Modified Ertl osteomyoplasty for terminal overgrowth in childhood limb deficiencies.

Terminal overgrowth continues to be a problem in children with amputations. Many operative treatment methods have been proposed, but no consensus has been reached regarding the procedure of choice. Six patients underwent a modified Ertl procedure for the treatment of terminal overgrowth in seven residual lower limbs (one bilateral). All these patients were skeletally immature. The average age at index procedure was 5 years 9 months (range, 1 year 3 months-6 years 11 months). Revision was necessary in four patients, with one patient requiring two revisions of the same limb. The modified Ertl osteomyoplasty can be performed safely in children, but appositional overgrowth may continue through the tibiofibular synostosis. The procedure is not recommended in skeletally immature patients.

Performance of digital filtering methods in orthotic and prosthetic CAD/CAM.

This report characterizes the performance of three digital filters, when applied to residual limb shape maps. The three filters were an averaging filter, a uniform window Fourier filter, and a Hamming window Fourier filter. The frequency responses of the three filters were calculated from theory, and experimentally observed. Experimental observations consisted of responses on single-frequency lobed shapes, and on residual limb shapes. Seven trans-tibial limb molds were digitized, three times each. Each resulting shape was then passed through each of the three filters. The before and after shapes were then compared. A Hamming window filter (low-pass frequency of 10 cycles per revolution, 24 coefficients, Hamming number of 0.25) achieved the best performance based on maintained amount of residual limb frequencies, and on visual observation.

A survey of function in children with lower limb deficiencies.

Function and prosthesis technical problems were surveyed in 258 experienced paediatric lower-limb prosthesis wearers. The two-part survey form consisted of the modified Prosthesis Evaluation Scale and the core module of the American Academy of Orthopaedic Surgeons/Council of Musculoskeletal Specialty Societies (AAOS/COMSS) Lower Limb Outcomes instrument. Eighty-eight percent (88%) of these paediatric subjects were able to wear their prosthesis more than 9 hours/day; only 3 subjects (1%) were not able to wear their limb at all. The average distance walked per day was reported to be 5.24 kilometres. Sixteen percent (16%) reported pain as "moderate" or worse. A majority reported not having a problem with perspiration, however, 20% had problems serious enough to limit prosthesis wearing time significantly. The most common reasons for temporary loss of limb use were pain (62 responses) and prosthesis failure (59 responses), followed by tissue breakdown (42 responses) and perspiration (30 responses). In general, the paediatric population achieves full use at a high rate, is much more active than the adult population, and experiences less limb pain.

A method of residual limb stiffness distribution measurement.

A method of recording a residual limb indentation stiffness map was developed for possible use as an aid in calculating prosthetic socket rectifications. The method was tested to determine the level of repeatability attainable. A hand-held, pencil-like device was used, with an air-driven piston that indented the tissue 10 times per second. The indentor tip contained an electromagnetic digitizer element that sensed position and orientation 120 times per second. The examiner moved the device around the limb; sampling was variable in density, and typically concentrated on critical areas. An interactive visual display of sampled data quality was used to guide sampling. The indentation maps typically contained approximately 4,000 locations, in a cylindrical coordinate system, with sampling locations spaced every 3.2 mm vertically, and every 0.087 radians tangentially. The behavior of the system was characterized using six test subjects on whom recorded indentations ranged from 1.5 to 21 mm. The largest range of indentations (i.e., worst disagreement) recorded at a single location was 5.4 mm. The average standard deviation on repeated measurement ranged from 7 to 15%, and averaged 0.67 mm in absolute terms. Many of the structurally significant anatomical features of the limbs were visible, including the patella and patellar tendon, fibular head, shin, biceps femoris tendon, semitendinosus, and popliteal area.

Wound healing in orthopaedic procedures for Klippel-Trenaunay syndrome.

Klippel-Trenaunay syndrome is a triad of cutaneous hemangiomas, varicose veins, and hypertrophy of soft tissue and bone; when combined with arteriovenous fistulas, the syndrome is known as Klippel-Trenaunay-Weber syndrome. Orthopaedic surgical management of localized limb-length discrepancy or hypertrophy in these conditions is frequently indicated, especially in the lower limb. Forty orthopaedic procedures in 21 patients were retrospectively reviewed. Nine (22.5%) wound complications were identified in this study group. All the complications were associated with transverse amputations. All required significant further treatment and extension of hospital stay. Wound complications should be anticipated in patients with Klippel-Trenaunay syndrome having orthopaedic surgical procedures, especially terminal amputations.

The intrinsic and extrinsic ligaments of the wrist. A correlation of collagen typing and histologic appearance.

20 fresh frozen human wrist specimens were dissected. Gross and histological examination and biochemical evaluation were performed on the intrinsic ligaments (scapho-lunate and luno-triquetral) and extrinsic ligaments (radio-scapho-capitate and radio-lunate). All ligaments were observed to have longitudinal collagen bundles. The intrinsic ligaments had large amounts of fibrocartilage near insertions and no elastin, while the extrinsic ligaments had little fibrocartilage and sparse amounts of elastin. The intrinsic ligaments were noted to have significantly more collagen Type 3 (41%) than the extrinsic ligaments (19%). These findings suggest that structural differences between the intrinsic and extrinsic ligaments of the wrist may in part account for the biomechanical observations that the intrinsic ligaments are stronger and elongate further prior to failure than the extrinsic ligaments.

The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: a prospective analysis.

Seventy-eight diaphyseal femur fractures in 77 children were stabilized with flexible intramedullary nails. The patients ranged in age from 2 + 9 to 18 years. All patients had open femoral growth plates at the time of fixation. Eleven percent of the fractures had an average varus or valgus malalignment of 6 degrees. Eight percent of the fractures had an average anterior or posterior malalignment of 8 degrees. Eight percent of the patients had a rotational malalignment that averaged 8 degrees. Sixty-eight percent of the children had equal leg lengths at follow-up. There were four unscheduled reoperations, but no major complications; all fractures united. The results obtained using flexible intramedullary nails for the stabilization of select pediatric diaphyseal femur fractures are comparable to nonoperative methods of treatment, but with less disruption to family life and a shorter hospitalization.

Tibial plateau fractures: evaluation with MR imaging.

Thirty patients with 31 tibial plateau fractures, initially diagnosed with standard radiography, were further studied with biplane linear tomography and magnetic resonance (MR) imaging. Each fracture was categorized according to the Schatzker classification. The extent of comminution and articular depression was determined for each modality. MR images were also evaluated for the presence of accompanying meniscal and ligamentous injury. In each case, MR imaging was noted to be as effective as tomography in depicting the amount of articular depression. MR imaging was found to be more effective than tomography in determining the extent of comminution. Beyond demonstrating the fracture, MR imaging was capable of revealing associated ligamentous and meniscal injuries. There was an increased prevalence of accompanying soft-tissue injuries in those fracture types that are associated with more violent forces and as the extent of articular depression increased. MR imaging is a useful and effective means of preoperatively evaluating tibial plateau fractures.

Posterior occipitoatlantal hypermobility in Down syndrome: an analysis of 199 patients.

We endeavored to determine the prevalence of occipitoatlantal hypermobility in individuals with Down syndrome, to establish objective radiographic criteria for this entity, and to correlate this with neurologic abnormality. In a retrospective analysis, upper cervical spine radiographs of 210 patients with Down syndrome were compared with those of 102 normal individuals. Radiographs were evaluated using the Powers ratio. Patients identified with radiographic evidence of posterior occipitoatlantal hypermobility were then examined clinically and compared with a matched group of patients with Down syndrome and normal Powers ratios. Of the patients with Down syndrome, 8.5% had a Powers ratio of < 0.55, which was indicative of posterior occipitoatlantal hypermobility (POAH). Furthermore, 66% of those with an abnormal Powers ratio had positive neurologic findings upon physical exam, a finding that was statistically significant when compared to a matched group of patients with Down syndrome and normal Powers ratio.

Electrical stimulation for idiopathic scoliosis.

To evaluate the effectiveness of lateral electrical spinal stimulation for idiopathic scoliosis, 87 patients treated with this modality were reviewed retrospectively. All patients had no prior treatment, had a documented progression of more than 5 degrees, and were skeletally immature. Forty-seven patients were compliant and followed until skeletal maturity or institution of other treatment. Fifty percent of patients with a high probability of progression required surgery. For compliant patients, 51% progressed 5 degrees or more and 36% progressed 10 degrees or more or required a change to another treatment modality. Statistical analysis demonstrated no significant difference in the probability of progression between this group of treated patients and previously published groups of untreated patients.

Traumatic subarachnoid-pleural fistula in a child. A case report.

A seven-year-old girl sustained a gunshot wound to the chest and spine. Evaluation of a persistent pleural effusion demonstrated a subarachnoid-pleural fistula. Surgical closure of the dural defect resulted in resolution of the fistula. Traumatic subarachnoid-pleural fistulae are rare. The diagnosis is reached by an awareness of fistula formation from penetrating or blunt trauma to the chest.

Anterior sleeve fracture of the capitellum.

The case of an articular sleeve fracture of the capitellum in an 8-year-old girl is presented. An accurate diagnosis of this injury and its extent was able to be made preoperatively only by arthrography. The use of arthography in injuries about the elbow in children is recommended.

Congenital clubfoot. Etiology, pathoanatomy, pathogenesis, and the changing spectrum of early management.

Congenital clubfoot is a common problem of uncertain etiology with a broad spectrum of clinical severity. Much remains controversial and unsolved about this disorder. It is agreed, however, that early management should be conservative and that operative management should comprehensively address the deformities, to avoid if possible, subsequent operations. No single monograph can comprehensively review all aspects of this complex disorder. Our intent has been to touch upon the basic concepts and philosophies, to give perspective to the overall picture, for some, and to provide a stimulus and basis for further investigation and review for others.

The Grice extra-articular subtalar arthrodesis in the treatment of spastic hindfoot valgus deformity.

The results of the Grice extra-articular subtalar arthrodesis were evaluated in 102 feet of 60 ambulatory patients with spasticity at an average of five years postoperatively. Results were satisfactory in 96 feet (94 per cent). Unsatisfactory results were attributed to recurrent deformity in four feet and over-correction in two. No other significant complications were identified. The Grice arthrodesis is recommended for hindfoot valgus deformity secondary to spasticity which is refractory to non-operative management.

Prostaglandin-induced hyperostosis. A case report.

The use of prostaglandin-E1 (PGE1) to maintain patency of the ductus arteriosus in infants with ductal-dependent congenital heart disease is now well established. A 2.5-month-old child with cyanotic heart disease who required long-term PGE1 infusions; developed widespread periosteal reactions during the course of therapy. Prostaglandin-induced subperiosteal hyperostosis should now be considered in the differential diagnosis of neonatal cortical proliferation.

Unrecognized pin penetration in slipped capital femoral epiphysis.

There are at least nine different techniques recommended to lower the incidence of femoral head penetration by fixation pins in the pinning of slipped capital femoral epiphyses. The routine use of fluoroscopy and placement of the fixation pins no closer than 8 mm (or one-third the radius of the femoral head) from the subchondral bone will leave a safe, workable margin. Confirmation of subchondral location after the procedure can be done with fluoroscopy. With the leg in maximal internal rotation, the fluoroscopic unit is rotated from anteroposterior (AP) to lateral under continuous monitoring to detect anterolateral and posteromedial quadrant penetrations. With the fluoroscopic unit in the lateral position, the foot is externally rotated 90 degrees, again under continuous monitoring, to visualize the anteromedial and posterolateral quadrants. If the femoral head cannot be well-visualized in the lateral view, use of a lateral x-ray machine and AP fluoroscopy can be helpful. Another useful technique when the head cannot be well-visualized is the injection of contrast medium through a cannulated screw.

Spinal abnormalities in pediatric patients: MR imaging findings compared with clinical, myelographic, and surgical findings.

Eighty-one pediatric patients with a variety of spinal disorders, including suspected dysrhaphism, scoliosis, neoplasia, and neurofibromatosis, underwent magnetic resonance (MR) imaging. The results were retrospectively compared with those of myelography followed by computed tomography (CT) and surgery. In patients with dysrhaphism, most abnormalities, including hydromyelia, inclusion tumors, and sites of cord tether, were demonstrated with MR imaging. Diastematomyelia and small hydromyelic cavities were indistinguishable on routine coronal and sagittal T1-weighted images; axial images with T2 weighting were optimal for this differentiation. MR imaging did not enable direct visualization of a thickened filum or evaluation of tethering with a thin, dorsally positioned neural placode. Congenital or severe scoliosis required lengthy studies with multiple planes of imaging or myelography and CT. Milder curvatures were readily evaluated with MR imaging, and neoplastic lesions, with the exception of intrathecal tumor seeding, were adequately defined.