Rod diameter prediction in patients with osteogenesis imperfecta undergoing primary osteotomy.

SUMMARY: Because the cross-sectional shape of the long bones of patients with osteogenesis imperfecta is often elliptical, the use of preoperative radiographs to determine intramedullary rod diameter in these patients undergoing osteotomy may be misleading. To investigate this, the authors correlated the narrowest inner bone diameter (NID) on preoperative radiographs to the rod diameter (RD) on postoperative radiographs. The authors evaluated 79 bones in 27 patients undergoing primary osteotomy with intramedullary fixation. Only 5% of the bones had an equal NID and RD, with 81% of bones having a smaller RD than the measured NID. Although a positive correlation was found between RD and NID (correlation coefficient 0.76), measurement of the NID on preoperative radiographs did not provide a good prediction of the actual RD used in this series of children with osteogenesis imperfecta.

Is a routine radiological consultation cost-effective for pediatric orthopedic radiographs?

This investigation was undertaken to determine the value of a routine radiological consultation on all examinations taken during the course of evaluation and treatment of children with elective orthopedic problems. Shriners Hospital in Los Angeles treats children with chronic orthopedic problems. All radiographs are ordered by an orthopedic surgeon. Currently all plain examinations are also read and reported by a pediatric radiologist. The study was a retrospective chart review. Three hundred nineteen radiographic examinations (6.7% of the total performed in calendar year 1995) were reviewed. The orthopedic surgeons documented the results of their readings in 69% of the cases, while the radiology staff documented 92% of the studies. The data do not show evidence of significant misinterpretations in the readings by the orthopedic surgeons. Therefore routine radiological consultation for all examinations is unnecessary in that specific setting. If a policy change were instituted, it would represent a major saving in health-care costs.

Postosteotomy healing in Pyle's disease (familial metaphyseal dysplasia). A case report.

Pyle's disease is rare skeletal dysplasia in which a defect in metaphyseal remodeling leads to grossly widened metaphyses of long bones. Genu valgum, one of the few clinical findings in this disease, may warrant surgical intervention. Postoperative healing is documented only in Pyle's original patient. A case is presented in which bilateral osteotomies were performed through the proximal tibia for progressive genu valgum. The osteotomies healed within 12 weeks when treatment was performed with standard techniques. This information will allow osteotomies to be performed with confidence.

Surgical risk for elective excision of benign exostoses.

The surgical risk and complication rates for the elective excision of benign osteochondromas and associated surgical procedures is presented. Eighty patients had excision of 285 osteochondromas and underwent 22 other related surgical procedures. There were 10 complications in the group (12.5% per patient population); the most common were peroneal neurapraxias. Other complications included an arterial laceration, a compartment syndrome, and a fibula fracture. The surgical risk for the management of osteochondromas is low and is comparable to the risk of other related, elective procedures. However, osteochondromas should not be routinely excised unless proper indications exist for their removal.

Variability in the assessment of acetabular index.

This study was undertaken to assess the inter- and intraobserver variability associated with the assessment of acetabular index. Five readers (three senior orthopaedic residents and two pediatric orthopaedic attendings) read each of 24 films on three separate occasions (360 total readings). An independent observer who was blinded to the results of the study assessed whether the radiographs would result in a reproducible acetabular index. Variability was increased for the radiographs that were deemed poorly reproducible by the independent observer. Interobserver variability exceeded intraobserver variability. Variability was comparable for senior orthopaedic residents and attending pediatric orthopaedic surgeons. Even in the group with the least variability (intraobserver variability for reproducible radiographs), the 95% tolerance interval was 8.35 degrees. The results of this study cast doubt on the reliability of the acetabular index based on a single reading.

Distal femoral extension osteotomy for knee flexion contracture in patients with arthrogryposis.

Severe knee flexion contractures in patients with arthrogryposis multiplex congenita were treated by distal femoral extension osteotomy. Thirty-two operations were followed for an average of 32 months. Contractures were corrected from 49 degrees to 6 degrees. During follow-up there was a loss of correction of 22 degrees at a rate of 0.9 degrees/ month. The angle of the distal femoral physis and the shaft of the femur was 2 degrees of flexion preoperatively, and postoperatively it measured 43 degrees of extension and at late follow-up it measured 19 degrees. Remodeling occurred at a rate of 1.0 degrees/month, which correlated with recurrence. All patients increased their ambulatory ability at least one level. There was one wound infection. Distal femoral extension osteotomy is effective and safe for the correction of knee flexion contracture. Recurrence occurs in all growing children.

Supracondylar femoral extension osteotomy: its complications.

Between 1979 and 1989, 105 supracondylar extension osteotomies of the femur were performed to correct knee flexion contractures. Disturbed by serious neurovascular complications, we reviewed our experience. Besides other complications, nine patients developed serious neurovascular complications; seven had permanent residua. There was no correlation between neurovascular complications and degree of preoperative contracture, patients' ages, or scarring from previous operation. We conclude that this osteotomy, although it appears to be technically simple, is potentially dangerous. We propose that the osteotomy be internally fixed and that the knee be flexed to relax the posterior neurovascular structures.

Extensor hallucis longus coaptation to tibialis anterior: a treatment for paralytic drop foot.

Between June 1982 and April 1983, a procedure to coapt the extensor hallucis longus (EHL) to the tibialis anterior was performed in eight post-polio patients to correct drop foot and to enable the EHL to be a more efficient dorsiflexor of ankle. Although at early follow-up, every patient was able to actively dorsiflex the ankle against gravity, at final review, (mean follow-up 7.8 years), only two patients could still do so. Three patients developed a cock-up toe deformity or dorsiflexion deformity of great toe. We have attributed the poor final results to stretching of the coaptation. Use of splints or orthosis for a longer period postoperatively and a more carefully designed physical therapy may have yielded better results. Alternatively, if the EHL is anchored to navicular bone better results may be obtained.

Stabilization of the interphalangeal joint of the big toe: comparison of three methods.

Three methods of stabilizing the IP of the big toe were compared. In group A, 10 patients underwent tenodesis of the extensor hallucis longus to the extensor digitorum brevis tendon. All of them developed a toe-drop; two patients had significant symptoms that required IP fusion. In group B, 19 patients underwent IP fusion using smooth or threaded intramedullary Kirschner wire fixation. There were nine nonunions, three requiring refusion. In group C, 32 patients underwent IP fusion using intramedullary screw fixation. There was one nonunion with screw failure that required revision. Although none of our patients considered the toe-drop after extensor hallucis longus tenodesis cosmetically unacceptable, this may not be so in other cultures. All complications following IP fusion with screw fixation were technical and are avoidable. When stabilization of IP is required, we recommend fusion of IP with screw fixation.

Proximal tibial extension medial rotation osteotomy to correct knee flexion contracture and lateral rotation deformity of tibia after polio.

A proximal tibial extension medial rotation osteotomy was performed on 17 tibias in postpoliomyelitis patients to correct knee flexion contractures simultaneously with the correction of lateral rotation deformity of the tibia through the same osteotomy. Gait improved in 10 patients. Five patients developed recurrence of knee flexion contractures; five more developed greater than 20 degrees genu recurvatum. One patient developed a common peroneal nerve palsy. Because of the high incidence of complications, we recommend that this procedure be abandoned.

Tendoachilles tenodesis to the fibula: a retrospective study.

Tendoachilles tenodesis to the fibula was performed in postpolio patients to improve their gait. The charts of 48 patients with 52 tenodeses were reviewed. The mean follow-up was 5.5 years. Gait improved in one-third. When the hindfoot was stabilized, gait improved in 40% of the patients, but when it was not stabilized, only 22% improved their gait. Excessive equinus developed in 18 patients, all of whom were less than age 12 years when operated. We conclude that it is reasonable to use this procedure to improve the gait of postpolio children with flail lower extremity, provided the hindfoot is stabilized.

Electromagnetic metal localization for removal of retained hardware in children.

Retained hardware embedded deep in soft tissues or overgrown with bone poses a challenge to the surgeon assigned to its removal. A prototype of a hand-held electromagnetic metal detector-locater was used to localize retained hardware. Stainless-steel pins, screws, plates, and staples were located in 21 consecutive hardware removal procedures in 19 pediatric patients. Time to find the hardware, length of incision, blood loss, tissue maceration, and operative time were minimized. This preliminary study suggests that a metal locater may be a valuable tool when retained hardware is not palpable or readily apparent.