Late onset recurrence of clinical signs after surgery for intervertebral disc extrusion in French bulldogs.

OBJECTIVES: To identify the prevalence of recurrence of clinical signs after initial successful decompressive surgery for intervertebral disc extrusion in French bulldogs. MATERIALS AND METHODS: A medical record search was performed to identify French bulldogs that experienced an initial successful outcome after surgery for thoracolumbar or cervical intervertebral disc extrusion. Collected information included signalment, neurological examination findings, intervertebral disc extrusion location, presence of vertebral malformations, kyphosis, type and extent of surgery. Decompressive surgery was not followed by extensive prophylactic fenestrations. Follow-up information was retrieved from medical records and telephone interviews with referring veterinary surgeons. RESULTS: Eighty-four French bulldogs with thoracolumbar (n=55) or cervical (n=29) intervertebral disc extrusion were included. Forty-three (51%) dogs that had decompressive surgery for thoracolumbar (n=29) or cervical (n=14) intervertebral disc extrusion suffered recurrence of signs. The median time between decompressive surgery and recurrence of clinical signs was 9 months and 21 days. Of the 29 dogs suffering recurrence of clinical signs following surgery for thoracolumbar intervertebral disc extrusion, 24 returned for recurrence of clinical signs localised to the thoracolumbar segments, while five returned for recurrence of signs localised to the cervical region. Of the 14 dogs who suffered recurrence of signs following surgery for cervical intervertebral disc extrusion, nine returned for signs localised to the cervical region, while five returned for clinical signs localised to the thoracolumbar region. CLINICAL SIGNIFICANCE: This study suggests a high rate of late onset recurrence of clinical signs after decompressive surgery for intervertebral disc extrusion in French bulldogs. This information can aid in the management of owner expectations.

Clinical presentation and outcome of dogs treated medically or surgically for thoracolumbar intervertebral disc protrusion.

To date, few studies have investigated the clinical characteristics of thoracolumbar intervertebral disc protrusion (IVDP). The aim of this retrospective study was to evaluate the presentation and outcome of dogs receiving medical or surgical treatment for thoracolumbar IVDP. Eighty-four dogs were included, with a median age of 9.4 years. German shepherd dogs and Staffordshire bull terriers were the most common breeds. Significantly more surgically treated dogs (n=53) had neurological deficits and were non-ambulatory, compared with medically treated (n=31). Outcome data were available for 27 of 31 medically managed dogs; 11 initially improved, 7 remained stable and 9 deteriorated. Of 18 dogs that initially improved or stabilised, 10 (55.6 per cent) demonstrated recurrence of clinical signs within 12 months of diagnosis. Outcome data were available for 45 of 50 surgically treated dogs that survived to hospital discharge; 34 improved, 9 remained stable and 2 deteriorated following surgery. Of 43 dogs that improved or stabilised with surgical treatment, 11 (25.6 per cent) demonstrated recurrence of clinical signs within 12 months of surgery. Overall, significantly more surgically treated dogs (71.1 per cent) had a successful outcome, consisting of sustained clinical improvement of more than 12 months duration, compared with medically treated dogs (29.6 per cent).

Endoscopic pelvic osteotomy for the treatment of hip dysplasia.

Adolescent and adult hip dysplasia can be surgically treated by rotating the acetabulum into a better weight-supporting position; however, open pelvic osteotomies are among the most invasive of all pediatric orthopaedic procedures. Endoscopic pelvic osteotomy offers the theoretical advantages of magnified visualization of the bone cuts, minimized surgical dissection, and rapid postoperative recovery. The technique of endoscopically assisted triple innominate osteotomy requires the combination of endoscopic skills and facility with more standard surgical approaches.

The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children.

BACKGROUND: The purpose of this study was to evaluate the perioperative complication rates associated with early surgical treatment (eight hours or less following injury) and delayed surgical treatment (more than eight hours following injury) of displaced supracondylar humeral fractures in children. METHODS: Fifty-two patients had early surgical treatment and 146 patients had delayed surgical treatment of a displaced supracondylar humeral fracture. The perioperative complication rates of the two groups were compared with the use of bivariate and multivariate statistical methods. RESULTS: There was no significant difference between the two groups with respect to the need for conversion to formal open reduction and internal fixation (p = 0.56), pin-track infection (p = 0.12), or iatrogenic nerve injury (p = 0.72). No compartment syndromes occurred in either group. Power analysis revealed that our study had an 86% power to detect a 20% difference between the two groups if one existed. CONCLUSIONS: We were unable to identify any significant difference, with regard to perioperative complication rates, between early and delayed treatment of displaced supracondylar humeral fractures. Within the parameters outlined in our study, we think that the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

Tension pneumothorax as a complication of video-assisted thorascopic surgery for anterior correction of idiopathic scoliosis in an adolescent female.

STUDY DESIGN: This case report illustrates the occurrence of intraoperative tension pneumothorax, a previously unreported complication occurring during anterior instrumentation for correction of scoliosis by video-assisted surgery. OBJECTIVES: To demonstrate a consequence of overadvancement of a Steinmann pin (guide wire). SUMMARY OF BACKGROUND DATA: Although intraoperative tension pneumothorax is admitted to be a theoretical complication of video-assisted surgery for anterior correction of idiopathic scoliosis, there has yet to be a case reported in the literature. This report presents the first case of this complication. METHODS: A 13-year-old girl who had right thoracic scoliosis with a curve measuring 54 degrees underwent video-assisted surgery discectomy and anterior spinal fusion with instrumentation of T5 through T11. Single-lung ventilation had been achieved with a double-lumen tube and the right lung was deflated. After approximately 4.5 hours of complication-free surgery, intraoperative fluoroscopy showed an approximately 2-cm overadvancement of a guide wire into the opposite hemithorax. Approximately 5 minutes after the overadvancement was corrected, the patient experienced a gradual increase in heart rate and a corresponding gradual decrease in oxygen saturation and both systolic and diastolic blood pressures. Approximately 35 minutes later, it was determined that the patient had sustained a tension pneumothorax of the left hemithorax. RESULTS: The patient underwent urgent partial reinflation of the right lung and a tube thoracostomy of the left thoracic cavity. Vital signs quickly returned to stable levels, and the left lung easily reinflated with the chest tube suction. The patient remained stable after the procedure was resumed (by right lung deflation). The remainder of the surgery and the postoperative course were uneventful. CONCLUSIONS: Although video-assisted surgery continues to gain popularity in the management of spinal deformities, the surgical team must be certain to pay meticulous attention to detail throughout the procedure. The early detection and treatment of complications can be life-preserving.

Two cases of osteochondroma recurrence after surgical resection.

Osteochondromas are the most common bone tumor found in children. A review of 114 resected osteochondromas over a 10-year period revealed recurrence in 2 cases. The overall recurrence rate of these lesions is less than 2% and was found to be 1.8% in this review.

Traumatic hip dislocation in children. Long-term followup of 42 patients.

To assess the impact of traumatic hip dislocations in the skeletally immature patient, 42 children younger than 16 years of age (average age, 9 years 10 months) who were treated at the authors' institution were studied. Data were collected from charts and radiographs and by completion of questionnaires. The average followup after injury was 10 years 1 month. The majority of dislocations (64%) were attributable to low energy injuries. Ipsilateral fractures about the hip occurred in 17% of patients. Avascular necrosis of the femoral head developed in 12% of patients, with the amount of time spent dislocated being the only statistically proven risk factor. Patients whose reduction was delayed greater than 6 hours had a 20 times higher risk of having avascular necrosis develop compared with patients whose hips were reduced in 6 hours or less. The use of computed tomography for joint asymmetry of 3 mm or greater and omission of bone scan screening were supported by this study. Functional outcomes were very good in this series with 95% of patients suffering mild (usually weather related) or no pain and 95% of patients suffering mild pain (intermittently noticeable) or no limp. A large percentage of the patients (78%) continued to participate in high demand activities such as football, soccer, and basketball.

Modulation of spinal deformities in patients with neurofibromatosis type 1.

STUDY DESIGN: A consecutive case retrospective chart and radiographic review. OBJECTIVES: To determine the incidence of nine radiographic dystrophic features acquired during the process of modulation, and to analyze the statistical correlation of these acquired dystrophic features with clinical progression of a spinal deformity. SUMMARY OF BACKGROUND DATA: In patients with neurofibromatosis, spinal deformities with seemingly few initial dystrophic features have shown a tendency to acquire dystrophic changes during long-term follow-up periods. Similarly, deformities with dystrophic changes can acquire further dystrophic features. This phenomenon is termed "modulation," a feature unique to spinal deformities in neurofibromatosis. These dystrophic changes may evolve slowly or aggressively, and may spread to other regions as well. METHODS: A review was done of the clinical records, photographs, radiographs, and other imaging studies of 457 patients referred between 1982 and 1995 with the diagnosis of neurofibromatosis Type 1. One hundred twenty-eight patients were diagnosed with a spinal deformity. Ninety-one patients who had a complete set of clinical and radiographic data were included in the study. Location and type of curve as well as the extent of spinal deformity were studied for their effect on the tendency for modulation. Initial spinal radiographs were analyzed for nine radiographic dystrophic features: rib penciling, vertebral rotation, posterior vertebral scalloping, anterior vertebral scalloping, lateral vertebral scalloping, vertebral wedging, spindling of the transverse process, widened interpedicular distance, and enlarged intervertebral foramina. Subsequent radiographs were analyzed critically for evolution, progression, or spread of these features. Correlation of acquisition in these dystrophic features with clinical progression in the spinal deformity, as measured in increments of scoliosis and kyphosis, was analyzed. RESULTS: In 81% of patients with spinal deformity diagnosed before 7 years of age and in 25% of patients with such a diagnosis after 7 years of age, evidence of modulation was observed. Location, side, and extent of the deformity and patient gender did not influence the propensity of the deformity to modulate. Correlation of modulation with clinical progression of the deformity showed rib penciling to be the only singular factor statistically influencing risk of progression. Of the deformities that acquired three or more penciled ribs, 87% showed significant clinical progression. No other radiographic dystrophic feature individually influenced progression. However, when three or more of the dystrophic skeletal features were acquired, the risk of progression reached statistical significance in 85% of patients. CONCLUSIONS: Spinal deformities in patients with neurofibromatosis 1 should be regarded as deformities in evolution. One should resist assigning these evolving deformities to either the dystrophic or nondystrophic end of the spectrum without considering the possibility of modulation across the spectrum. A spinal deformity that develops before 7 years of age should be followed closely for evolving dystrophic features (i.e., modulation). When a curve acquires either three penciled ribs or a combination of three dystrophic features, clinical progression is almost a certainty.

Intraoperative experience with neuromotor evoked potentials. A review of 60 consecutive cases.

STUDY DESIGN: A review of 60 surgical cases for correction of scoliosis, during which neuromotor evoked potentials and somatosensory evoked potentials were monitored. OBJECTIVES: To determine the validity and reliability of intraoperative neuromotor evoked potential monitoring in cases of scoliosis, where damage to the motor tracts of the spinal cord can occur. SUMMARY OF BACKGROUND DATA: Recently, the validity of neuromotor evoked potentials monitoring has been challenged, suggesting that the responses are not necessarily neuromotor evoked responses, but a combination of neuromotor and somatosensory evoked responses. This theory rendered the responses a potentially invalid measure of motor ability. However, despite controversy surrounding this topic, many professionals consider neuromotor evoked potential monitoring to be a successful and reliable measure of motor spinal cord function. METHODS: The results of neuromotor evoked potential testing were reviewed in 60 consecutive cases of children who underwent surgery for scoliosis. A standard protocol described in 1995 by Owen was used. RESULTS: Clinically useful neuromotor evoked potentials were obtained for 54 patients (90%). Inability to obtain neuromotor evoked potentials occurred in six patients (10%). CONCLUSIONS: This two-part study demonstrated the efficacy and reliability of neuromotor evoked potential monitoring during scoliosis surgery and examined the sources of difficulty in achieving accurate and valid results.

The fate of untreated developmental dislocation of the hip: long-term follow-up of eleven patients.

Eleven patients with developmental dislocation of the hip who had no treatment other than observation were followed up for an average of 40 years. Nine of the 11 patients had bilateral hip dislocations. None of the hips developed avascular necrosis. Overall clinical and functional results were very satisfactory despite uniformly unsatisfactory radiographs. These patients achieved a better quality of life than have many patients of similar age who have undergone surgical treatments aimed at reducing such late-presenting hip dislocations.

Neurofibromatosis in children: the role of the orthopaedist.

Type 1 neurofibromatosis (NF-1), also known as von Recklinghausen disease, is one of the most common human single-gene disorders, affecting at least 1 million persons throughout the world. It encompasses a spectrum of multifaceted disorders and may present with a wide range of clinical manifestations, including abnormalities of the skin, nervous tissue, bones, and soft tissues. The condition can be conclusively diagnosed when two of seven criteria established by the National Institutes of Health Consensus Development Conference are met. Most children with NF-1 have no major orthopaedic problems. For those with musculoskeletal involvement, the most important issue is early recognition. Spinal deformity, congenital tibial dysplasia (congenital bowing and pseudarthrosis), and disorders of excessive bone and soft-tissue growth are the three types of musculoskeletal manifestations that require evaluation. Statistics gathered from the Cincinnati Children's Hospital Neurofibromatosis Center database show the incidence of spinal deformity in children with NF-1 to be 23.6%; pectus deformity, 4.3%; limb-length inequality, 7.1%; congenital tibial dysplasia, 5.7%; hemihypertrophy, 1.4%; and plexiform neurofibromas, 25%. The orthopaedic complications can be managed, but only rarely are they cured.

Video-assisted thoracoscopy.

New therapeutic modalities for disorders of the pediatric spine must include video-assisted thoracoscopy. The endoscopic approach to the spine has involved an evolutionary approach. What began as an isolated drainage of a vertebral abscess was continued as a method of single discectomy; release of the annulus fibrosis with or without ligation of segmental vessels; rib resection for costoplasty; rib harvesting for intervertebral fusion; and most recently, insertion of correctional implants and fusion.

Pediatric vertebral and spinal cord tumors: a retrospective study of musculoskeletal aspects of presentation, treatment, and complications.

Fifty-two pediatric patients with documented vertebral and spinal cord tumors were reviewed to evaluate the musculoskeletal manifestations of presentation, treatment, and management of complications. Diagnoses included 16 malignant and 36 nonmalignant vertebral and spinal cord tumors. Mean age at diagnosis was 8 years 1 month, and the male-to-female ratio was 1.7:1. Overall, there was an average delay in diagnosis of 12 months for this group of patients. Mean clinical follow-up was 5 years. The two most common reasons for presentation were pain (67%) and spinal deformity (46%). Initial plain radiographs were positive in 82% of patients. Postlaminectomy spinal deformity occurred at a rate of 45% in patients undergoing laminectomies, and 60% of those with deformity required spinal fusion. Overall, 67% of the 52 patients underwent spinal fusion, with a 9% asymptomatic pseudarthrosis rate. Complications were common, with 1.9 complications per patient; 59% of complications required surgical management. There were no perioperative deaths. At follow-up, 19% of patients had neurologic deficits ranging from neurogenic bladder to lower extremity weakness and difficulty walking to quadriplegic. Eighty-six percent of patients were ambulating without difficulty at follow-up. The survival rate was 94% and the local recurrence rate was 27% at most recent follow-up.

Endoscopic discectomy increases thoracic spine flexibility as effectively as open discectomy. A mechanical study in a porcine model.

STUDY DESIGN: Two surgical techniques for anterior discectomy were compared biomechanically. The surgical procedures were performed in live, anesthetized, skeletally immature pigs. Spine flexibility was measured in vitro. OBJECTIVE: To determine whether endoscopic techniques for discectomy are as effective as open procedures in increasing spine flexibility. SUMMARY OF BACKGROUND DATA: Although studies have verified that discectomy increases spine flexibility, no study has confirmed whether endoscopic techniques increase flexibility as effectively as standard thoracotomy, which is a substantially different procedure. METHODS: The intervertebral disc between vertebrae T8 and T9 was resected from 30 live, anesthetized, adolescent pigs. In 15 pigs, the chest was opened via thoracotomy of the eighth rib, and the disc was excised. In the other 15 pigs, the disc was removed endoscopically. These motion segments and six intact controls were tested mechanically in side bending, flexion-extension, and axial rotation. RESULTS: No statistically significant differences in flexibility were found between open and endoscopic groups in any loading direction. The statistical power to detect a 20% difference between surgical groups was > or = 95%. CONCLUSIONS: Endoscopic and open techniques were equally effective in increasing spine flexibility. Because endoscopy may reduce surgical morbidity compared with open discectomy, these results support the use of endoscopy for the surgical correction of scoliosis before instrumentation.

Complications of intramedullary fixation of pediatric forearm fractures.

A retrospective review of 20 children with forearm fractures treated with intramedullary fixation is presented. Indications for surgery included fracture malreduction, open fracture, polytrauma, unstable fracture pattern, and compartment syndrome. Both radius and ulna were fractured in patients. Intramedullary fixation of both bones was performed in eight cases, ulna alone in nine, and isolated radius in three. A limited open approach to one or both bones was necessary for insertion of the intramedullary rod in 15 of 20 cases, including the eight open fractures. Eighteen complications occurred in 10 of 20 patients, including hardware migration, infection, loss of reduction, reoperation, nerve injury, significant decreased range of motion, synostosis, muscle entrapment, and delayed union. Despite the complications, 17 patients had excellent and two had good outcomes. Although excellent clinical results can be expected with intramedullary fixation, complications related to the surgical technique can be expected.

Hyphenated history: the Phelps-Baker test.

The language of orthopedics is filled with eponyms. Orthopedic surgeons speak cryptically to one another using code words and "orthopedic pig-Latin." Certain hyphenated eponyms are particularly interesting, because they represent people who came to be partners in orthopedic history. The derivation of the Phelps-Baker test, an important component of the hip examination of children who suffer from cerebral palsy, named in honor of Winthrop Morgan Phelps and Lenox D. Baker, is described in this report.

Thoracic tumors in children with neurofibromatosis-1.

Thoracic tumors have been infrequently reported as a complication of neurofibromatosis-1 (NF1). To determine the prevalence and clinical features of thoracic tumors seen in children with NF1, we reviewed medical records and imaging studies for a group of 260 pediatric patients with NF1 followed in a multidisciplinary NF Center. Extrapleural thoracic tumors were seen in nine patients with NF1, corresponding to a prevalence of 3.5% in this hospital-based series of patients. Pathological studies of the tumors demonstrated plexiform neurofibroma in four cases and neurofibrosarcoma in one case. The remaining four cases were suspected to be plexiform neurofibroma based on clinical features but have not been confirmed histologically. Three patients presented with symptoms of chest pain, syncope, or wheezing; six patients were asymptomatic at the time of diagnosis of the tumors. Physical findings frequently found in patients with thoracic tumors were scoliosis (especially focal scoliosis) and visible plexiform neurofibromas of the neck. We conclude that NF1 patients presenting with any of these signs and symptoms should be screened for thoracic tumors with chest X-ray and magnetic resonance imaging as needed. It is unknown whether screening asymptomatic NF1 patients with chest X-rays on a regular basis will result in an improved outcome.