Multimodality treatment of a multifocal osteoblastoma-like tumor of the lower extremity.

Osteoblastoma-like tumor is a rare condition with limited information on its orthopedic management in the current medical literature. The tumor histologically resembles an osteoblastoma, although the radiographic features are similar to those observed in primary vascular lesions. The treatment in the previously reported cases involved aggressive procedures including amputation, en bloc resection, and chemotherapy because of the uncertainty regarding the biological behavior of the tumor. We present a case of this entity that was successfully treated by a combination therapy including intralesional curettage with adjuvant cryotherapy, in situ and intravenous administration of bisphosphonates and radioablation.

Transverse-plane pelvic asymmetry in patients with cerebral palsy and scoliosis.

BACKGROUND: Pelvic obliquity and loss of sitting balance develop from progressive scoliosis in cerebral palsy (CP) and are indications for surgery. Our goal was to quantify pelvic asymmetry to help understand skeletal deformity in CP and its surgical correction. METHODS: We assessed pelvic angles and transverse plane symmetry in 27 consecutive patients with scoliosis and severe CP who had undergone computed tomography for spinal surgery (subjects). The program used allowed measurement of angles in the true transverse plane, compensating for any obliquity present. Measurements included angles of the upper and lower ilium with respect to the sacrum, acetabular anteversion, and sacroiliac joint angles. We compared subject measurements with those of 20 age-matched controls and used Student t test to determine whether subjects had greater asymmetry and if the asymmetry direction was correlated with the adducted hip and/or the scoliosis in subjects with windswept hips. RESULTS: Subjects had significantly more iliac angle asymmetry (P=0.01) and asymmetry of at least 10 degrees in these categories: upper ilium, 15 (mean difference, 18); above sciatic notch, 14 (mean difference, 17); just below sciatic notch, 15 (mean difference, 19); sacroiliac joint, 5; and acetabular anteversion, 6. No control had asymmetry greater than 10 degrees. Comparing subjects with and without windswept hips, the former had more asymmetrical upper iliac angles. In 16 subjects with windswept hips, the scoliosis curve convexity was ipsilateral to the more internally rotated ilium. In 4 of the 5 subjects with severely windswept hips, the side of the adducted hip had more inward iliac rotation than did the contralateral (abducted) hip. CONCLUSIONS: Transverse pelvic asymmetry, a little-recognized deformity in patients with severe CP, is most pronounced above the acetabulum and is more common in patients with windswept hips. Spine surgeons should be aware of such asymmetry because it may make iliac fixation challenging and account for some persistent postoperative deformity. LEVEL OF EVIDENCE: Case-control study, Level III.

Low profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up.

STUDY DESIGN: Retrospective review. OBJECTIVE: Anchor stability and prominence are problems with pelvic fixation in pediatric spinal deformity surgery. We compared the new sacral alar iliac (SAI) fixation technique (with a starting point in the sacral ala and in-line anchors deep under the midline muscle flap) with other methods of screw fixation. SUMMARY OF BACKGROUND DATA: Iliac anchors have been shown to provide the best form of pelvic fixation. A trajectory from the posterior sacral surface to the iliac wings has recently been described. To our knowledge, no clinical series has compared this method of pelvic fixation in children to others. METHODS: Of 32 consecutive pediatric patients who underwent SAI fixation, 2 died and 26 returned for follow-up (>2 years). Mean age at surgery was 14 years. Average screw size was 67 mm long and 7 to 9 mm in diameter. Clinical examinations, radiographs, and computed tomography scans were analyzed. Outcomes included pain over the implants, screw placement, implant prominence, radiographic lucency, need for revision, and infection. SAI patients were compared with 27 previous patients who had pelvic fixation via other screw techniques. RESULTS: For SAI fixation, correction of pelvic obliquity and Cobb angles were 20° ± 11° (70%) and 42° ± 25° (67%), respectively. For other pelvic fixation methods, those values were 10° ± 9° (50%), and 46° ± 16° (60%), respectively. Compared with other screws, SAI screws provided significantly better pelvic obliquity correction (P = 0.002) but no difference in Cobb correction. There were 2 lucencies adjacent to screws in both groups. Computed tomography scans of 18 SAI patients showed no intrapelvic protrusion, but 1 screw extended laterally (<5 mm). One early SAI patient required revision with larger screws, which relieved pain; there was 1 revision in the comparison group. SAI patients had no deep infections, implant prominence, late skin breakdown, or anchor migration; traditional patients had 3 deep infections (P = 0.09) and 3 instances of implant prominence, skin breakdown, or anchor migration. CONCLUSION: SAI pelvic fixation produces better correction of pelvic obliquity than do previous techniques. Radiographic and clinical anchor stability is satisfactory at 2-year follow-up.

Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation.

STUDY DESIGN: Three-dimensional computed tomography (CT) radiographic analysis. OBJECTIVE: To describe the parameters for a trajectory through a sacral starting point as a method of pelvic fixation in spinal deformity and to compare this technique with insertion from the posterior superior iliac spine (PSIS). SUMMARY OF BACKGROUND DATA: Long anchors projecting into the ilium provide optimal pelvic fixation. The traditional starting point in the PSIS requires muscle dissection and connectors or rod bends. METHODS: Twenty pelvic CTs of mature adolescents were analyzed using InSpace, a three-dimensional CT program, by 2 surgeons. Trajectory with maximal length and width through the sacral ala and iliac wing was obtained through CT imaging plane manipulation. Trajectory and starting-point parameters were measured. Parameters were evaluated and compared for insertion from the PSIS. RESULTS: Based on the ideal trajectory, the mean starting point in S2 was 25 mm caudal to the superior endplate of S1 and 22 mm lateral to the sacral midline (S2 alar-iliac [S2AI] path). Maximal mean S2AI distance was 105 mm (range, 74-129 mm; SD = 11 mm). Maximal mean length for PSIS insertion was 118 mm (range, 99-147 mm; SD = 13 mm). Mean angulation was 40 degrees (SD = 6 degrees ) laterally in the transverse plane and 39 degrees (SD = 6 degrees ) caudally in the sagittal plane. The mean difference between surgeons in selecting the trajectory was 2 degrees and 1 degrees in the transverse and sagittal plane, respectively. The S2AI pathway traversed 35 mm of sacral ala. The narrowest mean width of the ilium along this path was 12 mm (range, 6-18 mm). The starting point for the S2AI was 19 mm deep to the PSIS. The distance from skin for S2AI versus PSIS techniques was 52 and 37 mm, respectively. CONCLUSION: Iliac fixation through the S2 ala provides a reproducibly chosen starting point in line with S1 pedicle anchors. Implant prominence is minimized because the starting point is 15 mm deeper than the PSIS entry. It is less likely to be affected in cases using iliac crest bone graft harvest because of the more anterior position of the anchor in the ilium.

Postoperative orthopaedic neurovascular monitoring in the pediatric population.

BACKGROUND: Many orthopaedic procedures carry risks of neurovascular compromise. We hypothesized that risk factors for neurovascular compromise and for its delayed detection exist in the pediatric orthopaedic population. METHODS: We searched our institution's pediatric patient database from January 2004 through December 2006, randomly selecting (arbitrarily choosing every 20th patient) 286 patients, 34 of whom went to the operating room twice for 320 procedures. We retrospectively reviewed their records for these potential risk factors: altered communication ability (for age), abnormal baseline neurovascular status, imprecise documentation of neurovascular baseline status, nonspecific or inappropriate postoperative monitoring orders, and monitoring not carried out by nursing staff. Outcomes were analyzed via Fisher exact test (P < 0.05). RESULTS: Ten patients (3%) had new postoperative neurovascular events, and 4 (1%) were recognized to have neurological deterioration detected on a delayed basis. Fifty-seven (18%) had impaired communication ability (significant correlation with increased risk for neurovascular events), 97 (30%) had abnormal neurovascular preoperative status, and 21 (22%) had no specific documentation of neurovascular condition in the perioperative chart. Insufficient documentation of abnormal neurovascular baseline correlated significantly with an increased risk for delayed detection of postoperative neurovascular events. Although all written orders for neurovascular checks were carried out and specific with respect to timing, 133 patients (42%) had neurovascular monitoring orders that were nonspecific about the functions to be checked. All patients with delayed deficit detection had impaired ability to communicate, abnormal baseline values, or improperly written orders. CONCLUSIONS: The risk of postoperative neurovascular events is significantly higher in patients with impaired communication ability, and the risk for delayed detection of such events is significantly higher in patients without proper documentation of an abnormal neurovascular baseline. Clear documentation of baseline function may avoid delayed detection, and more specific monitoring processes may improve patient safety.

Case report: treatment of open femoral shaft fracture in a severely burned patient.

OBJECTIVE: To present a case report of a patient with an open fracture and severe burns and review the literature. METHODS: The patient was treated with intubation, intravenous antibiotics, and debridement and intramedullary nailing for the femur fracture. He later underwent multiple burn excision procedures with allograft and autograft skin coverage. The wound over the fracture was treated with dressing changes. The fracture was treated with nail exchange and bone grafting for atrophic nonunion. RESULTS: The patient was returned to full weightbearing and good function with a fully healed femur. CONCLUSIONS: Treatment of open fractures in burn patients should be tailored to the specific needs of the individual; they should be reduced and stabilized via internal fixation at the earliest opportunity and should be managed by minimizing wound colonization through successive debridement, wound care, and consideration of flap coverage.

Rates of perioperative complications associated with laminectomies in patients with achondroplasia.

BACKGROUND: Lumbar decompressive surgery can be complicated by dural tears, infection, nerve root injury, deep venous thrombosis, and epidural hematoma. However, perioperative complications of multilevel laminectomies in patients with achondroplasia rarely are reported. Our objective was to determine the perioperative complication rates associated with laminectomies in patients with achondroplasia. METHODS: We reviewed the medical records of the initial laminectomies for all ninety-eight patients with achondroplasia at our institution, which included twenty-eight patients who had had previous spine surgeries at other institutions, and determined the rates of complications in the following categories: neurologic, pulmonary, cardiovascular, and gastrointestinal complications; intraoperative dural tears; infections at the incision site; and mortality. RESULTS: Sixty (61%) of ninety-eight patients had at least one perioperative complication. By category, these included intraoperative dural tears, which occurred in 37% (thirty-six patients); neurologic complications, in 23% (twenty-three patients); infections at the incision site, in 9% (nine patients); deep venous thrombosis, in 3% (three patients); pulmonary complications, in 3% (three patients); and gastrointestinal complications, in 3% (three patients). The only death was caused by a pulmonary embolism. CONCLUSIONS: Perioperative complications are common in patients with achondroplasia undergoing multilevel laminectomies, and the perioperative care team should be aware of these complications when caring for these patients.

Tibial tubercle fragmentation: a clue to simultaneous patellar ligament avulsion in pediatric tibial tubercle fractures.

Simultaneous avulsions of the tibial tubercle and patellar ligament have been reported, but are rare. We present an 11-year-old boy who was initially diagnosed with a Type IIIA tibial tubercle avulsion fracture after falling off of his bicycle. Intraoperatively, following exposure and fixation of the tibial tubercle fragment, knee range of motion under live fluoroscopy revealed a stationary patella with no tension in the patellar ligament. The incision was extended and a distal avulsion of the patellar ligament from the tibial tubercle was identified, with a small flap of tibial tubercle periosteum remaining attached. Transosseous suture fixation of the avulsed periosteal flap was achieved with 2 No. 5 ethibond sutures placed through connecting drill holes. Postoperatively, the patient was placed in a long leg cast with the knee in extension for 6 weeks. The injury to healed and the patient returned to full activities, although he required 2 courses of physical therapy and 4.5 months to regain full range of motion. Preoperative diagnosis of simultaneous tibial tubercle fracture and patellar ligament avulsion can be difficult. Palpation of the patellar ligament for gaps may not be possible due to a large knee effusion. Most patients do not tolerate quadriceps testing on examination and do not have patella alta on radiographs. In retrospect, a clue to this diagnosis in our patient was the preoperative radiographic finding of multiple calcified fragments below the patella. The calcified fragments likely represent the avulsed tibial tubercle periosteum attached to the distal patellar ligament. In addition, the large tibial tubercle fragment is separated and rotated superiorly, a finding that was also noted in two other similar case reports.

Laminectomies and achondroplasia: does body mass index influence surgical outcomes?

Obesity is a widespread and potentially serious health problem in individuals with achondroplasia. In addition to obesity, such individuals commonly experience lumbar spinal stenosis. Although laminectomies have long been the method of choice for thorough lumbar decompression, to the best of our knowledge, the relationship between body mass index (BMI) and surgical outcomes after laminectomy in patients with achondroplasia has not been investigated in a large patient population. Through a retrospective medical record review of the initial laminectomies of all individuals with achondroplasia at our institution for whom adequate records were available, we evaluated the influence of BMI on surgical outcomes after laminectomy via four criteria: (1) change in Rankin score; (2) change in walking distance; (3) intra-operative and post-operative complications; and (4) need for subsequent revision laminectomies. The 49 individuals (mean BMI: 31.5 kg/m(2) at the time of laminectomy) were stratified into the standard BMI categories: normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), obese Class I (30-34.9 kg/m(2)), and a combined obese Class II (35-39.9 kg/m(2)) and obese Class III (>40 kg/m(2)). Our analysis indicated that there was no statistical difference between these groups in terms of the four criteria. When the study group was categorized into non-obese (normal weight and overweight) and obese (obese Classes I and II/III) groups, there was also no statistically significant improvement difference in terms the same four criteria. Our data suggest that obesity does not pose additional risks to laminectomy in individuals with achondroplasia.

Tip of the trade: a method of splinting for surgeons.

Mallet fingers are difficult to treat, especially in surgeons, who need to sterilize their hands continuously and who have constant strains placed on their fingers. We successfully treated a nondominant, fifth-digit, nonbony mallet finger in a surgical resident with a splint method composed of a bent, semitubular, small-fragment plate and Steri-strips (3-M, St. Paul, MN). This splinting method allowed the resident to continue performing surgeries while the injury healed.