Treatment of idiopathic scoliosis with the Wilmington brace. Results in patients with a twenty to thirty-nine-degree curve.

The results in seventy-nine adolescent patients (ninety-five curves) who had idiopathic scoliosis treated with the Wilmington brace are reported. The average follow-up was two years and six months (range, one to nine years). Before treatment, all of the patients had a curve that measured 20 to 39 degrees and a Risser sign of zero or 1. Although the magnitude of the curve was generally reduced by about 50 per cent with the initial application of the brace, a gradual loss of this initial improvement was observed both during active treatment and after the patient was weaned from the brace. Although twenty-seven (28 per cent) of the curves had progressed more than 5 degrees at follow-up, Lonstein and Carlson reported that the projected probability of progression of untreated 20 to 29-degree curves is 68 per cent. Thirty-six per cent of the thoracic curves, 16 per cent of the thoracolumbar and lumbar curves, and 28 per cent of the double major curves had progression of more than 5 degrees. However, only 11 per cent of the patients had a curve that progressed sufficiently to warrant fusion. Our findings indicate that the Wilmington brace favorably alters the natural history of 20 to 39-degree idiopathic curves.

Long-term follow-up of fascia lata transfer for the paralytic hip in myelodysplasia.

We evaluated the results of fifty-eight fascia lata transfers and anterior hip releases in thirty-three myelodysplastic patients with a minimum follow-up of 10.9 years. The procedure does not appear to achieve hip stability or prevent recurrent flexion deformity. Pelvic obliquity occurs secondary to scoliosis and results in increased instability of the hip on the high side and ischial decubitus ulcers on the low side. The degree of scoliosis and pelvic obliquity is related to the level of neural involvement. Similarly, ambulatory status is dependent on neural function and is not affected by instability of the hip.

The prognostic importance of the ossific nucleus in the treatment of congenital dysplasia of the hip.

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. Some investigators have suggested that the presence of the ossific nucleus of the femoral head at the time of closed or open reduction is associated with a lower rate of ischemic necrosis. This finding, if verified, could lead to a delay in the treatment of a dislocated hip until ossification of the femoral head has begun, which may be well after the age when the patient has started to walk. We conducted a computerized search of the medical records at our two tertiary-care children's hospitals to identify all patients with congenital dysplasia of the hip who had had a closed or open reduction between January 1, 1979, and December 31, 1993. One hundred and twenty-four patients (153 hips) who satisfied the criteria for inclusion were identified. The ossific nucleus was present in ninety hips and absent in sixty-three. Closed reduction was used in 112 hips and open reduction, in forty-one. Ischemic necrosis was identified in five hips (3 percent): four (6 percent) of the sixty-three hips that did not have an ossific nucleus and one (1 percent) of the ninety hips that had an ossific nucleus at the time of the reduction. With the numbers available for study, we could not detect a difference between these two groups. The age at reduction (p > 0.99), the method of reduction (p = 0.611), previous treatment with a Pavlik harness (p = 0.592), the use of preliminary traction (p = 0.602), concomitant procedures (p > 0.99), and a failure of the primary closed reduction (p = 0.579) were not associated with the development of ischemic necrosis after reduction. In our analysis of patients who were managed over a fifteen-year period, the data did not support the hypothesis that the presence of an ossific nucleus at the time of reduction of a congenitally dislocated hip is associated with a lower prevalence of ischemic necrosis of the femoral head. Sound operative principles dictate that operative reduction of a congenitally displaced hip should be performed when the child can be safely placed under anesthesia and without regard to the presence or absence of the ossific nucleus.

Hypoglossal nerve injury caused by halo-suspension traction. A case report.

STUDY DESIGN: A case report of injury to the hypoglossal nerve (CN XII) resulting from the use of halogravity traction in a child with severe cervicothoracic kyphosis after an anterior and posterior spinal release. OBJECTIVE: To describe one of the potential dangers of halo-suspension (gravity) traction, which has not been reported previously in the orthopedic literature. SUMMARY OF BACKGROUND DATA: Cranial nerve injuries resulting from halo-skeletal traction are a recognized complication of such treatment, especially in patients with myelomeningocele. Halo-suspension traction using the patient's body weight as counter-traction has been recommended to provide a less rigid force and to reduce complications. METHODS: The authors report on the mechanism of injury and clinical course in a 12-year-old boy with myelomeningocele and a bilateral CN XII injury caused by halo-suspension traction from onset to resolution. RESULTS: This patient had dysphagia and difficulty swallowing 5 days after surgery. His wheelchair traction at this point was approximately 40% of his body weight. The traction was reduced, and a corticosteroid was administered. The patient's symptoms began to abate 5 days later. At 6 weeks after injury, his cranial nerve function was normal. CONCLUSIONS: Although halo-suspension traction or halo-wheelchair traction may be less rigid, injury to the hypoglossal nerve can be produced with traction exceeding 40% of body weight. In the patient in the current report, resolution of this injury was complete within 5 weeks, an outcome that is consistent with those of other reported cases of CN XII injury.

Pedicle screw placement with intraosseous endoscopy.

This study was undertaken to evaluate the efficiency of intraosseous endoscopy for the insertion of pedicle screws. Adult sheep served as an animal model. Under general anesthesia, the authors exposed the posterior lumbar elements through a midline spinal approach and cannulated six to eight pedicles in each sheep, without the use of radiographic or fluoroscopic guidance. Placement of properly located holes as well as intentionally misdirected holes was attempted. Using the fiber optic endoscope, direct examination of the interior of 22 pedicle screw holes was performed. Nine deliberate and 2 unintentional perforations, for a total of 11 defects in 22 pedicles, were easily recognized. These were confirmed by gross examination after specimens were harvested. Defects as small as 2 mm in diameter, not detected on palpation with a standard probe, were able to be closely inspected. The use of intraosseous endoscopy may serve as a useful adjunct in the placement of pedicle screws.

Avoiding paraplegia during anterior spinal surgery. The role of somatosensory evoked potential monitoring with temporary occlusion of segmental spinal arteries.

Three patients paraplegic following anterior spinal fusion for congenital kyphoscoliosis were noted to have complete somatosensory evoked potential signal loss shortly after segmental arterial ligations at the apex of their respective kyphosis. This has prompted us to use temporary segmental arterial occlusion with somatosensory evoked potential monitoring prior to ligation during anterior spinal fusion. As a result, we have noted seven additional cases, out of a total of 44 cases monitored in this fashion, in which complete loss of somatosensory evoked potential signals, reversible by release of vascular clips, has occurred. For each of these additional cases the critical segmental arteries were identified and were not ligated, usually resulting in some modifications in the planned surgical procedure, and the patients remained neurologically intact. We recommend temporary segmental arterial occlusion with somatosensory evoked potential monitoring during thoracolumbar anterior spinal fusion to potentially avert ischemic neurologic injury. Based on published data and the experience described herein, this technique should be especially important in anterior spinal fusion for congenital kyphoscoliosis.

Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective evaluation of radiographs in patients undergoing anterior spinal fusion or posterior spinal fusion for adolescent idiopathic scoliosis. OBJECTIVE: To determine the most effective preoperative radiographic method for evaluating coronal plane flexibility by comparing preoperative and postoperative correction. SUMMARY OF BACKGROUND DATA: Curve flexibility is traditionally evaluated with side-bending radiographs. Recently, the fulcrum-bending radiograph was shown to provide better correction of thoracic curves undergoing posterior spinal fusion but was not evaluated in thoracolumbar/lumbar curves or in patients undergoing anterior spinal fusion. METHODS: Preoperative coronal radiographs of 46 consecutive patients undergoing spinal fusion for adolescent idiopathic scoliosis obtained while standing, lying supine, side-bending (maximally bending while supine), push-prone (padded bolsters applied to chest wall while prone), and fulcrum-bending (curve apex suspended over a radiolucent fulcrum while lateral) were compared with standing postoperative radiographs. Cobb angles were determined and evaluated for statistical significance. RESULTS: The fulcrum-bending radiograph demonstrated statistically better correction than other preoperative methods for main thoracic curves (P < 0.01) but fell short of demonstrating the correction obtained surgically. There was no statistical difference between side-bending, fulcrum-bending, or postoperative correction for thoracolumbar/lumbar curves (all P values > 0.07). The left side-bending was the most effective method for reducing upper thoracic curves (P < 0.001). There was no difference in the results obtained for curves corrected by anterior spinal fusion or anterior spinal fusion. CONCLUSION: To achieve maximal preoperative correction, thoracic fulcrum-bending radiographs should be obtained for evaluating main thoracic curves, whereas side-bending radiographs should continue to be used for evaluating both upper thoracic and thoracolumbar/lumbar curves.

A prospective comparison of neurogenic mixed evoked potential stimulation methods: utility of epidural elicitation during posterior spinal surgery.

STUDY DESIGN: A prospective study of 50 patients who underwent posterior thoracic or thoracolumbar instrumented spinal surgery from June 1998 through June 1999. OBJECTIVES: To highlight the advantages and disadvantages of neurogenic mixed evoked potential (NMEP) data obtained with three methods of stimulation: epidural, spinous process, and percutaneous. SUMMARY OF BACKGROUND DATA: Reports in the literature have established the efficacy of epidural, spinous process, and percutaneous stimulation of the NMEP response. The three methods have not been compared for reliability, sensitivity, and specificity. METHODS: The study group consisted of 50 patients who underwent posterior thoracic or thoracolumbar instrumented spinal surgery from June 1998 through June 1999. Somatosensory-evoked potentials were used to monitor upper and lower extremities. An attempt to obtain NMEPs was made in all patients by using percutaneous (PERC-NMEP), spinous process (SP-NMEP), and epidural (EPI-NMEP) stimulation. These data were evaluated for reliability, sensitivity, and specificity. The number of minutes monitored in the postcorrection period were calculated for each method, and stimulus intensities were noted. RESULTS: In the current study, PERC-NMEPs were obtained in 88% of the patients and were maintained in 91% of those cases, SP-NMEPs were obtained in 96% and maintained in 77%, and EPI-NMEPs were obtained in 100% and maintained in 88%. Data collection continued in the postcorrection period for 46 minutes for PERC-NMEPs, 19 minutes for SP-NMEPs, and 23 minutes for EPI-NMEPs. The study group had no true-positive or false-negative findings. CONCLUSIONS: Results showed that EPI-NMEPs provide reliable data in a greater number of patients than either SP-NMEPs or PERC-NMEPs. However, PERC-NMEP data are readily maintained during and after the critical time window after corrective spinal maneuvers. The NMEPs elicited with both percutaneous and epidural stimulation have a useful role in an intraoperative spinal cord-monitoring protocol.

Parents' and patients' preferences and concerns in idiopathic adolescent scoliosis: a cross-sectional preoperative analysis.

STUDY DESIGN: A multicenter cross-sectional study of parents' and patient's concerns and preferences regarding surgery for idiopathic scoliosis. OBJECTIVES: The purpose of this study was to analyze independently both the parents' and patients' assessments of upcoming surgery for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: No group has recently reported querying patients and their parents regarding expectations, preferences, reasons, and concerns about and for surgical treatment of adolescent idiopathic scoliosis. METHODS: Ninety-one sets of parents and patients were separately asked to complete questionnaires regarding the patients' upcoming idiopathic scoliosis surgery. Patients' ages ranged from 9 to 18 years, and data were collected from four centers and seven surgeons (all active members of the Scoliosis Research Society) from April through December 1998. Thirty-nine questions covered concerns (n = 6), reasons for surgery (n = 14), expectations (n = 9), assessment of life as is (n = 5), and scar preference (n = 5). RESULTS: The greatest concern about the surgery expressed by both parents and patients was neurologic deficit. The least concern for both was location and appearance of the scar. The highest expectation and main reason for having the surgery was to reduce future pain and disability as an adult. Families would be either somewhat or very dissatisfied to spend the rest of life "as is." CONCLUSION: Although parents and patients had similar ratings and concerns, the parents' concerns were higher, and expectations were greater than the patients'.

Efficacy of intraoperative monitoring for pediatric patients with spinal cord pathology undergoing spinal deformity surgery.

STUDY DESIGN: A retrospective study of 38 pediatric patients with spinal cord pathology who underwent corrective spinal deformity surgery from January 1989 through June 1998. OBJECTIVES: To report reliability and specificity in obtaining intraoperative data in this population. These data were compared with monitoring results obtained in a group of pediatric patients with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Reports in the literature suggest intraoperative monitoring for patients with spinal cord pathology may be of limited value. No optimal monitoring protocol has been suggested for this population. METHODS: The study group consisted of 38 pediatric patients with a diagnosis of spinal cord pathology who underwent corrective spinal deformity surgery from January 1989 through June 1998. All patients had lower extremity function. Somatosensory and neurogenic motor evoked potentials were used to monitor neurologic status during surgery. These data were compared with data obtained in 429 pediatric patients with idiopathic scoliosis. Study patients were divided into Group I, those who had had spinal cord surgery (n = 20), and Group II, those who had not (n = 18). RESULTS: Somatosensory evoked potentials were obtained in 93.2% and remained consistent with baselines in 87.2% of the study group patients. Neurogenic motor evoked potentials were obtained in 50.8% of the study subjects and remained consistent in 76.6% of those cases. The false-positive rate was 27.1% in the study group, compared with 1.4% in the group with idiopathic scoliosis. The study group had no true-positive or false-negative findings. Group I data differed from Group II data. CONCLUSIONS: Intraoperative monitoring should be used in patients with spinal cord pathology who undergo surgery for spinal deformity. Monitoring should not miss a neurologic deficit but demonstrates greater variability, resulting in more frequent use of an intraoperative wake-up test.

The Lenox Hill brace in anterolateral rotatory instability.

We evaluated the efficacy of the Lenox Hill Brace in controlling anterolateral rotatory instability (ALRI) of the knee. Thirty-six patients with ALRI previously fitted with the Lenox Hill Brace were examined and graded using standard clinical laxity tests. A comparison was made of the degree of instability with and without the brace applied. Of the 20 patients with ALRI, 89% of the knees with Grade I instability and 45% of those with Grade 2 instability were improved. Sixteen patients had combined anteromedial-anterolateral rotatory instability (AM-ALRI). Although AMRI was improved in all, ALRI was unchanged in 69%, in spite of proper brace specifications and fit.

Retrosternal displacement after physeal fracture of the medial clavicle in children treatment by open reduction and internal fixation.

Retrosternal displacement of the medial aspect of the clavicle after physeal fracture is rare. We treated six patients with this injury between 1995 and 1998, all as an emergency in order to avoid complications associated with compression of adjacent mediastinal structures. Attempted closed reduction was undertaken, but all required open reduction and internal fixation using a wire suture. There were no associated complications. Five were reviewed clinically and radiologically at a minimum of one year after operation. All had regained full use of the affected arm without pain and had resumed their preinjury level of activity including sports. Follow-up radiographs showed union in the anatomical position in all patients. We recommend attempted closed reduction in the operating room, followed, if necessary, by open reduction. Internal fixation after open reduction gives stable fixation with minimal morbidity.

The use of the Ilizarov technique in the correction of lower extremity deformities in children.

The first time the Ilizarov technique was used at Children's Hospital of Los Angeles, 25 limb segments were treated in 15 patients. Thirteen segments (52%) required angular correction, 6 (24%) required lengthening, and 6 (24%) required both angular correction and lengthening. Average angular correction was 21 degrees (8 degrees to 41 degrees); average length gained was 44 mm (25 to 85 mm). All patients except two achieved preoperative goals. A total of 17 minor (.68/limb) and four major (.16/limb) complications occurred in the 25 limb segments in the study. The total complication rate was .84 complications per limb segment. The most common complication was pin tract infection (11 patients). This comprised 52% of complications and occurred in 44% of limb segments.

Bone endoscopy: direct visual confirmation of cannulated screw placement in slipped capital femoral epiphysis.

Intraosseous endoscopic examination of the femoral neck and head was performed during the course of percutaneous screw fixation in 12 patients with slipped capital femoral epiphysis (SCFE). Visualization was satisfactory in 13 hips of these patients. We were able to distinguish trabecular bone and physeal cartilage endoscopically. Evidence of articular penetration was documented endoscopically in two patients. One patient had been referred for persistent hip pain and chondrolysis 6 months after screw insertion. Chronic joint penetration was observed endoscopically at the time of revision operation. In the second patient, transient pin penetration was visualized during cannulated screw fixation of a severe slip.

Common elbow fractures in children.

Approximately 75 percent of all fractures sustained by children occur in the upper extremities and frequently occur during a fall onto an outstretched hand. The majority of these injuries involve the wrist and forearm, but the elbow alone accounts for approximately 10 percent of all fractures in children. Elbow fractures in children are challenging because of the abundance of unossified cartilage and the high potential for limb-threatening damage to neurovascular structures. Common types of elbow fractures include supracondylar, lateral condylar, medial epicondylar, radial neck and transphyseal fractures.