvé-Perthes disease (LCPD) is not well-defined, and there is controversy regarding the long-term benefits related to clinical and functional improvement.

QUESTIONS/PURPOSES

Our goals were to determine whether shelf arthroplasty for LCPD (1) prevents the onset of early osteoarthritis; (2) improves pain, ROM, activity, and functional outcomes; (3) maintains or improves femoral head containment, sphericity, and congruency; (4) changes the acetabular index; and (5) is associated with a low rate of complications.

METHODS

We performed a systematic review of the medical literature from 1966 to 2009 using the search terms Perthes, shelf procedure, and acetabuloplasty. We excluded reports using multiple/combined treatment methods and those not clearly stratifying outcomes. Thirteen studies met the criteria. There were no Level I studies, one Level II prognostic study, five Level III therapeutic studies, and seven Level IV studies. Mean followup ranged from 2.6 to 17.9 years.

RESULTS

Only one study reported progression to early osteoarthritis in one patient. We found no evidence for improvement in ROM and continued pain relief at long-term followup. Mean decrease in lateral subluxation ratio was 13% to 30%, demonstrating an improvement in femoral head containment. Mean acetabular cover percentage improved 16% to 38%, and mean acetabular and center-edge angles improved 4° to 14° and 8° to 33°, respectively. There were no reports of any major complications after the procedure.

CONCLUSIONS

While radiographic measurements indicate improved coverage of the femoral head after shelf acetabuloplasty for LCPD, available evidence does not document the procedure prevents early onset of osteoarthritis or improves long-term function.

Triple innominate osteotomy for Legg-Calvé-Perthes disease in children: does the lateral coverage change with time?

BACKGROUND

Triple innominate osteotomy (TIO) is one of the modalities of surgical containment in Legg-Calvé-Perthes disease (LCPD). However, overcoverage with TIO can lead to pincer impingement.

QUESTIONS/PURPOSES

We therefore asked (1) whether TIO contained the femoral head in Catterall Stages III and IV of LCPD; (2) whether the center-edge (CE) angle, acetabular roof arc angle (ARA), and Sharp's angle changed during the growing years; and (3) what percentage of patients had radiographic evidence of pincer impingement beyond a minimum followup of 3 years.

METHODS

We identified 19 children who had 20 TIOs performed for Catterall Stages III and IV LCPD. Two blinded observers assessed sequential radiographs. Each observer made two sets of readings more than 2 weeks apart. Femoral head extrusion index, CE angle of Wiberg, ARA, and Sharp's angle were measured. Minimum followup was 3 years to document continued acetabular growth (mean, 3.8 years; range, 3-7 years).

RESULTS

All patients exhibited femoral head containment at last followup. Eleven of 20 hips demonstrated no radiographic evidence of pincer morphology beyond a minimum followup of 3 years (mean, 3.8 years). Patients with CE angle corrected to 44° or less and an ARA of greater than -6° after TIO did not demonstrate a pincer morphology at last followup.

CONCLUSIONS

TIO resulted in femoral head containment in all cases. Lateral acetabular coverage changed during the growing years in all patients. Surgical correction beyond 44° of CE angle and -6° of ARA should be avoided to prevent pincer morphology later.

Reliability of plain radiographic parameters for developmental dysplasia of the hip in children

INTRODUCTION

Few studies have evaluated the reliability and reproducibility of the femoral neck-shaft angle (NSA), center-edge angle (CEA), and acetabular index (AI) in young children with developmental dysplasia of the hip (DDH). We wanted to determine whether these parameters could be used reliably by practitioners.

METHODS

Fifty radiographs from 21 children with DDH were reviewed. Analysis was performed by three observers, at two time periods. The intra- and inter-observer reliability for each measure was assessed.

RESULTS

At time period one, we noted a "high" level of agreement between observers when measuring the NSA, a "low" level when measuring the CEA, and a "moderate" level when measuring the AI. At time period two, we noted a "very high" level of agreement between observers when measuring the NSA and a "high" level when measuring the CEA and AI. When comparing the measurements of observer 1 at the two different time periods, we noted nearly "very high" agreement when measuring the NSA, a "moderate" agreement when measuring the CEA, and a "high" agreement for the AI. In comparing the measurements of observer 2, we noted "very high" agreement for the NSA and "high" agreement for the CEA and AI. In comparing the measurements for observer 3, we noted nearly "very high" agreement for the NSA, nearly "high" agreement for the CEA, and "high" agreement for the AI.

CONCLUSION

It is difficult to reliably measure three-dimensional pelvic morphology on a frontal plane radiograph, especially when important pelvic landmarks have yet to ossify.

Three-dimensional delayed gadolinium-enhanced magnetic resonance imaging of hip joint cartilage at 3T: a prospective controlled study

PURPOSE

To assess acetabular and femoral hip joint cartilage with three-dimensional (3D) delayed gadolinium-enhanced magnetic resonance imaging (dGEMRIC) in patients with degeneration of hip joint cartilage and asymptomatic controls with morphologically normal appearing cartilage.

METHODS AND MATERIALS

A total of 40 symptomatic patients (18 males, 22 females; mean age: 32.8±10.2 years, range: 18-57 years) with different hip joint deformities including femoroacetabular impingement (n=35), residual hip dysplasia (n=3) and coxa magna due to Legg-Calve-Perthes disease in childhood (n=2) underwent high-resolution 3D dGEMRIC for the evaluation of acetabular and femoral hip joint cartilage. Thirty-one asymptomatic healthy volunteers (12 males, 19 females; mean age: 24.5±1.8 years, range: 21-29 years) without underlying hip deformities were included as control. MRI was performed at 3 T using a body matrix phased array coil. Region of interest (ROI) analyses for T1Gd assessment was performed in seven regions in the hip joint, including anterior to superior and posterior regions.

RESULTS

T1Gd mapping demonstrated the typical pattern of acetabular cartilage consistent with a higher glycosaminoglycan (GAG) content in the main weight-bearing area. T1Gd values were significantly higher in the control group than in the patient group whereas significant differences in T1Gd values corresponding to the amount of cartilage damage were noted both in the patient group and in the control group.

CONCLUSIONS

Our study demonstrates the potential of high-resolution 3D dGEMRIC at 3 T for separate acetabular and femoral hip joint cartilage assessment in various forms of hip joint deformities.

Proximal humerus fractures in the pediatric population: a systematic review

PURPOSE

Proximal humerus fractures and epiphyseal separations in skeletally immature children and adolescents are traditionally treated non-operatively. Recently, authors have described the operative fixation of these injuries, particularly in older children and adolescents with displaced fractures. We performed a systematic review of the literature to identify operative indications for proximal humerus fractures in children and to compare the results by age, displacement, and treatment modality.

METHODS

A systematic review of the literature from January 1960 to April 2010 was performed. All studies with patients under the age of 18 years who were treated for a proximal humerus fracture either operatively or non-operatively were included.

RESULTS

The available literature is largely composed of uncontrolled case series (Level IV). According to findings, the literature shows that asymptomatic union is the rule in proximal humerus fractures in children and adolescents. Poorer outcomes were noted in operatively treated patients, patients with more displaced fractures, and older patients.

CONCLUSIONS

The currently available literature supports a non-operative treatment approach, particularly in younger children with more growth remaining. Older patients (>13 years) with more widely displaced fractures may benefit from anatomic reduction with stabilization, though the data in the literature at this point is too weak to strongly recommend this approach. Further analysis with a more rigorous scientific method is necessary to evaluate the optimum treatment modality in this subgroup.

Case reports: two cases of glenohumeral chondrolysis after intraarticular pain pumps

BACKGROUND

Acute idiopathic chondrolysis in young adults is rare. The etiology often is unknown and outcomes can be devastating owing to rapid development of painful secondary osteoarthritis. There have been some recent reports of chondrolysis after arthroscopic shoulder procedures. Animal and laboratory data suggest chondrolysis is related to the use of intraarticular pain pumps, although there is no conclusive evidence that this is causative in patients.

CASE DESCRIPTION

We present two cases of young adults with chondrolysis of the humeral head after intraarticular pain pump use with humeral head resurfacing and biologic glenoid resurfacing.

LITERATURE REVIEW

Several authors report glenohumeral chondrolysis after shoulder arthroscopy involving the use of bupivacaine pain pumps. In addition, experimental animal studies have confirmed the presence of chondrolysis after bupivacaine infusion.

PURPOSES AND CLINICAL RELEVANCE

These cases provide additional evidence of an important association between postarthroscopic chondrolysis of the glenohumeral joint and the use of bupivacaine pain pumps.

Arthroscopically assisted removal of intraosseous ganglion cysts of the distal tibia

Intraosseous ganglia of the distal tibia are rare. We evaluated the feasibility of surgically treating these lesions with an arthroscopically assisted technique. Five patients with symptomatic distal tibial ganglia underwent surgical curettage and excision with this technique. All patients underwent débridement of the chondral lesion and hypertrophied synovial lining when present, probing of the portal to the ganglion, and subsequently thorough curettage with bone grafting performed through a cortical window made from a separate small incision. Biopsy confirmed the diagnosis in all patients. All patients had eventual relief of symptoms with good integration of bone graft at final followup. There were no recurrences at a minimum followup of 19 months (mean, 38.6 months; range, 19-69 months). Mean time for return to full function was 15.4 weeks (range, 8-17 weeks). There were no intraoperative or postoperative complications. The mean American Orthopaedic Foot and Ankle Society scores increased from 73 points (range, 67-77 points) preoperatively to 94 points (range, 90-100 points) postoperatively. Arthroscopically assisted surgical treatment of ganglia of the distal tibia in the appropriate patient is a reasonably simple technique that relieves symptoms and helps the patient to regain normal gait and full function with no recurrence (in our small series).

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Orthopaedic issues in the musculoskeletal care of adults with cerebral palsy

AIMS

Orthopaedic care of adults with cerebral palsy (CP) has not been well documented in orthopaedic literature. This paper focuses on some of the common problems which present themselves when adults with CP seek orthopaedic intervention. In particular, we review the most common orthopaedic issues which present to the Penn Neuro-Orthopaedics Program.

METHOD

A formal review of consecutive surgeries performed by the senior author on adults with CP was previously conducted. This paper focuses on the health delivery care for the adult with orthopaedic problems related to cerebral palsy. Ninety-two percent of these patients required lower extremity surgery. Forty percent had procedures performed on the upper extremities.

RESULTS

The majority of problems seen in the Penn Neuro-Orthopaedics Program are associated with the residuals of childhood issues, particularly deformities associated with contractures. Patients are also referred for treatment of acquired musculoskeletal problems such as degenerative arthritis of the hip or knee. A combination of problems contribute most frequently to foot deformities and pain with weight-bearing, shoewear or both, most often due to equinovarus. The surgical correction of this is most often facilitated through a split anterior tibial tendon transfer. Posterior tibial transfers are rarely indicated. Residual equinus deformities contribute to a pes planus deformity. The split anterior tibial tendon transfer is usually combined with gastrocnemius-soleus recession and plantar release. Transfer of the flexor digitorum longus to the os calcis is done to augment the plantar flexor power. Rigid pes planus deformity is treated with a triple arthrodesis. Resolution of deformity allows for a good base for standing, improved ability to tolerate shoewear, and/or braces. Other recurrent or unresolved issues involve hip and knee contractures. Issues of lever arm dysfunction create problems with mechanical inefficiency. Upper extremity intervention is principally to correct contractures. Internal rotation and adductor tightness at the shoulder makes for difficult underarm hygiene and predispose a patient to a spiral fracture of the humerus. A tight flexor, pronation pattern is frequently noted through the elbow and forearm with further flexion contractures through the wrist and fingers. Lengthenings are more frequently performed than tendon transfers in the upper extremity. Arthrodesis of the wrist or on rare occasions of the metacarpal-phalangeal joints supplement the lengthenings when needed.

CONCLUSIONS

The Penn Neuro-Orthopaedics Program has successfully treated adults with both residual and acquired musculoskeletal deformities. These deformities become more critical when combined with degenerative changes, a relative increase in body mass, fatigue, and weakness associated with the aging process.

Tibial tuberosity fractures in adolescents

BACKGROUND

Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm.

METHODS

We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria.

RESULTS

There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively.

CONCLUSION

Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open as appropriate) gives good results. All the patients in our series had surgical fixation as per different indications that have been elaborated. It is important for clinicians to recognize that compartment syndrome remains a significant concern post-injury and in the perioperative period. Close monitoring and timely intervention is recommended. A simple treatment algorithm is presented for clinicians to help manage these injuries.

Fixation techniques for split anterior tibialis transfer in spastic equinovarus feet

Equinovarus of the foot is the most common lower extremity deformity following traumatic brain injury. We evaluated outcomes of the split anterior tibialis tendon transfer (SPLATT) for correction of equinovarus in 47 patients with hemiplegic traumatic brain injury and specifically studied differences in outcomes with two tendon fixation techniques. Seventeen patients constituting Group I underwent fixation with one technique and 30 constituting Group II had another technique. Patients in both groups had appropriate procedures based on dynamic electromyography and gait analyses. Both groups were demographically comparable. All 47 feet were corrected to plantigrade position. Thirty-six of 47 patients became brace-free at final followup. There was a notable decrease in the use of ambulatory aids and ambulatory status improved in both groups. There were three fixation-related complications in Group I and none in Group II. Surgical correction of the spastic equinovarus with SPLATT, in the appropriate patient, with or without associated tendon procedures helps to achieve and maintain correction, improves the ambulatory status of the patient, and eliminates the need for bracing in as much as 77% of patients. We recommend the Group II construct owing to the considerably lower complication rate.

Abnormal scarring with keloid formation after osteochondroma excision in children with multiple hereditary exostoses

INTRODUCTION

Multiple hereditary exostoses (MHE) is an autosomal dominant condition characterized by numerous cartilage-capped exostoses/osteochondromas in areas of actively growing bone. Abnormal scarring with keloid formation after osteochondroma excision in children with MHE has not been previously described.

METHODS

A retrospective double-cohort study was undertaken to determine if children with MHE have a higher rate of abnormal scarring with keloid formation after osteochondroma excision when compared with those with solitary osteochondroma. In the initial phase, all consecutive children with MHE that underwent excision of osteochondroma with a minimum 2-year postoperative follow-up were identified. A control group of age-matched cases of solitary osteochondroma was subsequently identified. All patients were interviewed for wound healing problems and noncosmetic scarring. All patients with unsatisfactory scars were asked to send pictures and/or were invited for follow-up. Data were statistically analyzed.

RESULTS

Eighty-three surgeries were performed in 25 patients with MHE, whereas 25 surgeries were performed in 25 patients with solitary osteochondroma. Twelve keloid scars were noted in 7 patients with MHE, and no keloids were noted in any of the patients in the solitary group. Diagnosis of MHE was a statistically significant risk factor for formation of keloids after surgery (P < 0.05).

DISCUSSION

Abnormal scarring with keloid formation after osteochondroma excision in MHE has not been previously reported. Although this study has limited numbers, the results demonstrate a statistically significant correlation between keloid formation and MHE. The risk for abnormal scarring and keloid formation should be discussed with all patients before surgery.

Scoliosis correction in an adolescent with a rigid spine syndrome: case report

STUDY DESIGN

Details of presentation and approach to the treatment of scoliosis in a case of a Rigid Spine Syndrome (RSS).

OBJECTIVE

To report on the results of conservative and operative treatment of scoliosis associated with RSS, and, based on this, to propose an assessment and treatment protocol for this condition.

SUMMARY OF BACKGROUND DATA

Congenital muscular dystrophies (CMD) are a group of disorders marked by hypotonia at birth and a generally nonprogressive course of muscle weakness. Spinal rigidity is present in a number of patients with CMD. RSS is classified as a CMD, and is characterized by early rigidity of the spine, limb contractures, and restrictive respiratory dysfunction. An approach to the treatment of scoliosis in RSS has not been established.

METHODS

Details of history, diagnostic tests, and treatment of an adolescent with RSS associated with progressive scoliosis and cervical spine extension contracture is presented. The role of brace treatment, Botox (Allergan, Inc., Irvine, CA), and details of operative correction, including histology of back muscles, is defined.

RESULTS

In this case of RSS with rigid scoliosis nonresponsive to brace therapy and Botox injections, an anterior thoracolumbar spine fusion with instrumentation was successfully performed for correction of the scoliosis, and the cervical spine was addressed through a posterior approach and an occiput-cervical fusion. We outline the details of surgical procedure and restoration of spinal balance in both sagittal and coronal planes.

CONCLUSIONS

The chromosomal bases of CMD and characteristic features of RSS, including diagnostic tests, have been reviewed. Surgical intervention with spinal deformity fusion, correction, and instrumentation is indicated in RSS with progressive spinal imbalance not responding to conservative therapy is safe and can give promising results.

Surgical management of pelvic sarcomas in children

Pelvic sarcomas are uncommon in childhood. Survival rates of children with pelvic sarcomas have shown significant improvements over the past few decades. Correspondingly, there has been an increase in limb-sparing surgical procedures being performed in these children. This could be attributed in part to the newer generation imaging techniques, wider armamentarium of surgical techniques of reconstruction, and limb-salvage and advances in neo-adjuvant chemotherapy and radiotherapy. Reconstruction after resection of pelvic sarcomas while preserving function of the hip and limb can be extremely challenging especially in children where there are issues of growth potential and limb-length discrepancies. This article focuses on the presentation and epidemiology of different types of pelvic sarcomas in children, the current state-of-art of imaging and surgical management of children with pelvic sarcomas.

Spondylocostal dysostosis: thirteen new cases treated by conservative and surgical means

STUDY DESIGN

Prospective assessment of a cohort of patients affected by spondylocostal dysostosis.

OBJECTIVE

To report on the results of conservative and operative management of spondylocostal dysostosis and, based on this, to propose an assessment and treatment protocol for the condition.

SUMMARY OF BACKGROUND DATA

Spondylocostal dysostosis and spondylothoracic dysostosis are subtypes of Jarcho-Levin syndrome, a hereditary condition manifested by vertebral body and related rib malformations. Mortality prevails in spondylothoracic dysostosis because of more severe respiratory compromise.

METHODS

Details of prenatal and postnatal diagnosis, history, and management of 13 patients with spondylocostal dysostosis are presented. All patients were treated postnatally with repeated chest physiotherapy. Two patients refractory to conservative treatment underwent surgical intervention: the first had a chest wall reconstruction via a latissimus dorsi flap, the second a posterior spinal instrumented fusion for progressive scoliosis.

RESULTS

Prenatal ultrasound in 4 of 13 cases showed full details of vertebral and rib anomalies. Thoracic and lumbar hemivertebrae were most common, leading to congenital scoliosis in 10 of 13 cases. A number of extraskeletal abnormalities were also identified. At an average follow-up of 4.5 years, the survival rate was 100% with a remarkable decrease of the rate of respiratory complications. Surgical treatment in selected cases led to satisfactory results.

CONCLUSIONS

Prenatal diagnosis of spondylocostal dysostosis allows exclusion of spondylothoracic dysostosis and aids genetic counseling in quantifying the risk to siblings. Postnatally, prompt management of these patients with physiotherapy leads to prolonged survival. Surgical intervention may then be indicated to stabilize chest wall or spine deformities, with promising results.

Quadriplegia in a 10 year-old boy due to multiple cervical neurofibromas

STUDY DESIGN

A case report of a child with quadriplegia as a result of neurofibromatosis type I who had cervical laminectomy for spinal cord decompression followed by occipitocervical instrumentation is described.

OBJECTIVES

To describe the consequences of severe neurofibromatosis type I and an effective surgical technique of occipitocervical instrumentation.

SUMMARY OF BACKGROUND DATA

Neurofibromatosis type I is one of the most commonly inherited genetic disorders in the human population. Extensive intraspinal involvement by neurofibromas can cause significant distortion of normal spinal structure as well spinal cord compression. Extensive laminectomy (with subsequent risk of postsurgical kyphosis) is often required for adequate decompression of the spinal cord.

METHODS

The clinical and radiographic presentation of a child with severe neurofibromatosis type I resulting in quadriplegia is described. The severe neurologic deficit was caused by compression of the spinal cord by intraspinal neurofibromas. Extensive laminectomy was required to adequately decompress the spinal cord. Occipitocervical fusion from the occiput to C6 was done to stabilize the spine and prevent future kyphosis.

RESULTS

Decompression of the spinal cord led to complete neurologic recovery, and instrumentation of the cervical spine was successful in preventing the development of postlaminectomy kyphosis in this pediatric patient.

CONCLUSIONS

The reported case emphasizes the need for treating acute neurologic symptoms caused by spinal cord compression in neurofibromatosis type I as well as addressing the future risk of spinal deformity following laminectomy.

A study of epidural pressures in infants

BACKGROUND

The pressures exerted on fragile structures in the infant during epidural injections have never been studied previously.

METHODS

We measured the pressure changes in the epidural space of 20 infants during injection of local anaesthetic solutions. The pressures developed during passage of the epidural needle through the ligaments of spine and in the epidural space during the injection of 1 ml at two rates of injection, over 1 and 2 min and the residual pressure 1 and 2 min after each injection were studied.

RESULTS

The mean pressure while the needle was being advanced through the ligamentum flavum was 69.14 +/- 36.95 mmHg. The epidural pressure after needle had just penetrated the ligament without eliciting the loss of resistance was 1 +/- 9.759 mmHg. A distinct pulsatile waveform identical to the pulse waveform was observed as soon as the epidural space was entered. The pressure rise varied according to the rate of injection. The pressures were 27.79 mmHg when the rate of injection was 1 ml.min(-1), with a residual pressure after 1 min of 12 +/- 5.53 mmHg and 10.14 +/- 5.53 mmHg after 2 min of injection. When the rate of injection was 1 ml.2 min(-1), the pressures were 15.66 +/- 9.48 mmHg with a residual pressure after 1 min of 14.79 +/- 5.15 mmHg and 12.93 +/- 5.46 mmHg after 2 min of injection.

CONCLUSIONS

The residual pressures seem to vary more with the volume injected than the rate of injection or the pressures developed during the injection. The relationship between the rate of injection and pressures is significant when compared with adults where the pressures have been measured after an injection rate of 1 ml.s(-1) and 1 ml.5 s(-1). This is a very fast rate compared with our rates of injection of 1 ml over 1 and 2 min. Based on the findings of this study, we recommend a rate of 1 ml.2 min(-1) in infants. In neonates, a slower rate of injection would be preferable.

Familial torticollis with polydactyly: manifestation in three generations

Familial transmission of congenital muscular torticollis (CMT) has been reported in the literature, and postaxial polydactyly has been frequently reported in familial cases, but, to our knowledge, familial CMT with postaxial polydactyly has not been described. In this article, we report a rare case of CMT with postaxial polydactyly in 3 generations of a family and suggest an autosomal-dominant pattern of inheritance in these cases.

Complications of anaesthesia and surgery for laryngotracheo-oesophageal cleft

Laryngotracheo-oesophageal cleft presents great difficulty in airway management. Tracheostomy and/or bilateral endobronchial intubation to secure the airway and a feeding gastrostomy are essential to sustain life until major definitive surgery can be planned. We describe the anaesthesia for these emergency life saving procedures in a 1.1-kg, 2-day-old neonate of 29 weeks gestation with apnoeic spells. Endoscopy to diagnose the extent of cleft, probable tracheostomy and gastrostomy were planned. Oesophagoscopy and bronchoscopy revealed a grade 3-4 cleft. Inadequate spontaneous ventilation during these procedures necessitated positive pressure ventilation. This resulted in a gaseous distension of an intact stomach which could be decompressed into the oesophagus. After the bronchoscopy, the use of a 3-mm tracheal tube without a Murphy's eye minimized the distension during gastrostomy. There was an accidental extubation after gastrostomy. Emergency reintubation with a 4-mm tracheal tube with a Murphy's eye resulted in gastric distension which led to tension pneumoperitoneum with a disappearance of PECO2. Misdiagnosis of this as loss of airway led to repeated intubations and extubation until the pneumoperitoneum was suspected and decompressed. After this setback, the baby's condition deteriorated over the next few hours ending fatally. The problems and suggestions to avoid these complications are discussed.

Difficult intubation in a case of ankylosing spondylitis: a case report

A case of severe ankylosing spondylitis involving the entire spine was to be operated for lumbar osteotomy. She had fixed rigidity of the cervical spine with minimal rotational movement, inability to lie down supine and severe restrictive lung disease with hypoxemia (pO2 = 65 mmHg). An awake intubation was performed and the patient was operated under general anaesthesia in the prone position. Intraoperative "wake-up" test was performed to judge whether extent of straightening was excessive. Postoperatively, she was electively ventilated and extubated uneventfully after 24 hours.