Re-alignment and intramedullary rodding of the humerus and forearm in children with osteogenesis imperfecta: revision rate and effect on fracture rate.

PURPOSE: Intramedullary rodding is indicated for patients with osteogenesis imperfecta (OI) to manage deformity and help treat recurrent fractures. Historically, the focus of intramedullary stabilisation has been the lower extremity. Here we report our experience of intramedullary rodding of the humerus and forearm in children with OI and its impact on the fracture rate of those bone segments. PATIENTS AND METHODS: This is a retrospective chart review of all OI patients who have undergone re-alignment and intramedullary rodding of the humerus or forearm between October 1994 and February 2016. Patient demographics, surgical information, complications and pre-operative and post-operative fracture rates were gathered. RESULTS: A total of 45 upper extremity segments (26 humeri, 19 forearms) were rodded at an average age of 8.7 years (3.1 to 19.2). Of these, 15 (33.3%) of the bone segments required a return to the operating room at a mean 30.8 months (1 to 90) post-operatively. Fracture data was available for 24 of the bone segments. The average number of pre-operative and post-operative fractures was 3.58 (SD 2.84) and 0.46 (SD 0.72) respectively. The average pre-operative and post-operative fracture rates were 0.87 fractures/year (SD 0.47) and 0.10 fractures/year (SD 0.16) respectively. CONCLUSION: In this OI population, re-alignment and rodding appeared to reduce the fracture rate of the humerus and forearm. Among our population, one third returned to the operating room and one fifth required revision to a new intramedullary implant. This data may help families better understand the potential outcomes of upper extremity realignment and rodding and its effect on the rate of upper extremity fractures.

Complications of blade plate removal.

The AO fixed-angle blade plate is commonly used to obtain fixation in proximal femoral osteotomies. This device provides stable fixation and obviates the need for postoperative immobilization. There are no reports in the literature on the rate and types of complications associated with blade-plate removal. We report our rate and type of perioperative and early postoperative complications associated with removal of fixed-angle blade plates in a pediatric population. With an overall complication rate of 5.3% and a major complication rate of 2.0%, our study showed that removal of the blade plate was a relatively safe procedure in those patients troubled by prominent/painful hardware or skin breakdown.

Is there a relationship between hypertension and lower-extremity contracture release in cerebral palsy?

Recent reports have suggested a relationship between release of lower-extremity contractures and the development of hypertension in cerebral palsy and poliomyelitis patients. A retrospective study was performed on 119 cerebral palsy patients who had undergone lower-extremity contracture releases. Temporary elevation of systolic blood pressure in the perioperative and intraoperative periods occurred in 46 patients (39%), and temporary elevation of diastolic blood pressure occurred in 14 patients (12%). Type of cerebral palsy, patient age, patient sex, type of anesthesia, and type of procedure were not significantly correlated with the temporary blood pressure elevations. No patient developed sustained elevation of systolic and diastolic blood pressure. We conclude that lower-extremity contracture release in pediatric patients is not associated with an increased incidence of postoperative hypertension.

An unusual presentation of intoeing in a child.

Ganglion cysts are commonly seen in orthopedic and general practice. Compression of the common peroneal nerve by a ganglion cyst is rare in children; to the authors' knowledge, only five cases in patients younger than 18 years have been reported. A ganglion cyst was found in a 3-year-old child who was brought in for an evaluation of intoeing and was found subsequently to have a mass in the proximal aspect of the right leg. The literature is reviewed with attention to specific recommendations for the evaluation of soft tissue masses and the utility of imaging modalities.

The role of dual energy x-ray absorptiometry in aiding the diagnosis of pediatric osteogenesis imperfecta.

The role of dual energy x-ray absorptiometry (DEXA) in the evaluation of the pediatric patient with multiple fractures has not been well established. We retrospectively examined the medical records of 45 patients who had presented to our institution with multiple fractures of unknown cause, who were not known to have osteogenesis imperfecta, and who had obtained DEXA as part of their evaluation. Of these, 26 patients had sufficient clinical data for inclusion in this study. Patients underwent DEXA of the anteroposterior spine and whole body. A z score was calculated to normalize the DEXA values for age. The diagnosis of osteogenesis imperfecta was correlated with the outcome of each DEXA scan to assess the validity of DEXA as a diagnostic tool. The DEXA of the anteroposterior spine had the highest sensitivity at 91.7%, while DEXA of the whole body had the highest specificity at 100.0%. Decreased bone mineral density may be associated with osteogenesis imperfecta, and DEXA is helpful in detecting low bone mineral density that may be missed on plain radiographs of children with milder forms of osteogenesis imperfecta.

Fortuitous diagnosis of iliac osteomyelitis: septic arthritis of the hip in the neonate.

The neonate is unable to relate specific complaints of pain and may not exhibit the usual signs of illness or infection. Septic arthritis of the hip is a surgical emergency in the neonate, and it should be considered in any irritable or ill child who has a high index of suspicion. Prompt diagnosis and immediate treatment are necessary. Nearly all babies undergo routine examination of the hip for dysplasia. It is recognized that limitation of abduction of the hip in the neonate may not represent developmental dysplasia of the hip but may represent other etiologies, such as fracture, infection, congenital anomaly, or tumor. The following case report illustrates the importance of careful clinical evaluation of an apparent asymptomatic neonate.

Measurement of rib vertebral angle difference. Intraobserver error and interobserver variation.

STUDY DESIGN: The rib vertebral angle difference was measured on 50 juvenile scoliosis radiographs. Three observers measured each radiograph independently and on three separate occasions to determine interobserver and intraobserver error. OBJECTIVE: To determine the interobserver and intraobserver error in measuring the rib vertebral angle difference. SUMMARY OF BACKGROUND DATA: The rib vertebral angle difference is a commonly used measurement, the reliability of which has not been tested rigorously. METHODS: Fifty standing radiographs of juvenile scoliosis were measured. All patients were Risser 0 at the time of measurement. All angles were measured by the method of Mehta using the same protractor and apical vertebra to avoid confounding variables. Three surgeons individually measured the 50 radiographs randomly and on three separate occasions. All markings were erased before remeasurement. RESULTS: The intraobserver error was determined to be 4.4 degrees. The interobserver error was 3.6 degrees. The interobserver accuracy was 6.2 degrees. CONCLUSIONS: The rib vertebral angle measurement is highly reproducible and is a valid measurement.

Accessory bones of the foot: clinical significance.

In an effort to improve orthopedic clinic utilization, we reviewed the incidence of normal radiographic variants in the foot referred from the emergency room or outpatient clinic. The study was undertaken because normal radiographic variants are often confused with fracture. A retrospective study of all foot radiographs referred to the foot clinic at Madigan Army Medical Center was carried out. Distribution of normal radiographic variants and their confusion with fracture were evaluated. Thirty-six percent of all foot radiographs had identifiable accessory bones. The most common accessory bones in descending order were: os peroneum, accessory navicular, and os trigonum. All of the accessory bones identified in our study were asymptomatic. A thorough knowledge of location of normal accessory bones is mandatory and localization of foot symptoms by history and physical examination are necessary to facilitate correct diagnosis and treatment and to avoid unnecessary referral of these patients.

Lumbar and lumbosacral fusion using Steffee instrumentation.

Posterior and posterolateral spinal fusion with the Steffee variable plating system have been performed on 176 patients at Walter Reed Army Medical Center since November 1985. This report covers the authors' early experience using the Steffee device on 39 patients. All of the 39 patients (100%) were available for a minimum follow-up of 2 years. Complications occurred in 26% of the patients. Radiographic pseudarthrosis occurred in 8% of the patients. The findings suggest that lumbar and lumbosacral fusion supplemented with Steffee plate instrumentation are associated with a low incidence of pseudarthrosis and acceptable morbidity overall.

Foreign body arthroscopically retrieved from the elbow.

A patient was found to have a tea-cup-handle fragment in her elbow joint. The fragment was removed arthroscopically. Interestingly, the patient was unaware of its presence and was asymptomatic for > 29 years.

Goretex fabric as a cast underliner in children.

The efficacy of using Goretex fabric as a cast liner to improve skin care was evaluated. A prospective study was performed of 20 patients undergoing casting using Goretex underliners. At each cast change or at the end of casting, skin condition was evaluated. No change in any standard treatment protocol regarding cast changes was made because of the Goretex liner. Goretex fabric provided improved ease of care and prevented cast soiling. The breathability of the fabric was believed to be a benefit in decreasing skin irritation.

Shelf arthroplasty in patients who have Legg-Calvé-Perthes disease. A study of long-term results.

We reviewed the long-term functional and roentgenographic outcomes of severe Legg-Calvé-Perthes disease in two similar groups of patients, one of which was managed with a shelf arthroplasty and the other, by a variety of non-operative means. Twenty hips in nineteen patients were treated with traction and, when necessary, adductor tenotomy to attempt reduction of the subluxation; this was followed by a shelf arthroplasty to increase the arc of the acetabulum and result in coverage of the femoral head. The average duration of follow-up was nineteen years (range, two to forty-seven years). The initial center-edge angle and the anteroposterior Mose sphericity measurement were significantly improved at the most recent follow-up (p greater than or equal to 0.05), and the average Iowa hip score was 91 points. Hinge abduction, which was producing incongruity, was eliminated in eleven of fourteen hips after the operation. The outcomes for the second group, consisting of eighteen hips in seventeen patients who were managed non-operatively, were also reviewed, at an average duration of follow-up of twenty-eight years (range, seven to forty-five years). No significant improvement in the center-edge angle or the anteroposterior Mose sphericity measurement was observed at the most recent follow-up, and the average Iowa hip score was 81 points. There was no significant difference in the range of motion of the hip between the groups. We believe that shelf arthroplasty is a favorable option in the treatment of Legg-Calvé-Perthes disease when additional bone is needed at the lateral aspect of the acetabulum to cover the extruded portion of the femoral head, to prevent additional incongruity and thereby delay the early onset of degenerative changes.

Oblique tibial osteotomy in the correction of tibial deformity in children.

A new method of oblique tibial metaphyseal osteotomy that uses a single osteotomy cut has been used to allow correction of multiplanar rotational deformities in children. Graphs are used to predict the necessary angle of osteotomy. The osteotomy is performed through a 1-cm incision in the proximal tibial metaphysis, using multiple drill holes and an osteotome. Correction is maintained by casting with or without internal fixation. Fourteen such osteotomies have been followed an average of 27 months without major complications. This osteotomy allows maximal maintenance of length, stability, and metaphyseal contact through a small, cosmetically acceptable incision. Minimal soft-tissue dissection is necessary.