Postoperative radiographs after pinning of supracondylar humerus fractures: are they necessary?

BACKGROUND: The purpose of this study was to evaluate the necessity of early postoperative radiographs after pinning of supracondylar humerus fractures by determining both the percentage of patients who displayed change in fracture fixation and whether these changes affected their outcome. METHODS: A series of 643 consecutive patients who underwent operative management of Gartland type II and III fractures at our institution between January 2002 and December 2010 were reviewed. Demographic data were obtained through chart review, including age, sex, extremity, fracture type, and mechanism. Intraoperative fluoroscopic images were compared with postoperative radiographs to identify changes in fracture alignment and pin placement. RESULTS: A total of 643 patients (320 females, 323 males) with a mean age of 6.1 years (range, 1.1 to 16.0) were reviewed. Fifty-seven percent of fractures were classified as type II and 43% were type III. The overall complication rate was 8.8% (57/643). Pin backout or fracture translation was seen in 32 patients (4.9%) at the first postoperative visit. All of these patients sustained type III fractures. One of these patients required further operative management. Patients with changes in pin or fracture alignment did not demonstrate a statistically significant difference in time to first postoperative visit (P=0.23), days to pin removal (P=0.07), or average follow-up time (P=0.10). Fracture severity did not correlate with change in alignment (P=0.952). No postoperative neurological complications were observed in patients with alignment changes. CONCLUSIONS: Mild alignment changes and pin migration observed in postoperative radiographs after pinning of supracondylar humerus fractures have little effect on clinical management parameters or long-term sequelae. Radiographs can therefore be deferred until the time of pin removal provided adequate intraoperative stability was obtained. LEVEL OF EVIDENCE: Level IV.

Comparative analysis of hook, hybrid, and pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis.

BACKGROUND: Spinal instrumentation in adolescent idiopathic scoliosis (AIS) aims to correct spinal deformity and maintain long-term spinal stability until bony healing is ensured. The purpose of this study was to compare the minimum 2-year postoperative radiographic and clinical results of posterior spine correction and fusion with all-hook instrumentation versus hybrid segmental instrumentation versus pedicle screw instrumentation for AIS from a single institution. METHODS: A total of 105 patients with AIS who underwent a posterior spinal fusion with segmental pedicle screw (35), hook (35), or hybrid (35) instrumentation were sorted and matched according to the following criteria: similar age at surgery, identical Lenke curve types, curve magnitude, and Risser grade. Patients were evaluated before, immediately after, and at 2 years after surgery for radiographic parameters, complications, and outcome, as well as on the basis of the Scoliosis Research Society (SRS) questionnaire. RESULTS: The age and Risser grade, major curve Cobb angle, apical vertebral rotation (AVR), apical vertebral translation (AVT), lowest instrumented vertebral tilt, global coronal and sagittal balance, lumbar lordosis, and thoracic kyphosis were determined as part of preoperative evaluation. All 3 groups showed significant differences between the preoperative and postoperative major curve Cobb angle, lowest instrumented vertebral tilt, AVT, and AVR. At the latest follow-up, lumbar lordosis, thoracic kyphosis, and global coronal and sagittal balance remained similar among the 3 groups. Major curve Cobb angle, AVT, and AVR were significantly different--the hook group's measurements were significantly higher than the other groups, but there was no difference between the pedicle screw and hybrid groups. Major curve correction rate was significantly different among all groups (screw=71.9%±13.8%, hybrid=61.4%±16.6%, hook=48.1%±19.7%) (P<0.001). The pedicle screw group had the least amount of correction loss but there was no statistically significant difference between groups (screw=2.6±6.7 degrees, hybrid=4.5±7.4 degrees, hook=4.4±6.2 degrees) (P=0.35). The hook group had the least amount of AVT correction, but the screw group and the hybrid groups were similar (pedicle=67.3%±15.5%, hybrid=57.5%±22.4%, hook=39.9%±32.5%) (P<0.001). Surgery time and blood loss were higher in the screw group. No differences in global SRS-22 scores were demonstrated between the patients treated with pedicle screw, hybrid, and hook constructs; however, the satisfaction domain was higher in the screw group at the latest follow-up. CONCLUSIONS: Pedicle screw and hybrid instrumentations offer significantly better spinal deformity correction than hook constructs in major curve coronal correction, AVT, and AVR. Patients with pedicle screw instrumentation had the greatest curve correction percentage, maintenance of this correction in the coronal and sagittal planes, and higher patient satisfaction by the SRS outcome scores. Global SRS-22 scores were similar at 2-year follow-up in all groups. LEVEL OF EVIDENCE: Therapeutic level III retrospective comparative study.

Reliability and necessity of computerized tomography in distal tibial physeal injuries.

OBJECTIVE: Complex distal tibial physeal fractures can be difficult to characterize on plain radiographs. The role of computed tomography (CT) scans in the evaluation and treatment decision of these injuries is unclear. We aimed to determine whether or not the addition of CT would improve the reliability of fracture classification and treatment decision. METHODS: Five independent observers evaluated 50 distal tibial physeal fractures on 2 separate occasions for Salter Harris (SH) classification and treatment decision (surgical/nonsurgical) using plain radiographs (round 1) and combination of radiographs and CT (round 2). During round 1, observers were asked if they would order a CT, and during round 2, they were asked if the CT was useful. These rounds were repeated at 2 to 4 weeks to assess intraobserver reliability. Statistical analyses were performed to assess inter and intraobserver reliability using Kappa coefficient (κ). RESULTS: Intraobserver reliability for SH classification showed substantial agreement, κ=0.76 and κ=0.80, respectively, during round 1 and 2. Interobserver agreement on the SH class was lower during round 1 and 2 (κ=0.67 and κ=0.57, respectively). There also was almost perfect intraobserver and interobserver agreement in the measurement of displacement at the fracture site during both rounds 1 and 2. Intraobserver reliability for treatment decision was substantial, κ=0.74 and κ=0.80, respectively, during round 1 and 2. However, interobserver agreement for treatment decision was moderate (κ=0.48) and fair (κ=0.36), respectively, during round 1 and 2. Surgeons indicated that they would like to order CT scans for 66% of the time in round 1, but the interobserver agreement as to who would best benefit from the CT was only fair (κ=-0.23). The main purpose of ordering the CT was to delineate fracture anatomy (55% of the time) and the observers felt CT would add to their treatment decision only 26% of the time. During round 2, 75% of time surgeons felt that CT scan was useful. CT was thought to be most useful in guiding screw placement (56% of the time) and not as useful (28% of time) for treatment decision making. CONCLUSIONS: Addition of CT in complex distal tibial physeal fractures did not increase interobserver reliability to classify the fracture or the treatment decision. Surgeons reported that the CT was most useful to plan screw placement and changed their treatment decision in about a fifth of the cases.

Can a bone marrow-based graft replacement result in similar fusion rates as rib autograft in anterior interbody fusion procedures for adolescent thoracolumbar scoliosis?

STUDY DESIGN: Nonrandomized consecutive case series comparing interbody spine fusion with autograft versus bone marrow-based graft replacement (BGR). OBJECTIVES: Effectiveness of bone marrow-based graft versus rib autograft in achieving anterior interbody fusion of the thoracolumbar/lumbar spine. SUMMARY OF BACKGROUND DATA: The use of bone marrow (BM) with graft materials was shown in a prior study to aid with bone regeneration. Limited clinical data are currently available to demonstrate the effectiveness of BM for spinal applications. Engineered matrices of collagen type I coated with hydroxyapatite and combined with BM have been safely used in both spinal and long bone applications. METHODS: Nineteen consecutive patients from 2003 to 2006 underwent anterior interbody fusion through an anterior approach with dual-rod instrumentation and structural interbody support for thoracolumbar scoliosis. Within 19 patients, there were 42 disc levels treated with graft replacement material combined with BM (BGR+BM) and 25 disc levels with rib autograft. The mean follow-up time was 17 months with a minimum of 6 months. Clinical and radiographic data included Scoliosis Research Society (SRS)-22 questionnaires and pain and fusion assessments of posterior-anterior and lateral radiographs, collected preoperatively and at 6, 12, and 24 months, postoperatively. RESULTS: At 6 months, 72% of BGR+BM segments versus 44% of autograft segments were defined as fused. All BGR+BM segments were fused by 12 months, and all autograft segments were fused by 24 months. There was no pseudoarthrosis or instrumentation failure, and interbody fusion rate was 100%. The average correction was 73.5+/-13.5%. The overall loss of correction from the immediate alignment to postoperative follow-up was less than 4%. There was no loss of sagittal plane alignment or measured kyphosis. No morbidity was observed at the BM aspiration site. CONCLUSIONS: Anterior spinal fusion using bone marrow-based graft substitutes for thoracolumbar adolescent idiopathic scoliosis demonstrated equivalent results to rib autograft when used with dual-rod instrumentation and structural support. In this patient series, the rate of fusion was faster in the bone marrow-treated segments. These results suggest that for patients as described in this cohort, bone marrow-based graft replacements can thus be used as an alternative, or adjunct, to autograft to achieve interbody fusion in scoliosis surgery.

Electronic monitoring of scoliosis brace wear compliance.

PURPOSE: Accurate evaluation of patient compliance with scoliosis brace usage has been a challenge for physicians treating patients with adolescent idiopathic scoliosis. This inability to accurately measure compliance has resulted in difficulty in determining brace treatment efficacy. This prospective study was performed to demonstrate the efficacy of using a new electronic brace compliance monitor, the Cricket. METHODS: The Cricket is a small encased circuit that can be attached to the brace and, by means of a temperature sensor, can record brace wear times. This study included ten subjects with adolescent idiopathic scoliosis who were prescribed the Wilmington scoliosis brace (thoraco-lumbo-sacral orthosis) into which the Cricket sensor was incorporated. Subjects kept a diary of brace wear times. RESULTS: Comparisons of data for the Cricket, subject diaries, and prescribed brace wear were evaluated. The mean error between the diary times and Cricket recording was 2%. Patient compliance was 78%. CONCLUSIONS: The Cricket is a reliable, accurate, and sensitive device to determine patient compliance with scoliosis brace usage.

Complications of intrathecal baclofen pump therapy in pediatric patients.

BACKGROUND: The aim of this study was to investigate and evaluate complications of intrathecal baclofen (ITB) pump implantation and maintenance in children with cerebral palsy. METHODS: We reviewed our entire consecutive series of pediatric patients treated with ITB between 1997 and 2006 at our hospital. There were 174 patients with a diagnosis of cerebral palsy, 8 with mixed dystonia, 2 with athetosis, and 3 with pure dystonia. During follow-up, 8 deaths occurred with no evidence of pump or catheter malfunction in any way contributing to the cause of death. Acute infection within 60 days of the surgery and late infection rates were calculated on the basis of number of incidents and incidents/follow-up patient years, respectively. Independently, a blinded caregiver phone questionnaire was completed in 92 cases. RESULTS: There were 316 surgical procedures; 161 were initial ITB pump implants at our institution. The average age at initial implant was 12 years, with an average follow-up of 3 years, 2 months. There were 80 planned replacement procedures (46 battery expirations and 3 planned pump replacements during posterior spinal fusion, 26 catheter replacements for posterior spinal fusion, and 5 reinsertions). There were 78 procedures in 57 patients related to complications, and the acute infection rate was 4.0%. The probability of developing a late infection was 1.0% per year of follow-up. On the basis of the follow-up questionnaire, 81% of parents/caregivers were satisfied with the treatment, and 87% would recommend ITB therapy. CONCLUSIONS: ITB therapy is a safe and effective treatment for severe spasticity in the pediatric population, but does have a 31% rate of complications requiring surgical management over a 3-year treatment period. Parents and caregivers have a high rate of satisfaction and most would recommend the treatment to others.

Botulinum toxin type A injection in alleviating postoperative pain and improving quality of life in lower extremity limb lengthening and deformity correction: a pilot study.

BACKGROUND: The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population. METHODS: Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major. RESULTS: Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group. CONCLUSIONS: This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings.

Bilaterally dislocated hips treated with the Pavlik harness are not at a higher risk for failure.

BACKGROUND: The purpose of this study is to evaluate the efficacy of the Pavlik harness treatment in patients with bilaterally dislocated hips, and to compare them with cases with unilaterally dislocated hips. METHODS: Twenty-nine patients (58 hips) were identified who presented with bilateral dislocated hips with no earlier treatment and received dynamic ultrasound examination. The comparison group consisted of 38 patients (38 hips) with unilateral hip dislocation treated with the same protocol. Successful treatment was defined as relocation/reduction of the hips within 3 weeks of Pavlik harness application. RESULTS: Seventeen of 29 patients (59%) in the bilateral group (7 bilateral, 10 unilateral) and 22 of 38 patients (58%) in the unilateral group failed the harness treatment. There was no difference in the duration of harness wear for successful patients regardless of presentation. CONCLUSIONS: Patients presenting with bilaterally dislocated hips treated with the Pavlik harness are at no greater risk for failure than patients presenting with unilateral hip dislocation. LEVEL OF EVIDENCE: Level 3.

Antibiotic-loaded allograft decreases the rate of acute deep wound infection after spinal fusion in cerebral palsy.

STUDY DESIGN: A retrospective matched cohort study with control group. OBJECTIVE: To compare the infection rate after posterior spinal fusion with unit rod instrumentation with or without gentamicin-impregnated allograft bone in children with cerebral palsy (CP). SUMMARY OF BACKGROUND DATA: Previous studies evaluating wound infection rates after spinal fusion surgery in children with CP report an 8.7% to 10% wound infection rate. The concept of using antibiotic-loaded bone graft (AbBGF) to provide local antibiotics has been explored in high risk patients, such as those with osteomyelitis or infected joint arthroplasty. There have been no reports of using AbBGF prophylactically in spine surgery. METHODS: After IRB approval, the medical records of 220 children with CP who underwent spinal fusion with unit rod instrumentation for a primary spinal deformity between January 2000 through December 2006 at a single institution were retrospectively reviewed. We evaluated the incidence of postoperative wound infection in patients with AbBGF and those without bone graft (BGF). RESULTS: One hundred fifty-four patients received AbBGF during spinal fusion surgery and 6 patients (3.9%) developed a deep wound infection. Ten (15.2%) of the 66 patients without AbBGF developed a deep wound infection. The difference between groups was statistically different (P = 0.003). The mean age at surgery, preoperative Cobb angle, correction rate, operative time, and estimated blood loss were not statistically different between the 2 groups (P > 0.05). The length of hospital stay was decreased in the AbBGF group (P < 0.05). CONCLUSION: The incidence of deep wound infection after spinal fusion in 220 children with CP scoliosis decreased from 15% to 4% with the use of prophylactic antibiotics in the corticocancellous allograft bone.

Baclofen pump implantation and spinal fusion in children: techniques and complications.

STUDY DESIGN: Retrospective clinical and radiographic review of complications related to intrathecal baclofen therapy (ITB) and posterior spine fusion (PSF) in patients with cerebral palsy. OBJECTIVE: To report the technical considerations and complications associated with ITB in patients undergoing PSF. SUMMARY OF BACKGROUND DATA: A common treatment for spasticity in children with cerebral palsy is ITB. This population also has a high incidence of severe spinal deformities requiring PSF. METHODS: There were 4 groups: A, 26 patients with PSF before ITB; B, 11 patients who underwent PSF and ITB concurrently; C, 25 patients with PSF after ITB; and D, the control group: 103 patients with ITB only. Complications and infections were tabulated from a retrospective chart review and ongoing surveillance data. Multiple chi analyses were used to compare the number of patients who experienced complications and infections among the groups. The operative sequence and catheter management techniques for the various scenarios are described in detail in the text. RESULTS: The outcome by group was as follows: group A had 5 catheter malfunctions and 2 infections at the pump site, group B had 2 catheter malfunctions, 1 hypermobile pump and 1 infection at the spinal site, group C had 3 catheter malfunctions, 1 infection at the pump site and 1 infection at the spinal site. The control group had 23 catheter malfunctions, 5 pump failures, 8 infections at the pump site, and 1 infection at the spinal site. Multiple chi analyses showed no difference in the number of infection or device/catheter complications among any of the groups. CONCLUSION: The rate of ITB therapy complications is not increased despite PSF in any order of the procedures. There are technical details in each situation that require attention. With understanding of the appropriate techniques of catheter management, ITB pumps can be implanted and managed without an increased complication rate before, during or after spinal fusion surgery.

Efficacy and safety of percutaneous epiphysiodesis.

BACKGROUND: The aims of this study were to evaluate outcomes of percutaneous epiphysiodesis, as described by Bowen, in 97 patients and to assess complications and determine whether the effect of the epiphysiodesis will accurately follow the Moseley chart predictions. METHODS: A total of 97 patients were reviewed retrospectively. Fifty-six girls and 41 boys, with a mean skeletal age of 12.6 years (range, 10-16 years) at the time of operation, were followed up until skeletal maturity, a mean of 3.8 years (range, 1-10 years). RESULTS: The mean residual leg length discrepancy (LLD) in 88 patients at maturity was 1.3 cm (range, 0-3.5 cm). In 9 patients, the epiphysiodesis was combined with a femoral lengthening or femoral shortening. The residual leg length discrepancy in these 9 patients was 3.3 cm at maturity (range, 0-6.5 cm). Minor complications including knee effusion (n = 2), superficial wound infection (n = 1), and exostosis (n = 3) occurred in 6 patients. Failure of the epiphysiodesis was the only major complication seen (n = 3). CONCLUSIONS: This study shows that complications are infrequent when performing percutaneous epiphysiodesis and that the Moseley straight-line method accurately and efficaciously predicted the timing for percutaneous epiphysiodesis in all but one patient who had unpredictable growth from hemihypertrophy secondary to a hemangiomatosis.

Diagnostic imaging of the knee in children with arthrogryposis and knee extension or hyperextension contracture.

PURPOSE: Amyoplasia (type 1), characterized by quadrimelic limb involvement, is one of the most common types of arthrogryposis. In children with hyperextension or extension contracture of the knee, subluxation or dislocation of the knee joint with an associated subluxation or dislocation of the patella is frequently seen. Patellar malpositioning may be secondary to congenital hypoplasia of the patellar groove of the femur and/or dysplasia of the patellofemoral joint. A contracted quadriceps tendon and illiotibial band, as seen in extension contractures of the knee in arthrogryposis, may also contribute to patella alta and lateral subluxation of the patella. The aim of our study is to determine the position of the patella in children with quadrimelic arthrogryposis and knee extension contracture. METHODS: The inclusion criteria for this study were as follows: patients diagnosed with arthrogryposis multiplex congenita group 1, a knee extension contracture present from birth, follow-up from birth or early childhood, at least yearly physical examinations, and a knee ultrasonography or magnetic resonance imaging study performed. Patellar position was determined, and the cartilaginous femoral sulcus angle, as well as the osseous femoral sulcus angle, was measured. RESULTS: Clinically, none of patella in any of the patients could be palpated before surgery. The patella was displaced superiorly and laterally in 16/16 knees as seen on ultrasonography. Magnetic resonance imaging also showed the patella to be displaced superior and laterally. CONCLUSIONS: All patients in our series with extension contracture of the knee and type 1 arthrogryposis had a patella that was superior and lateral to the patellar groove. We found that quadricepsplasty and relocation of the patella improved knee flexion. All patients regained active knee extension in 6 months postsurgery. LEVEL OF EVIDENCE: Level III-diagnostic.

Difficult thoracic pedicle screw placement in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective radiographic and clinical consecutive case series. OBJECTIVE: The objective of this study was to identify patients treated with posterior spinal fusion and pedicle screw instrumentation for adolescent idiopathic scoliosis (AIS) in whom it was not possible to place a planned pedicle screw, and describe the possible difficulties in screw placement. SUMMARY OF BACKGROUND DATA: Despite the knowledge of anatomic characteristics of upper thoracic spine pedicles and considerable experience in thoracic pedicle screw placement, inserting pedicle screws in some patients with AIS may be difficult. METHODS: We reviewed 96 patients with AIS in whom the intent was to use an all-screw construct in 2004. Placement of the pedicle screws was usually by the freehand method, with intraoperative fluoroscopy used as needed. If a screw could not be safely placed after multiple attempts, a down-going supralaminar or transverse process hook was placed. Medical records were reviewed and radiographs were measured by one of the authors. RESULTS: We identified 17 cases (18%) in which a hook had been placed. All cases had a major thoracic curve (Lenke 1, 2, and 3) and the single hook had always been placed at the most cephalad level of the construct on the patient's right side. The most common levels for hook placement were T3 and T4; these pedicles were noted to be sclerotic, narrow, and have a moderate amount of rotation on the preoperative posterior-anterior and side bending radiographs. CONCLUSIONS: Care should be exercised during pedicle screw instrumentation in the apical region of the proximal thoracic curve, whether structural or nonstructural, especially in the concavity. The preoperative radiographs may give helpful clues to intraoperative challenges of pedicle screw insertion at the uppermost level of instrumentation. Hook fixation was satisfactory in this scenario.

Diagnostic evaluation using whole-body technetium bone scan in children with cerebral palsy and pain.

BACKGROUND: Pain in noncommunicative children can be difficult to localize and diagnose. The purpose of this study is to report our experience using a 3-phase whole-body technetium bone scan as a screening tool in identifying the source of persistent pain in children with profound disabilities who cannot communicate. METHODS: We reviewed the medical and imaging records of 45 patients who met the inclusion criteria of the study, which included a diagnosis of spastic quadriplegic cerebral palsy with severe motor and cognitive impairment, persistent pain of more than 1 week in duration with no recognizable source, and a 3-phase whole-body bone scan as part of the pain workup. RESULTS: The study group included 26 females and 19 males with an average age at presentation of 13.5 years (range, 3-20 years). A positive bone scan was seen in 24 patients (53%). The diagnosis and the source of pain were identified in all 24 patients with a positive bone scan, with the bone scan being instrumental in establishing a diagnosis or localization in 22 patients. An orthopaedic diagnosis was not established in the 21 other patients with a negative bone scan. Based on the bone scan results, additional imaging was obtained at the anatomical location indicated. The bone scan was used to establish a diagnosis of fracture in 10 of 24 patients. Other diagnoses included 3 patients with painful internal hardware, 2 with sinusitis, 2 with infections, and 1 with an obstructed kidney. CONCLUSIONS: Whole-body bone scan is a viable imaging option to identify the source of persistent pain in children who are noncommunicative. The bone scan can assist in localizing the source of pain and direct the location for further imaging as needed.

Intrauterine gangrene of the lower extremity in the newborn: a report of two cases.

We describe 2 cases of intrauterine gangrene involving the lower extremity in 2 unrelated neonates. Both cases were complicated by prematurity, and 1 case was complicated by an intrauterine distal femur fracture and twin-twin transfusion syndrome. Both cases resulted in profound ischemic necrosis from the knee to the foot, requiring knee disarticulation. In both cases, a follow-up period of 7 years is now completed, and no further medical or surgical complications have arisen.

Pectoralis major release to improve shoulder abduction in children with cerebral palsy.

The aim of our study was to evaluate the surgical results after pectoralis major muscle release in children with cerebral palsy and to assess a caregiver's satisfaction in patient's care after this procedure.Twenty-one shoulders in 13 patients were analyzed at least 12 months after surgery. All but 1 patient involved in our study had quadriplegic type of cerebral palsy involvement. In 17 limbs, only pectoralis release was performed; in 4 limbs, latissimus dorsi release was added. After clinical examination, a questionnaire was used to determine the caregiver's assessment. The passive range of abduction and flexion was maintained at an angle greater than 90 degrees in 10 patients. External rotation was restricted in 6 patients. All caregivers would recommend this surgery to another patient. All but one reported improvement in care of the patients after surgery. The indication for this surgical procedure is limited only to the selected cerebral palsy cases in which custodial care is impaired by shoulder adduction contracture. The 2 main indications for the procedure are the limitations in the ability to bathe the axilla and the difficulty in dressing.

The use of computed tomography to assess acetabular morphology in Morquio-Brailsford syndrome.

PURPOSE: Morquio-Brailsford syndrome (MS) is an autosomal recessive lysosomal storage disorder, a mucopolysaccharidosis, characterized by abnormal metabolism of glycosaminoglycans. Major treatable concerns in patients with MS involve C1 to C2 instability, genu valgum, and hip subluxation. Untreated hip subluxation has been shown to predispose to early onset of arthritis of the hip. Early appropriate pelvic osteotomies may restore (improve) load transmission and retard the onset of arthritis. Computed tomographic (CT) measurements can help determine the site and severity of acetabular deficiency, aiding in selection of the appropriate acetabular procedure. Acetabular morphology in MS has not been described in the literature. The purpose of this study was to evaluate morphology (shape) of the acetabulum in MS using two-dimensional (2-D) CT scans. METHODS: To assess the acetabular roof, the acetabular index was measured on anteroposterior radiographs of the pelvis. Various CT measures were used to assess the acetabular anatomy in the axial plane. RESULTS: The average acetabular index on the anteroposterior radiographs of the pelvis was 33 degrees (average age-matched difference from normal, 12 degrees). Two-dimensional CT (axial cuts) showed that the average acetabular anteversion angle was close to normal, measuring 10.9 degrees. The average anterior acetabular index was 58.8 degrees (average age-matched difference from normal, 10.6 degrees), and posterior acetabular index was 53.8 degrees (average age-matched difference from normal, 3.8 degrees). Calculated axial acetabular index ranged from 90 to 133 degrees (mean, 112.6 degrees; average difference from normal, 14.5 degrees). CONCLUSIONS: Two-dimensional CT of the hip in patients with MS demonstrated a severe dysplasia of the anterior acetabular wall and the roof of the acetabulum, although the acetabular version was normal. Treatment of hip dysplasia in MS should focus on increasing the overall depth of the acetabulum to better contain the femoral head. Two-dimensional CT is recommended before bony acetabular procedures to assess the degree of acetabular deficiencies. SIGNIFICANCE: Computed tomography of the acetabulum is helpful in preoperative decision making and planning before an acetabular procedure in patients with Morquio-Brailsford syndrome.

Lateral acetabular growth stimulation following a labral support procedure in Legg-Calve-Perthes disease.

BACKGROUND: The main goal of containment treatment in cases of Legg-Calvé-Perthes disease is to prevent hip deformity, which leads to arthritis in adulthood. Recently, the shelf arthroplasty (the labral support procedure) has been proposed as a method of containment. The purpose of the present study was to evaluate growth stimulation of the acetabulum in patients with unilateral Legg-Calvé-Perthes disease by measuring acetabular depth and height following treatment with the labral support procedure. Uninvolved, contralateral hips and hips that were treated with proximal femoral varus osteotomy were used to compare growth. METHODS: Sixty-five consecutive patients with unilateral Legg-Calvé-Perthes disease that had been treated with the labral support procedure (forty-nine) or a proximal femoral varus osteotomy (sixteen) were evaluated on the basis of radiographic and clinical data that had been obtained at the time of surgery as well as at one, three, and five years after surgery. Acetabular dimensions (depth, height, and total depth with shelf) were measured and, to eliminate radiographic magnification error, the data were expressed in ratios between the involved and uninvolved sides. RESULTS: Preoperatively, both surgical groups were comparable. Acetabular depth indexes at the time of surgery were not different between the groups (p = 0.46). At one, three, and five years postoperatively, the mean depth indexes in the labral support group were significantly higher than those in the proximal femoral varus osteotomy group (F = 5.417, p = 0.001), and trend analysis showed a significant quadratic effect over time in the labral support procedure group (F = 13.132, p = 0.001). The acetabular height indexes at the time of surgery were not different between groups and showed 11% to 13% acetabular overgrowth. The acetabular height indexes in both groups remained unchanged at the time of follow-up (F = 2.82, p = 0.1). The total depth index showed decreasing linear trend values over the period studied (F = 35.115, p = 0.001). CONCLUSIONS: Overgrowth of the acetabulum occurs naturally and early in the course of Legg-Calvé-Perthes disease and is more pronounced in terms of height. The labral support procedure induces additional lateral growth of the true acetabulum (excluding the shelf) for three years following surgery, whereas a proximal femoral varus osteotomy does not. Thus, beneficial effects of the labral support procedure are lateral acetabular growth stimulation, prevention of subluxation, and shelf resolution after femoral epiphyseal reossification. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.