Management of Slipped Capital Femoral Epiphysis: The Hawai'i Experience.

Slipped capital femoral epiphysis (SCFE) is a growing problem amongst children in Hawai'i as well as throughout the world. With increasing rates of childhood obesity, SCFEs are affecting more patients at younger ages. This makes the treatment of SCFEs critical as many children with SCFEs have significant growth remaining. There are a host of treatment options based on different classification schemes which can make it difficult to determine the appropriate care for a SCFE patient. In our practice, patients are treated based on a combination of angular displacement, stability as defined by Loder, and patient age. The procedures vary from single screw in-situ fixation for a mild deformity to a modified Dunn procedure for a high-grade deformity in the skeletally immature patient. For all our open fixation methods, epiphyseal perfusion is monitored with an 18-gauge needle attached to an arterial monitor and we routinely remove fixation after physeal closure. Excellent outcomes have been noted for the modified Dunn in our practice. This article describes the algorithm used to treat SCFE in Hawai'i at a tertiary children's medical center.

An intra-articular ganglion cyst in a patient with juvenile idiopathic arthritis.

We report an intra-articular ganglion cyst (IAGC) presenting as knee pain and a mass in a patient with longstanding Juvenile Idiopathic Arthritis (JIA). We could not find a similar case of an IAGC occurring in the knee of JIA patients in the literature. IAGC may need to be included as a possibility in patients with inflammatory arthritis with new-onset knee pain, especially in those with a palpable mass. MRI was useful in distinguishing IAGC from more worrisome causes of a knee mass. Orthopedic input was helpful in diagnosis and treatment. In addition, methotrexate therapy was effective in bringing about a long-lasting remission.

Bilateral radial ulnar synostosis and vertebral anomalies in a child with a de novo 16p13.3 interstitial deletion.

We describe an 8-year-old boy with developmental delay, clinical bilateral radial ulnar synostosis, Klippel-Feil anomaly, and other vertebral deformities who was found to have a de novo deletion of 114.5kb at 16p13.3. The deletion contains five genes and three miRNAs. The genes are E4F1, DNASE1L2, ECI1, RNPS1, and ABCA3; miRNAs are MIR3677, MIR940, and MIR4717. The specific deletion has never been previously reported. We describe the phenotype of the boy and review the genes in the deleted region. None of the regulatory elements have any known linkage to skeletal formation and/or maintenance. We believe this deletion is causative given that it was de novo and that this patient cannot be easily explained as having any other specific recognizable pattern of human malformation.

An internet-based referral/consultation system for the U.S.-associated Pacific Islands: its contribution to orthopedic graduate medical education at Tripler Army Medical Center.

To evaluate the benefit of the Pacific Island Health Care Project (PIHCP) to our orthopedic graduate medical education program, we performed a retrospective review of our 8-year operative experience with patients referred through this program. Between July 1994 and June 2002, 69 patients underwent 79 orthopedic operative procedures. Patients were categorized by primary diagnosis, anatomic site involved, and surgical treatment rendered. Because many of the patients referred from the PIHCP with tumors were noted to have either unusually large lesions or advanced-stage disease, further analyses of tumor stage and pathologic grade were made. Seven of the 14 oncologic cases surgically treated in our department in the past 8 years were referrals from the PIHCP. Unique operative procedures performed for these tumor patients included one forequarter amputation, one hip disarticulation, one hemipelvectomy, two partial scapulectomies, and one distal ulna excision. We conclude that the PIHCP referrals provide an important and relatively unique contribution to the clinical and operative experience of our orthopedic residents. These patients from the Pacific basin also enhance our orthopedic graduate medical education program by exposing our residents to the special socioeconomic and cultural issues related to caring for people from developing insular countries.

Treatment of lower extremity injuries due to antipersonnel mines: blast resuscitation and victim assistance team experiences in Cambodia.

The two teams comprising the fiscal year 2001 Blast Resuscitation and Victim Assistance mission had the opportunity to learn from and practice mine injury treatment principles with experienced local and international war surgeons in Cambodia. Treatment principles were modifications of International Committee of the Red Cross recommendations. A total of 14 acute lower extremity mine injuries were treated. Surgery generally consisted of an open amputation or thorough irrigation and debridement using equipment readily available in any U.S. military field hospital. The surgical techniques will be described in detail. Delayed primary closure occurred 5 days later followed by prosthesis fitting (for amputees) in an International Committee of the Red Cross facility 12 weeks later. Other options and techniques will be discussed with an emphasis on applicability to U.S. military field surgery.

Functional bracing in the treatment of delayed union and nonunion of the tibia.

We treated 16 delayed unions and 57 nonunions of the tibial diaphysis with a below-the-knee functional brace. In 48 cases, bracing was preceded by fibular ostectomy, and ten patients had an additional bone graft. We were able to follow 67 patients, of whom six (8.7%) failed to respond to treatment. In patients with nonunion, bony healing occurred with a median of 4 months. There was no difference in the speed of healing according to the level of the defect. Shortening of the limb following ostectomy of the fibula had a mean of 3 mm in the delayed-union group and 5 mm in the nonunion group.

Dual-phase 99mTc-sestamibi imaging: its utility in parathyroid hyperplasia and use of immediate/delayed image ratios to improve diagnosis of hyperparathyroidism.

OBJECTIVE: Dual-phase (99m)Tc-sestamibi (methoxyisobutylisonitrile [MIBI]) imaging is the technique of choice for hyperparathyroidism (HPT), especially for localizing parathyroid adenomas. Prior studies have shown its utility for detecting hyperplasia is equivocal, but we believe this is not true. We attempted to quantitate the region-of-interest counts per pixel between immediate images and delayed images (I/D ratio) and use this ratio to distinguish normal parathyroid versus hyperplasia versus adenoma. METHOD: Anterior pinhole and upper thorax images with a low-energy, high-resolution collimator at 20 min and 2 h after (99m)Tc-MIBI injection were obtained on 54 subjects. The results were analyzed retrospectively as hyperplasia, adenoma, or normal parathyroid by the persistence of activity in 2 or more foci, a solitary focus, or no activity on the delayed images. These interpretations were compared with pathology when available. I/D ratios were computed for all scans, and mean ratios were calculated for each type of pathology (normal parathyroid, hyperplasia, and adenoma). The resulting ratios were analyzed with a t test to determine significant differences between the ratios. RESULTS: Sensitivity and specificity were 96% and 88%, respectively, for parathyroid hyperplasia. Mean I/D ratios were 2.26 +/- 0.68, 2.80 +/- 0.95, and 3.10 +/- 0.77 for subjects with hyperplasia, adenoma, and normal parathyroid, respectively (hyperplasia vs. normal, P = 0.020; adenoma vs. normal, P = 0.381; hyperplasia vs. adenoma, P = 0.033). CONCLUSION: Dual-phase (99m)Tc-MIBI imaging is more sensitive and specific for parathyroid hyperplasia than reported previously, supporting its use to localize hyperplastic glands preoperatively and to help guide resection. A thyroid ratio between immediate and delayed images will aid in distinguishing hyperplasia from normal parathyroid in uncertain cases.

Destructive posttraumatic subtalar synovitis.

Destructive posttraumatic synovitis is a rare entity usually involving the knee. This case report details the evaluation and treatment of a rapidly progressive and destructive subtalar lesion that occurred in a healthy 27-year-old man after incidental trauma. Initial orthopedic evaluation revealed diffuse ankle tenderness and mild effusion. Radiographic and laboratory studies showed normal findings. Bone scan revealed significantly increased uptake in the talus. Subsequent computed tomography scan and magnetic resonance imaging studies showed a lateral soft-tissue mass invading both the talus and calcaneus with destruction of the subtalar joint. Tissue biopsy samples revealed hypertrophic synovium with villous projections, occasional giant cells, and occasional hemosiderin deposits. The lesion caused rapid and progressive destruction of the subtalar joint despite aggressive conservative measures. Ultimately, the patient underwent a subtalar arthrodesis that led to the resolution of his symptoms and resumption of work and recreational activities. While posttraumatic synovitis is a rarely encountered condition, the orthopedic surgeon must have an index of suspicion, perform a systematic evaluation, and render definitive treatment to ensure a successful outcome.