Comparison of supine bending, push-prone, and traction under general anesthesia radiographs in predicting curve flexibility and postoperative correction in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective study comparing supine bending, push-prone, and traction under general anesthesia (UGA) radiographs in adolescent idiopathic scoliosis. OBJECTIVE: To compare the effectiveness of 3 different flexibility methods on structural and nonstructural main thoracic (MT) and thoracolumbar/lumbar (TL/L) curves. SUMMARY OF BACKGROUND DATA: Supine side bending radiographs are the major method for determining curve reducibility. Push-prone radiographs show structural and compensatory curves on the same radiograph, but have not shown comparative reducibility in recent studies. Traction UGA is a relatively new modality which may offer similar or improved flexibility, while also showing structural and compensatory curves on the same radiograph. METHODS: Fifty-eight patients with adolescent idiopathic scoliosis were prospectively studied with standing PA and lateral, supine bending and push-prone radiographs before surgery; traction UGA radiographs intraoperatively; and standing PA and lateral radiographs after surgery. RESULTS: Traction UGA demonstrated equal flexibility to supine bending in structural MT and TL/L curves, with a trend towards more flexibility in severe MT curves > or = 60 degrees, while push-prone demonstrated significantly less flexibility. Each of the methods showed significantly less flexibility than postoperative correction in MT curves, while traction UGA and supine bending were not significantly different than postoperative correction in TL/L curves. Analysis of nonstructural TL/L curves showed that traction UGA and push-prone were not significantly different than postoperative correction, while supine bending overestimated postoperative correction. CONCLUSION: Traction UGA offers flexibility equivalent to supine bending for structural MT and TL/L curves, and flexibility comparable with push-prone for nonstructural TL/L curves. Traction UGA also shows both structural and compensatory curves on the same radiograph, and ultimately may provide a better estimate of spinal balance.

Orthopaedic implications of multiple gestation pregnancy with triplets.

Intrauterine crowding has been implicated as a risk factor in several orthopaedic conditions, such as developmental dysplasia of the hip (DDH), metatarsus adductus, and torticollis. The goal of this study was to see whether orthopaedic conditions associated with intrauterine crowding were more frequent in multiple gestation pregnancies, specifically in triplets. The authors reviewed their experience over a 10-year period with 261 children who were products of triplet pregnancies. They surveyed 13 orthopaedic conditions and found only one condition, torticollis, that had a greater incidence than that reported in single gestation pregnancies. A 0% incidence of DDH was found in these patients. Routine ultrasound screening cannot be recommended in these patients based on these results.

Treatment of compartment syndrome: transverse fasciotomy as an adjunct to longitudinal dermatofasciotomy: an in vitro study.

OBJECTIVE: This study describes a previously unpublished technique for compartment release that combines adjunctive transverse fasciotomies with a limited longitudinal dermatofasciotomy and compares its efficacy with a standard extensile longitudinal dermatofasciotomy. DESIGN: Limited 10-cm longitudinal dermatofasciotomies were performed bilaterally on 14 cadaveric specimens (28 legs). Next, we performed transverse fasciotomies on 1 limb and performed extensions of the longitudinal incision on the contralateral limb. Subsequent changes in compartment pressures were recorded after each release. Two-tailed paired and unpaired Student t tests were performed for statistical analysis with significance set at P < 0.05. SETTING: Anatomy laboratory. RESULTS: After a 10-cm longitudinal dermatofasciotomy, the average compartment pressure was 17 +/- 7.1 mm Hg proximally and 15.5 +/- 7.4 mm Hg distally. With an extensile 16-cm longitudinal incision, a significant decrease in compartment pressure was seen both proximally (6.5 +/- 3.1 mm Hg) and distally (4.7 +/- 4.7 mm Hg). With adjunctive transverse fasciotomies, a significant reduction in compartment pressure also was observed proximally (6.9 +/- 6.1 mm Hg) and distally (6.1 +/- 5.4 mm Hg). There was no statistically significant difference in compartment pressures between an extensile 16-cm incision and 10-cm incision combined with transverse fasciotomies both proximally and distally (P = 0.84 and P = 0.5, respectively). CONCLUSIONS: A combined approach of transverse fasciotomies with a limited longitudinal dermatofasciotomy in this in vitro compartment syndrome study is as effective as a standard 16-cm longitudinal release in the anterior compartment of this cadaveric leg model.

Degenerative disorders of the lumbar and cervical spine.

Degenerative disorders in the spine are normal, age-related phenomena and largely asymptomatic in most cases. Conservative management of lumbar and cervical spondylosis is the mainstay of treatment, and most patients with symptomatic degenerative changes respond appropriately with nonsurgical management. Surgical intervention can be considered an appropriate and viable option when conservative measures have failed. Treatment options should always be directed toward the specific nature and location of the patient's individual pathology. Although current standards in the surgical management of lumbar and cervical degenerative disorders include discectomy, neural decompression, and instrumented spinal arthrodesis, new approaches that address this often-challenging clinical entity are on the horizon.

Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation.

Anatomic restoration of displaced fracture-dislocation of the tarsometatarsal junction of the foot is essential, as even "minor" disruptions of this joint complex leads to poor clinical results. In order to determine a "key" element associated with good or poor functional outcomes, 11 patients with excellent radiographic results following surgical treatment of unilateral closed Lisfranc fracture-dislocation of the tarsometatarsal joint of the foot were evaluated at an average of 41.2 (range, 14 to 53) months following their injury and surgery. Their average age was 40.6 (range, 21 to 58) years. AOFAS midfoot scores averaged 71.0 (range, 30 to 95). Radiographic analysis at follow-up revealed anatomic reduction in 10 of 11. Eight of 11 had evidence of arthritis of the tarsometatarsal joints. Clinical alignment was normal in all subjects, with nine of 11 clinically exhibiting decreased relative range of motion. Gait analysis was performed with the F-Scan (Tekscan, Boston, MA) in-shoe pressure-monitoring system. Vertical ground reaction force was recorded under the hallux, first metatarsal head, lateral metatarsals, and heel. Stance phase duration, rate of loading, rate of unloading, peak loading, and total loading were recorded at each of the named regions. There was no statistical difference in the parameters measured between the injured and normal control feet. The results of this study reveal that when anatomic reduction is accomplished in tarsometatarsal fracture dislocation of the foot, objective measures of gait analysis are returned to normal. In spite of excellent radiographic results and return to normal dynamic walking patterns, subjective patient outcomes were less than satisfactory. It is presently well accepted that fracture-dislocations of the tarsometatarsal junction of the foot are best treated with anatomic restoration by closed, percutaneous or open methods. Many individuals achieve poor functional results. It is well accepted that patients are likely to develop late joint deformity at the tarsometatarsal junction, joint separation, and radiographic and clinical evidence of post-traumatic arthritis when anatomic reduction is not obtained. (1-7) The goal of this study was to determine if clinical results and subjective patient outcomes are assured with anatomic reduction. It appears that the major function of the tarsometatarsal joint complex is the regulation and redirecting of loading forces during weightbearing. There is very limited motion of the tarsometatarsal joint during walking. (8) This knowledge has prompted support for anatomic restoration following injury. Even with seemingly anatomic restoration of normal alignment, many patients fare poorly. The goal of this study was to objectively analyze the components of vertical ground reaction force during walking in patients who had evidence of excellent surgical reduction measured on follow-up weightbearing radiographs following isolated injury to the tarsometatarsal joint complex. We hoped to detect some key element of gait altered by the injury, and responsible for why patients fare poorly following this injury. By dissecting out the components of mechanical loading and unloading of the foot during walking, we wished to determine if there was a "key" factor associated with either favorable or unfavorable subjective clinical outcomes.