Mulberry Heart Disease and Hepatosis Dietetica in Farm Pigs (Sus scrofa domesticus) in a Research Setting.

Perioperative complications and deaths occurred while developing a novel surgical model of pediatric kyphosis in 10 to 12 kg male farm-raised Yorkshire piglets. All piglets appeared clinically normal preoperatively. Intraoperative complications included tachycardia, respiratory acidosis, and death. Postoperatively, clinical signs included posterior paresis, head pressing, prolonged anesthetic recovery, difficulty rising, and sudden death. Necropsies were performed on all piglets. Some morbidity and mortality were accurately attributed to the spinal surgery. However, the index piglet for this report died suddenly approximately 16 to 18 h after surgery. Necropsy of this animal revealed clear, serosanguineous pleural and pericardial effusions along with myocardial hemorrhage and hepatic lesions, consistent with mulberry heart disease and hepatosis dietetica, respectively. Serum vitamin E and selenium levels from this animal were below age-specific lab reference ranges. Clinical signs of vitamin E and selenium deficiency are most common in fast-growing weaner piglets. The added stress of major surgery may exacerbate the condition in young piglets. Resolution of morbidity and mortality in both juvenile and adult pigs occurred upon the use of an alternate vendor able to provide feed analyses meeting industry standards, although serum levels of vitamin E and selenium in similar ages and breed of swine were still occasionally slightly below reference ranges.

Creation of a Porcine Kyphotic Model.

STUDY DESIGN: Large animal study. OBJECTIVE: Create a thoracic hyperkyphotic deformity in an immature porcine spine, so that future researchers may use this model to validate spinal instrumentation and other therapies used in the treatment of hyperkyphosis. SUMMARY OF BACKGROUND DATA: Although several scoliotic animal models have been developed, there have been no reports of a thoracic hyperkyphotic animal model creation in an immature animal. The present study was designed to produce a porcine hyperkyphotic model by the time the pig weighed 25 kg, which corresponds to the approximate weight of a child undergoing surgery for early-onset scoliosis (EOS). METHODS: Successful surgical procedures were performed in 6 consecutive 10-kg (male, 5-week-old) immature Yorkshire pigs. Procedure protocol consisted of 1) a left thoracotomy at T10-T11, 2) screw placement at T9 and T11, 3) partial vertebrectomy at T10, 4) posterior interspinous ligament transection, and 5) placement of wire loop around screws and tightening. Weekly x-ray imaging was performed preoperatively and postoperatively, documenting progressively increasing kyphosis as the pig grew. Necropsy was performed 5-6 weeks after surgery, with CT, slab section, and histologic analysis. RESULTS: Average T9-T11 kyphosis (measured by sagittal Cobb angle) was 6.1° ± 1.4° (mean ± SD) preoperatively, 30.5° ± 1.0° immediately postoperation, and significantly increased to 50.3° ± 7.2° (p < .0001) over 5-6 weeks in 6 consecutive pigs at time of necropsy. CONCLUSIONS: An animal model of relatively more rigid-appearing thoracic hyperkyphotic deformities in immature pigs has been created. Subsequent studies addressing management of early-onset kyphosis with spinal instrumentation are now possible. LEVEL OF EVIDENCE: Level V.

Experience with definitive instrumented final fusion after posterior-based distraction lengthening in patients with early-onset spinal deformity: single center results.

Limited reports exist with regard to clinical and radiographic details of patients with early-onset spinal deformity (EOSD) undergoing definitive instrumented final fusion (FF) following implantation of a growing construct. Charts and radiographs were queried for all patients who underwent FF after management of EOSD with a distraction-based posterior construct at a single institution from 2006 to 2017. Patients managed during the growth modulation period with either proximal rib or spinal fixation were included. Thirteen patients qualified for inclusion. Spinal deformity etiologies were varied (neuromuscular: 5, idiopathic: 4, congenital: 4). Average age at implantation was 6.5 years, and patients underwent an average of 8.15 lengthening procedures over an average of 69 months. After the growing program, modest correction in main coronal Cobb was obtained at FF (average 52.4° before FF, 37.6° following FF, P<0.001; average percent improvement of 27%). Five patients required posterior column osteotomies. Using criteria proposed by Flynn and colleagues, 'minimal' coronal correction was achieved in 23% of patients and 'moderate' in 77%. No patient achieved 'substantial' (>50%) correction. Subjective poor bone quality was appreciated in 67% of patients, and 85% were noted to have areas of autofusion over previously spanned levels. Two (15%) patients sustained a total of four complications. After growth modulation procedures, EOSD deformities are generally stiff, bone quality is often subjectively poor, and autofusion is common, even after use of proximally rib-based systems. Modestly improved coronal Cobb correction can be obtained at FF but may require single or multiple posterior osteotomies. Intraoperative difficulties can be expected, and clinicians should be alert for intraoperative and postoperative complications.

Resident Physician Duty-hour Requirements: What Does the Public Think?

INTRODUCTION: To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR). METHODS: A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism. RESULTS: Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic. DISCUSSION: Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

An alternate method of fixation for management of early-onset deformity with thoracic kyphosis.

BACKGROUND: Although methods currently used for management of early-onset scoliosis are effective, the presence of excessive thoracic kyphosis is associated with an increased instrumentation failure rate. METHODS: An alternate method of upper thoracic fixation by using a 4-rib construct was developed by necessity when the author was presented with 2 cases of early-onset deformity with severe kyphosis and osteoporosis. RESULTS: With a minimum 3-year follow-up, both cases have demonstrated gratifying clinical and radiographic results. CONCLUSIONS: This method is presented as an alternate method of upper thoracic fixation when increased pullout forces secondary to thoracic kyphosis are anticipated. LEVEL OF EVIDENCE: IV.

The use of bone grafts and bone graft substitutes in pediatric orthopaedics: an overview.

Bone graft substitutes have become progressively more widely used, and are currently heavily marketed. To make intelligent decisions, a complete knowledge of autograaft and allograft bone healing is essential, including the definition of "sterile". Differences in donor selection and tissue processing may confound the user not familiar with the implications of these different approaches. Specific products include demineralized bone matrix (DBM), specific growth factors (recombinant BMP's), ceramic grafts, and platelet-rich plasma (PRP). There are a number of useful applications of bone graft substitues for pediatric orthopaedists, but the data base is evolving. This paper describes the current status of these products.

Subtrochanteric valgus osteotomy for chronically dislocated, painful spastic hips. Surgical technique.

BACKGROUND: Many treatments have been proposed for a painful chronically dislocated hip in a child with spasticity who is unable to walk. The valgus subtrochanteric femoral osteotomy was originally described as a treatment for a missed congenital hip dislocation in a young adult who was able to walk. The purpose of this study was to investigate the outcomes of a modified Hass subtrochanteric valgus osteotomy for the treatment of symptomatic chronic hip dislocations in patients with spasticity due to neuromuscular disorders. METHODS: Patients were identified by surgical codes. Medical records were reviewed for surgical indications, complications, and results. Preoperative and postoperative radiographs were assessed. Caregivers were contacted and asked to complete a brief survey detailing the pain that the patient experienced with daily activities before and after surgery as well as other information. RESULTS: Thirty-one Hass osteotomies in twenty-four consecutive patients were performed by one surgeon between 1995 and 2005. Although fifteen patients (63%) had at least one complication (including urinary tract infection, pneumonia, hardware failure, and heterotopic bone formation), the majority of the patients were doing well at an average of forty-four months postoperatively. The duration for which the patient could sit, ease of transfers, and ease of diaper changes had all improved according to the caregivers. Fourteen of fifteen caregivers who replied to the question stated that they were satisfied with the operative results and would have the procedure done again if they had the decision to make. CONCLUSIONS: The modified Hass osteotomy provides children who have symptomatic hip dislocations due to neuromuscular disorders with reproducible pain relief and improves ease of positioning by their caregivers. The complication rate, although high, was comparable with that of similar surgical procedures in this patient population. Concurrent femoral head resection at the time of the proximal femoral osteotomy was not necessary in this group of patients.

Subtrochanteric valgus osteotomy for chronically dislocated, painful spastic hips.

BACKGROUND: Many treatments have been proposed for a painful chronically dislocated hip in a child with spasticity who is unable to walk. The valgus subtrochanteric femoral osteotomy was originally described as a treatment for a missed congenital hip dislocation in a young adult who was able to walk. The purpose of this study was to investigate the outcomes of a modified Hass subtrochanteric valgus osteotomy for the treatment of symptomatic chronic hip dislocations in patients with spasticity due to neuromuscular disorders. METHODS: Patients were identified by surgical codes. Medical records were reviewed for surgical indications, complications, and results. Preoperative and postoperative radiographs were assessed. Caregivers were contacted and asked to complete a brief survey detailing the pain that the patient experienced with daily activities before and after surgery as well as other information. RESULTS: Thirty-one Hass osteotomies in twenty-four consecutive patients were performed by one surgeon between 1995 and 2005. Although fifteen patients (63%) had at least one complication (including urinary tract infection, pneumonia, hardware failure, and heterotopic bone formation), the majority of the patients were doing well at an average of forty-four months postoperatively. The duration for which the patient could sit, ease of transfers, and ease of diaper changes had all improved according to the caregivers. Fourteen of fifteen caregivers who replied to the question stated that they were satisfied with the operative results and would have the procedure done again if they had the decision to make. CONCLUSIONS: The modified Hass osteotomy provides children who have symptomatic hip dislocations due to neuromuscular disorders with reproducible pain relief and improves ease of positioning by their caregivers. The complication rate, although high, was comparable with that of similar surgical procedures in this patient population. Concurrent femoral head resection at the time of the proximal femoral osteotomy was not necessary in this group of patients.

Posterior acetabular wall deficiency in Down syndrome.

Trisomy 21 or Down syndrome is the most common chromosomal anomaly and is associated with musculoskeletal abnormalities related to a generalized ligamentous laxity. Approximately 1% to 7% of Down syndrome patients have hip instability. Prior studies on the topic recommend Salter innominate osteotomy, capsular plication, and a varus derotational osteotomy of the proximal femur, which typically is in an anteverted and valgus position. The authors present a previously unreported bilateral finding in two patients noted on three-dimensional reconstruction computed tomography: deficiency of the posterior acetabular wall. Each was treated using a modification of the Pemberton osteotomy in which a wedge of iliac crest graft is placed posteriorly to hinge the posterior wall into a position of better posterior coverage of the femoral head. Both patients' hips have remained stable more than 10 years postoperatively. Follow-up imaging demonstrates well-remodeled osteotomy sites and excellent posterior coverage of the femoral heads.

Overuse injuries in pediatric athletes.

Children can be seemingly invincible, with inexhaustible energy. Even the elite young athlete, however, may lack the experience to realize when his or her level of activity is increasing the risk of sustaining injuries related to overuse. Coaches, trainers, parents, and physicians need to monitor the activities of young athletes, modify factors that may place them at increased risk of injury, and enforce periods of "relative rest" when necessary. Factors that can increase the risk of overuse injuries can be identified and modified if possible. Environmental factors include the use of sport-specific equipment (ie, running shoes instead of cleats for running activities) and properly sized equipment. Children of the same age will be of different sizes; "one size fits all" is not a good enough policy in this diverse population. Training factors include magnitude, frequency, and intensity. Children should be asked if they are participating in more than one team or sport simultaneously. Also, because the child's interest may exceed his or her skill level, young athletes optimally should be taught sport-specific skills to prevent injuries related to improper biomechanics. Finally, anatomic factors should be assessed, including alignment, laxity, flexibility, and muscle balance. These factors cannot always be changed, but coaches can modify training regimens and suggest strength and flexibility training to counteract specific weaknesses. Young athletes have a long future of activity ahead of them. Even if they never reach the Olympics or compete in the National Basketball Association (NBA), the injuries that occur in young athletes can have significant repercussions long after they leave the competitive arena.

Training Programs for Volunteer Coaches: More Time, More Money.

Good youth coaches are supposed to be teachers, psychologists, philosophers, and businesspersons. The author surveyed an Oklahoma soccer club to find out how coaches and parents rated themselves and each other.