Contrasts in gait mechanics of individuals with proximal femoral focal deficiency: Syme amputation versus Van Nes rotational osteotomy.

Lower-limb kinematics and kinetics during preferred and fast speeds of walking were measured in persons with proximal femoral focal deficiency to compare outcomes after Syme amputation (nine subjects) with those after Van Nes rotational osteotomy (10 subjects). Subjects with a Van Nes rotational osteotomy and full tibial rotation (seven subjects) demonstrated prosthetic knee function during stance as they were able to support a flexed-knee posture at both speeds and produced greater knee-extensor moments at preferred speeds as compared with the Syme group (p < 0.05). Nonprosthetic limb compensatory mechanics were significantly exacerbated in subjects with a Syme amputation compared with the Van Nes group: (a) stance-phase vaulting, resulting in greater inappropriate ankle-power generation at both walking speeds, (b) excessive hip-extensor moments at fast speeds, (c) excessive hip-power absorption and generation at both speeds, and (d) excessive knee-joint power generation at both speeds (p < 0.05). The improved gait after Van Nes rotational osteotomy is one factor that should be considered when making clinical decisions for children with proximal femoral focal deficiency.

Normal postoperative febrile response in the pediatric orthopaedic population.

Postoperative fever in the pediatric orthopaedic population remains a clinical concern even though prior studies concluded that fevers are a poor predictor of surgical complications. In this retrospective study of 177 patients, we established guidelines regarding the degree and time course of fever we should expect based on the perioperative conditions of magnitude of surgery, duration of surgery, need for intraoperative transfusion, estimated blood loss, age, and gender. To provide a more sensitive assessment of fever, we developed composite temperature curves for each patient and defined the area under these curves as the total febrile response (TFR). This allowed us to assess fever as a cumulative event, taking into account both its magnitude and duration. A multivariate model then determined that of the perioperative conditions studied, intraoperative transfusion status and estimated blood loss were most helpful in predicting a patient's TFR. The results of this study can be used as an additional tool for assessing postoperative progress and whether a fever is within the normal limits indicated by a patient's perioperative variables.

Humerus shaft fractures in young children: accident or abuse?

We performed a retrospective review of 34 humerus shaft fractures (HSFs) in children younger than 3 years to determine the frequency of child abuse in young children with this injury. Data were obtained from hospital records (including previous and subsequent emergency, clinic, and inpatient notes), radiographs, and county childprotective services. Cases were reviewed independently by four physicians and were classified as probable abuse, probable not abuse, and indeterminate. Only 18% were classified as probable abuse. The history and findings other than the fracture itself were critical in establishing cause. Neither age nor fracture pattern is pathognomonic of abuse, but suspicion should remain high. A detailed history, complete physical examination, and appropriate radiographic investigation are required in every case either to make the diagnosis of abuse or to avoid the trauma of a false accusation.

Surgical correction of angular deformity of the knee in children with renal osteodystrophy.

Twenty-nine children with renal osteodystrophy (RO) and angular deformities about the knee were studied, including 19 in whom 36 corrective operations were performed. Corrective osteotomy of the distal femur was performed in 20 knees, osteotomy of the proximal tibia in 11 knees, combined femoral/tibial osteotomy in three knees, and medial physeal stapling in two knees. The indication for surgery was a deformity significant enough to interfere with gait. Complications occurred in three patients and recurrence severe enough to require repeated surgery occurred in four patients. Patients who required repeated osteotomy appeared to have had poor metabolic control during the initial surgery, as measured by an increased alkaline phosphatase. Surgery for children with RO and knee deformities is quite feasible but requires careful surgical planning and preoperative metabolic stabilization. Whether to correct the femur or tibia can be determined by evaluating full-length films of the lower extremities.

Musculoskeletal coccidioidomycosis. A review of 25 cases.

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal involvement is rare, and there are few reports with clear recommendations regarding treatment. The purpose of this study was to review a series of 25 patients with musculoskeletal coccidioidomycosis and to assess their outcomes with respect to presentation and treatment. There were 36 lesions among the 25 patients, 8 located in the spine, with the remainder distributed throughout the body. Seventeen patients had a delay in diagnosis of more than 1 month. Eight patients had an elevated white blood cell count, and 10 had an elevated sedimentation rate. Only 7 of the patients had an overt pneumonia before the musculoskeletal presentation. Twenty-four patients underwent formal irrigation and debridement and 22 patients had at least 1 course of Amphotericin B. The average followup after the initiation of treatment was 3.5 years, ranging from 2 to 10 years. Seven patients had recurrent lesions that required further surgical intervention, 4 of whom had a delay in diagnosis of more than 1 month. There were 3 deaths. All surviving patients were free of disease at final followup.

Delayed reduction of traumatic knee dislocation. A case report and literature review.

Knee dislocation after high energy trauma poses a major challenge to patients and treating physicians. The case presented documents the history and treatment of an unreduced posterior knee dislocation discovered 24 weeks after injury. Delayed surgical reduction was achieved, and satisfactory results were obtained with 22 months of followup of the patient. A detailed review of the literature found no comparable examples of longstanding traumatic dislocations of the knee but shed light on the probable cause for this unusual case. Close clinical followup, even after appropriate initial treatment of knee dislocations, is needed to eliminate similar occurrences.

Measurement error of spondylolisthesis as a function of radiographic beam angle.

Slip progression in patients with spondylolisthesis is most commonly identified by comparing serial lateral radiographs of the lumbosacral spine. Although the demonstration of a progression in slip in a symptomatic individual can be an indication for surgical intervention, accurate measurements remain somewhat elusive. This is because of factors that introduce error into the measurement process itself. Foremost among these is the comparison of lateral radiographs that are not "true lateral" radiographs but rather have an unknown variable obliquity to the radiologic beam. To define the relationship between the measured slip and the obliquity of the x-ray beam angle from the true lateral, an experimental model was constructed with a fixed degree of slip at the L5-S1 level. Three different fixed degrees of slip (approximately 25, 50, and 75%) were studied. The standard deviation and hence the inherent measurement error of the measured slip increased as the obliquity of the beam away from the true lateral increased. In addition to this, the standard deviation as a function of beam angle from the true lateral also appeared to increase for larger slips.

The spine in osteogenesis imperfecta: a review of treatment.

Progressive spinal deformity can be an anathma for indivudials with osteogenesis imperfecta. Scoliosis or khyphosis develop indolently, being less dramatic than long bone fractures, but once significant deformities evolve, they tend to remain progressive on into adulthood. State of the art spinal fixation systems are of little help in correcting such deformities due to poor bone stock. However, most curves can be arrested by posterior spinal fusion, performed either in situ, or by utilizing basic Harrington type instrumentation with methylmethacylate supplemtation for the hook sites, along with Drummond wires where feasible. Platybasia is yet another issue involving the spine which may be complicated by neurologic deterioration. It has been posulated as a cause of death, but can respond to shunting and brain stem decompression when recognized.

Dorsal defect of the patella.

Dorsal defect of the patella is a benign subchondral lesion of unknown etiology, located in the superolateral region of the patella. The lesion presents with a characteristic radiographic appearance consisting of a rounded focus of radiolucency surrounded by a sclerotic margin. Although often an incidental finding on knee radiographs, it occasionally may be symptomatic. It occurs in males and females with equal frequency, is bilateral in up to one third of individuals, and is most frequently found in adolescents. This report describes a series of eight such lesions in five patients.

Tibial physeal changes in renal osteodystrophy: lateral Blount's disease.

In a group of 27 children with chronic renal failure and renal osteodystrophy, we identified eight patients with significant involvement of the proximal tibial physis (15 knees). The radiographic changes observed were analogous to those observed in tibia vara (Blount's disease) but involved the lateral physis rather than the medial physis. This observation is offered as further evidence that such changes are related to eccentric weight-bearing rather than alternative etiologies such as trauma, infection, or heredity.

Continued growth of the proximal part of the tibia after prosthetic reconstruction of the skeletally immature knee. Estimation of the minimum growth force in vivo in humans.

We studied five skeletally immature patients who had a cemented endoprosthetic replacement involving the proximal part of the tibia because of a malignant tumor. In each patient, the cement-column fractured, allowing additional physeal growth. With plain radiographs and scanograms, we determined the cross-sectional areas of the physes, the cement-mantle, and the tibial component. Using the known tensile strength of polymethylmethacrylate cement, we then calculated the minimum force that the growth plates must have overcome to fracture the cement. This averaged 584 newtons per square centimeter. This observation of continued tibial growth after partial physeal ablation with a cemented prosthesis in skeletally immature patients presented a unique opportunity to estimate the force generated in the human physis during growth.

Fibular deficiency and the indications for Syme's amputation.

Recent literature on the subject is reviewed, and the role of Syme's amputation, reconstructive surgery and prosthetic management is discussed in relation to the severity of the condition. Amputation, which should be performed between 18 months and two years old is specifically recommended for total fibula absence with ankle instability. The operative technique is detailed.

Selective posterior rhizotomy for spastic cerebral palsy. A review.

Selective posterior rhizotomy (SPR) is a neurosurgical procedure designed to alleviate spasticity in cerebral palsy. SPR depends on intraoperative monitoring of the electromyogram in conjunction with a careful preoperative assessment prior to the division of certain posterior nerve rootlets within the spinal canal. SPR is important to orthopedists, who are frequently called on to evaluate spastic patients. An outline of the physiology and clinical background of SPR is essential for an understanding of present efforts to alleviate spasticity.

Clavicle fractures in the newborn.

A retrospective review of 21,632 live births from January 1982 to July 1987 was performed to determine the incidence and risk factors associated with fractures of the clavicle in the newborn. Fifty-eight fractures (57 patients) were identified, for an incidence of 2.7 clavicle fractures per 1000 live births. Fractures of the clavicle were associated with heavy neonates and shoulder dystocia. Three patients had concurrent clavicular fractures and Erb's palsy. These findings suggest that the incidence of clavicle fractures in the newborn may be reduced by identifying the macrosomic fetus and by minimizing shoulder dystocia. When clavicle fractures occur, a brachial plexus injury should be ruled out.

Popliteal pterygium syndrome: an orthopaedic perspective.

Popliteal pterygium syndrome (PPS) is a rare autosomal dominant disorder consisting of popliteal webs and craniofacial, genitourinary, and extremity anomalies. The popliteal webs make this syndrome particularly important to the orthopaedic surgeon. The resultant fixed flexion deformity can be severe, at times approximating the ischium to the calcaneus. The neurovascular bundle is contained in the web's posterior subcutaneous (S.C.) margin, which makes surgery precarious and difficult. We reviewed four patients between 1964 and 1986, three of whom were severely affected with fixed flexion deformities at the knee. Distal femoral shortening and extension osteotomies provided good results, and this procedure should be considered earlier rather than later in treatment of this problem.

Rotational osteotomy for proximal femoral focal deficiency.

Thirteen patients who had a proximal femoral focal deficiency and were treated with a rotational osteotomy of the tibia (Van Nes procedure) were evaluated at an average of five years after operation. Five patients needed a repeat osteotomy of the tibia: four because the limb had spontaneously derotated toward the original position and one because the limb had had insufficient rotation at the time of operation. One patient had a disarticulation at the ankle after the first stage of a planned two-stage procedure because the mother was not happy with the child's appearance. In ten limbs, the distal femoral growth plate and epiphysis were removed and in two, the femoral epiphysis and growth plate and the tibial growth plate were removed so that the joint of the prosthetic knee would be positioned at the proper height at the completion of the child's growth. Neither growth plate was removed from one limb, the shorter one in the child who had bilateral involvement. A ten-point grading scale based on use and fit of the prosthesis, gait, range of motion of the ankle, use of external support, and final height of the ankle compared with that of the contralateral knee was used to evaluate the result, which was excellent in six patients, good in four, fair in one, and poor in one. One patient, who had a disarticulation at the ankle, was excluded from the final evaluation. Rotational osteotomy provided good function and acceptable cosmetic appearance in the patients who had unilateral involvement.

Closed femoral shortening modification using an internal splint.

A new device and modified procedure to facilitate closed femoral shortening are described. The method reduces operative time, radiograph exposure, and potential intraoperative complications.

Congenital dislocation of the knee.

Twenty-three congenital knee dislocations in 17 patients were reviewed after an average follow-up of 11 years. There was a 30% incidence of breech delivery along with a 41% incidence of clubfoot. Treatment in serial casts was successful in 10 knees; 13 required operations. Prognosis was most favorable in unilateral cases and when surgery was performed before 2 years of age. Quadriceps lengthening during knee surgery facilitated the subsequent reduction of ipsilateral dislocated hip.

The Chiari osteotomy. A review of 58 cases.

Fifty-eight Chiari osteotomies performed in 51 patients were reviewed retrospectively. The indications for surgery were painful subluxation, instability, or poor acetabular coverage. The average age at surgery was 16 years (range, 7-45), and the average follow-up period was 40 months. The majority of the patients had congenital hip dislocation, but also included were patients with cerebral palsy, Legg-Calvé-Perthes disease, polio, infection, coxa vara, and epiphyseal dysplasia. Supplemental bone grafts were applied as needed. The functional results were unrelated to age, with 26 excellent, 28 good, and four poorly functional hips. After operation, 39 out of 41 had total pain relief, 41 out of 58 had a normal acetabular index, and 54 out of 58 had a normal center-edge angle. Trendelenburg gaits were unchanged by the Chiari osteotomy, but trochanteric transfer improved the gait in few cases.