Partial wound closure after surgical correction of equinovarus foot deformity.

Full correction of severe equinovarus foot deformities is frequently lost at the end of surgical release when the surgeon closes the skin incision. We retrospectively review 31 feet in 22 patients whose medial skin incisions were left open (typically 10 mm) to heal by secondary intention. The criterion to leave a wound open was if primary closure with the foot in full correction might compromise circulation to the skin or if closing the incision would require loss of corrected position. One or two cast changes were performed under outpatient anesthesia at 7- to 14-day intervals for wound care. All wounds except one were healed by week 6 at time of outpatient clinic cast removal. The appearance of the incisions is similar to feet in which primary closure is possible. One foot required split-thickness skin grafting at 3 weeks postoperatively to achieve wound coverage. There were no infections. We conclude that primary skin closure is not essential after surgical correction of equinovarus foot deformity, and that correction need not be compromised to approximate skin.

Endocrine disorders and orthopedic problems in children.

Endocrine excesses or deficiencies frequently result in alterations of height as compared with age-matched children. Less clinically obvious are significant alterations in bone metabolism leading to osteoporosis, which can affect the child and may affect the patient as an adult. Slipped capital femoral epiphysis appears to be associated with a variety of endocrine disorders, particularly hypothyroidism. The hormonal treatment of various endocrine and nonendocrine disorders has been associated with alterations of bone metabolism, or of bone maturation, as well as with producing or aggravating orthopedic disorders.

Reduced transverse spinal area secondary to burst fractures: is there a relationship to neurologic injury?

A retrospective case-control study was undertaken to determine the best technique to measure neural canal encroachment at each lumbar level following burst fracture and its relationship to the presence of neurologic deficit. Only patients with postinjury CT scans demonstrating a disrupted posterior body with a retropulsed bone fragment were included. Patients were divided into groups based on the level of bony injury (T12-L5) and neurologic status. Neurologic injury was classified as follows: normal (N), root (R), or cauda equina/conus/paraplegic/paraparetic (C/P). The mean transverse spinal area (TSA, cm2), spinal canal percentage patency (PP), and midsagittal diameter (MSD) were determined for each neurologic group and lumbar level. A "calculated" TSA, based on midsagittal and anterior-posterior diameters, was also derived for each patient. The data were compared level by level and correlated with the patient's neurologic status. At L1, the critical TSA was 1.0 cm2. All patients with TSAs less than this were paraplegic. At both T12 and L1, TSAs in the range of 1.0-1.25 cm2 were observed in both normal and neurologically impaired patients. A critically significant TSA was not established for levels T12, L2, L3, L4, or L5; however, the data indicated that a smaller TSA can be tolerated at successively caudal levels without neurologic deficit. No meaningful correlation between root injury and TSA was observed. The data also indicated that measurement of TSA is a more accurate method for evaluating neural canal encroachment than PP or MSD. The "calculated" TSA is a simple, objective method for obtaining this information without the aid of a computer. This study suggests that absolute TSA should be utilized in future studies evaluating decompressive treatment of thoracolumbar pathology.

Pediatric seatbelt injuries: diagnosis and treatment of lumbar flexion-distraction injuries.

Motor vehicle accidents are the major cause of flexion-distraction injuries of the thoracolumbar spine. In a retrospective review, we present the results of operative treatment for six pediatric patients who sustained such injuries while wearing seatbelts. There were three purely ligamentous injuries, two bony injuries (Chance fractures), and one combination injury. There were also concomitant neurological and intra-abdominal injuries. Of note is that two patients had either their spinal or abdominal injury missed on initial evaluation. All patients were treated surgically with open reduction and internal fixation. At average follow up of 2 years, all patients had a full range of motion with no back pain. Five had returned to their preinjury activity levels, while the sixth patient was paraplegic from his injury but was able to ambulate at home with crutches and knee-ankle-foot orthoses. We recommend operative reduction and two-level fusion of these injuries when (1) instability is apparent in either a purely ligamentous injury or an overtly unstable fracture-pattern, (2) significant kyphosis is present which cannot be reduced or maintained in a cast, or (3) there is associated neurological or intra-abdominal injury.

Spinal injuries in 57 patients 17 years or younger.

Spinal column and cord injuries are rare in children and adolescents, and few reports in the literature that specifically address this subject. A retrospective review of medical records and radiographs of 57 patients was undertaken to identify age-related injury patterns, the incidence of neurologic deficits, and the presence of associated injuries. The most common injury in very young patients was spinal cord injury without radiographic abnormality or spinal cord injury with non-contiguous radiographic abnormality. The most common injury in older children was flexion-distraction injury, often associated with intraabdominal trauma. Adolescents tended to sustain injury patterns similar to adults.

Triple arthrodesis in the treatment of fixed cavovarus deformity in adolescent patients with Charcot-Marie-Tooth disease.

Ten adolescent patients with Charcot-Marie-Tooth disease (12 feet) were evaluated an average of 7 years, 7 months following triple arthrodesis (TA) for the treatment of cavovarus deformity. The TA was the primary or index bone procedure. At follow-up, five feet were plantigrade, asymptomatic, and radiographically fused at all three joints. Three feet were plantigrade and asymptomatic, but two had talonavicular pseudarthrosis and one had calcaneocuboid pseudarthrosis. Three feet were radiographically fused at all three joints, but in nonplantigrade positions and symptomatic. One foot required a revision TA. In general, TA offers adolescent Charcot-Marie-Tooth patients a stable plantigrade foot in the face of a progressive disorder. The residual deformity, revision, and pseudarthrosis rates are similar to those for adults. Postoperative pain was related to a nonplantigrade foot and not to the presence of pseudarthrosis. It is not known whether a nonplantigrade foot was a result of incomplete surgical correction or recurrent deformity due to progressive muscle imbalance.

Unusual causes of back pain in athletes.

Typical causes of back pain in the athlete include muscle strain, intervertebral disc injury, interspinous bursitis, and spondylolysis. If initial evaluation does not indicate that any of these potential conditions is the cause, the physician or trainer should consider less common conditions. In this report, we discuss the identification and management of five unusual causes of back pain in the high school and college athlete: (a) disc space collapse after herniated disc excision, (b) sacralization of L5, (c) facet fracture of L5, (d) fracture of the lumbar vertebral apophysis, and (e) interosseous herniation of the lumbar disc.

Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years.

The distribution of 2,650 long-bone fractures in children is presented. Fractures involving the humerus, radius, ulna, femur, tibia, and fibula were classified according to Salter and Harris. Growth plate injuries accounted for 30% of fractures. Nonphyseal fractures occurred twice as often in the upper extremity as in the lower extremity. Girls with physeal fractures on the average were 1.5 years younger than boys with the same type of fracture in the same location.

Anterior plating of unstable cervical spine fractures.

Medical records and radiographs of 16 patients who had anterior decompression, bone grafting, and plating of grade III and IV (Allen 1982) unstable cervical spine injuries were reviewed. Surgery was performed within 15 days of injury, reductions were achieved and maintained at follow-up, and fusion occurred in all cases. Neurologic function stabilised or improved in all cases. However, 3 patients (19%) had complications that necessitated additional surgery: one patient with undiagnosed non-contiguous posterior instability, and 2 patients for broken plates. These complications, in retrospect, could have been avoided.

Decreasing homologous blood transfusion in spinal surgery by use of the cell saver and predeposited blood.

Blood loss and blood replacement are necessities in spinal surgery. They also have increasing risks. Three blood replacement options and combinations were investigated in patients undergoing major spinal deformity surgery. In Section 1, intraoperative replacement from harvested cell saver blood was investigated in 35 patients. This group averaged 40% (20-60%) return of the red cell mass lost intraoperatively. In Section 2, intraoperative replacement via predeposited autologous blood was investigated in 41 patients. The predeposited blood replaced 64% of the intraoperative red cell mass lost. In Section 3, ten single-stage and ten two-stage spinal surgery cases using both cell saver and autologous predeposited blood were investigated. With this program, 90% of the single-stage patients did not require additional homologous blood, while 80% of the two-stage patients did. In Section 4, 65 patients undergoing six general types of spinal surgery were examined to determine the number of predeposited autologous units needed to avoid homologous blood during hospitalization. Guidelines for determining optimal donation were developed assuming the use of intraoperative cell saver use.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

As initial surgical management for rigid equinovarus deformities, 16 children with arthrogryposis (30 involved feet) and 16 myelodysplastic children (26 involved feet) underwent primary talectomies or extensive posterior-medial releases (PMR). When compared with primary PMRs in arthrogrypotic children, primary talectomies revealed a greater number of good and fair results, decreased recurrence rates, less procedures per foot, and maintenance of ambulatory status. Recurrent forefoot and cavus deformities were present after primary talectomies. Primary talectomy in arthrogrypotic children was more effective than posterior-medial releases or secondary (salvage) talectomy. Because of the small number of feet involved, the role of primary talectomy in myelomeningocele was not clarified by this study. Radical PMRs in myelodysplastic children resulted in a significant number of hindfoot valgus deformities that required secondary procedures.

The influence of contoured distraction rods on thoracic sagittal curves.

The influence of sagittally contoured rods on thoracic sagittal curves was studied in 19 patients who underwent fusion and instrumentation for right thoracic idiopathic scoliosis. Group I included 13 patients who underwent fusions with contoured rods and no releases. Group II included six patients who had anterior or posterior spinal release procedures in addition to contoured rods and fusion. Harrington distraction rods were contoured to either increase, decrease, or maintain preoperative thoracic kyphosis. The number of kyphotic curves that changed in the intended direction, the degree of change, the relationship of the rod contour to the patient's postoperative kyphosis, and the postoperative rod contour were compared. Thirty-eight percent of the curves in group I underwent change in the unintended direction while 62% of group I curves and 100% of group II curves changed in the intended direction. The curves that demonstrated intended change exhibited variability in the relationship of the postoperative kyphosis to the rod contour. In no case did the postoperative rod kyphosis exceed the measured intraoperative rod kyphosis.

Evaluation of the role of concave rib osteotomies in the correction of thoracic scoliosis.

The role of concave rib osteotomies was studied in a series of 25 patients with right thoracic idiopathic scoliosis who underwent Harrington distraction instrumentation and segmental sublaminar wiring of the thoracic curve. Group I had ten patients with rigid curves who had instrumentation, fusion, and segmental concave rib osteotomies. Group II had 15 patients with flexible curves who underwent instrumentation and fusion alone. Preoperative side bending curve reduction averaged 23% in Group I and 49% in Group II. Postoperative correction was similar in both groups with Group I achieving 60% (+/- 10%) overall correction and Group II, 57% (+/- 8%). Group I underwent 56% further reduction from side bending compared with Group II's 12% reduction. It was concluded that if preoperative side bending correction was below 35% of standing curve, curve correction comparable to flexible cases could be achieved through multiple concave rib osteotomies. Neurologic risk was not increased, but there was increased pulmonary morbidity of 30%.

Bullet within the spinal canal.

A 13-year-old girl suffered a single gunshot wound to the abdomen that resulted in multiple small bowel perforations and an incomplete neurologic injury involving her lower extremities. Physical exam failed to locate an exit wound. Radiographs revealed the bullet within the spinal canal at the thoracolumbar junction. It was subsequently removed on a non-urgent basis.

Hormonal studies in patients with slipped capital femoral epiphysis without evidence of endocrinopathy.

In a prospective study, plasma levels of T3, T4, thyroid stimulating hormone (TSH), cortisol, testosterone, growth hormone, and somatomedin-C were tested in 20 consecutive adolescent patients with slipped capital femoral epiphysis (SCFE) in an effort to identify any occult endocrinopathy. All patients had the clinical diagnosis of SCFE confirmed on radiographs. The patients were examined by the pediatric endocrinology service and were without clinical evidence of an endocrinopathy. Of 140 hormonal determinations only four different patients had four abnormal values. Routine sampling of these hormones in patients without clinical evidence of endocrinopathy is not indicated.

Closed Ender nailing of femoral shaft fractures in adolescents.

Closed intramedullary Ender nailing of 16 femoral fractures in 15 children, 9-15 years of age, was studied retrospectively. Seven patients (46%) had additional injuries. The average time to independent ambulation was 7.1 days, and hospitalization time averaged 11.4 days. There were no infections, nonunions, or malunions. On follow-up, averaging 45.2 months, no patient had deformity of greater than 10 degrees in any plane. No patient had clinical loss of motion, leg length discrepancy, or radiographic evidence of growth disturbance.

Microbiological degradation of organic components in oil shale retort water: organic acids.

The losses of benzoic acid and a homologous series of both mono- and dibasic aliphatic acids in oil shale retort water were monitored with time (21 days) in liquid culture (4% retort water, vol/vol) inoculated with soil. The organic acids constituted approximately 12% of the dissolved organic carbon in retort water, which served as the sole source of carbon and energy in these studies. The levels of the acids in solution were reduced by 80 to 90% within 9 days of incubation. From mass balance calculations, the decrease in dissolved organic carbon with time of incubation was equal to the formation of CO(2) and bacterial cell carbon. The decrease in the level of the acid components, either from degradation to CO(2) or incorporation into bacteria, would account for approximately 70% of the loss in dissolved organic carbon within the first 9 days of incubation and would account for approximately 50% of the loss over the entire 21-day incubation period.