Issues in surgical treatment of thoraco-lumbar injuries associated with spinal cord injuries in children and adolescents.

To evaluate standards of care in surgical treatment of thoracolumbar injuries (TLIs), we reviewed the cases of 79 surgically treated patients (39 males, 36 females) with TLIs and spinal cord injuries occurring from January 1985 to January 2000. We assessed radiographs of fracture-dislocation reductions; restorations of sagittal and coronal alignment of injured segments; instrumentation levels and strategies; operations, and reoperations. Mean age at time o f injury was 14.1 years. The majority of injuries were thoracic, and posterior spinal fusion with instrumentation was the most common index procedure performed. Mean follow-up was 23.4months. Reoperation rate was 20%. Problems in achieving fracture reduction, selecting correct instrumentation levels, restoring proper sagittal alignment, an d planning a nd performing surgeries were more prevalent in patients treated before 1990 but are still problematic, even with use of modern segmental instrumentation, and frequently require revision to improve function or relieve symptoms. These results indicate a wide range in standards of care in surgical treatment of TLIs.

Complications related to postoperative casting after surgical treatment of subluxed/dislocated hips in patients with cerebral palsy.

Three hundred sixteen subluxed/dislocated hips (222 patients) underwent upper femoral osteotomy. Of these, 286 (90.5%) hips were casted (average patient age: 8.9 years) and 30 (9.5%) were not (average patient age: 13.6 years). Average follow-up was 4.7 years. Complications in the casted/noncasted groups (per hip) were: 43/0 (15%/0%) skin sores; 11/1 (3.8%/3.3%) wound infections; 6/0 (2.1%/0%) instrumentation failures; 22/1 (7.7%/3.3%) reoperations; and 13/1 (4.5%/3.3%) rehospitalizations. Differences between the groups were not statistically significant. Casted patients were younger and more neurologically involved. Casting is useful to ensure healing of osteotomies, prevent instrumentation failure and injury to the operated legs, and allow for ease of handling. Complications that occurred were managed and had no long-term sequelae.

The structural implications of a unilateral facial skeletal cleft: a three-dimensional finite element model approach.

OBJECTIVE: For children born with a unilateral facial skeletal cleft, oral motor function is impaired and skeletal development and growth are asymmetrical with regard to the midsagittal plane. This study was designed to verify that a unilateral skeletal cleft and its dimensions (i.e., depth and width) affect the severity of the asymmetric stress and strain distribution within the maxilla. METHODS: A three-dimensional finite element model of a normal maxilla was developed from pediatric, subject-specific computerized tomography scan data. A clefting pattern then was introduced to simulate varying degrees of deformity in geometry, with the bone properties and boundary conditions held constant. The asymmetric index was introduced to quantify the asymmetrical stress and strain distribution within the maxilla with regard to the midsagittal plane. RESULTS: The unilateral skeletal cleft led to a nonuniform, asymmetric stress and strain distribution within the maxilla: intensified on the noncleft side and weakened on the cleft side. As the depth of the unilateral cleft increased, the stress and strain distribution became increasingly asymmetric as measured by the asymmetric index. In contrast, the width of the cleft had minimal effect on the asymmetrical stress and strain distribution. INTERPRETATION/CONCLUSION: These results implied that a child born with a unilateral cleft would be expected to have an asymmetric skeletal development between the noncleft and the cleft sides as a consequence of an asymmetric functional loading pattern.

The superior mesenteric artery syndrome in patients with spinal deformity.

STUDY DESIGN: A retrospective review. OBJECTIVE: To determine the incidence of the superior mesenteric artery syndrome (SMAS) after surgical correction for scoliosis and if it is influenced by newer derotation/translation surgical systems. SUMMARY OF BACKGROUND DATA: The SMAS is a known complication after surgery. METHOD: Of 2939 charts reviewed, 17 patients between 1960 and 2002 matched inclusion criteria. RESULTS: Our incidence of the SMAS was 0.5%. Onset of symptoms was 7.2 days. Several scoliosis diagnoses were included in the study group. Instrumentation that was used included: nondistraction systems (n = 14), Harrington rod with body cast (n = 1), Luque rod with sublaminar wires (n = 1), and casted in situ posterior spinal fusion (n = 1). Before surgery, 10 of 17 patients weighed less than the 50th percentile. Mean preoperative BMI was 18.6 kg/cm/cm. Postoperative height gain averaged 3.175 cm, and weight loss at onset of symptoms averaged 4.5 kg. There were 14 patients who required nasogastric suction for an average duration of 10.2 days, 11 required hyperalimentation, and 5 concurrently received hyperalimentation with enteric feeding. The SMAS recurred in 2 patients. CONCLUSIONS: Postoperative weight loss appears to be more important for the development of the SMAS than asthenic body type. Newer derotation/translation corrective techniques have not eliminated the SMAS. Gastrointestinal imaging is indicated when nausea and vomiting occur 6-12 days after surgery, associated with early satiety and normal bowel sounds. Decompression and nutritional support remain the mainstays of treatment.