The orthopedists' perspective: bone tumors, scoliosis, and trauma.

Although a detailed, comprehensive look at pediatric orthopedists' use of imaging is beyond the scope of this article, we offer an orthopedist's perspective of the role imaging plays in the care of children with tumors, scoliosis, and trauma. Given the growing, dynamic state of a child's skeleton, the long-term consequences of injury must always be considered.

Role of computed tomography in the classification and management of pediatric pelvic fractures.

In adults, pelvic computed tomography (CT) scanning plays an important role in the treatment of pelvic fractures; however, the role of CT scanning in the management of pediatric pelvic fractures is unclear. The purpose of this study was to investigate the efficacy of CT scanning in the management of pelvic fractures in children. One hundred three consecutive patients were identified. All patients underwent anteroposterior plain radiographic evaluation; CT scans were performed in 62. Three orthopaedic surgeons independently reviewed the plain radiographs and determined fracture classification and management. Subsequently, each observer was shown corresponding CT scans and again determined classification and management. Interobserver agreement was calculated using Kappa statistics. After the addition of CT scans, the mean changes in classification were nine (15%) and in management two (3%). Plain radiographs alone reliably predicted the need and type of operative intervention. Kappa statistics demonstrated "excellent" agreement for classification and management without and with CT scans. We reliably determined fracture classification and management based on plain radiographs alone.

Congenital vertebral anomalies in ischiopagus and pyopagus conjoined twins.

A review of clinical records and radiographs revealed that five of 10 patients with conjoined twinning (three of six ischiopagus and two of two pyopagus twins) had congenital vertebral anomalies including hemivertebrae (3), multiple thoracic anomalies (1), right hemisacral agenesis (1), and three lumbar vertebra (1). No mirror image anomalies were identified, and different regions of the spine were involved in the two cases in which both twins had anomalies. Coexisting visceral and musculoskeletal anomalies included dextrocardia (3), atrial septal defect (1), congenital vertical talus (2), Sprengel's deformity (1), and multiple unilateral foot anomalies (1). Hip subluxation or dislocation was seen in five of eight ischiopagus or pyopagus twins after separation and required femoral and pelvic osteotomies. Lumbar scoliosis not associated with congenital vertebral anomalies was seen in two ischiopagus twins. These observations suggest an association between ischiopagus and pyopagus conjoined twins and congenital vertebral anomalies, and their coexistence is explained best by a nonspecific teratogenic insult during early embryogenesis.

In vitro analysis of periprosthetic strains following total knee arthroplasty.

Clinical case studies have disclosed certain risk factors associated with periprosthetic fracture in elderly patients. How the mechanical strength of the distal femur is changed by total knee arthroplasty (TKA) has not been elucidated. Using elderly cadaveric femora, this study evaluated both periprosthetic strains and associated fracture patterns arising from an in vitro simulation of a fall onto the distal femur. The data showed a significant increase in anterior and posterior mechanical strain following TKA. Neither stemless nor stemmed versions of two cemented Howmedica prostheses (Rutherford, NJ) reduced distal femur strains to baseline values. However, neither produced a disproportionate frequency of periprosthetic fractures. Although not formally evaluated herein, bone geometry/density may contribute more profoundly to the occurrence of periprosthetic fracture than the implants tested.

Anterior cruciate ligament reconstruction in adolescents with open physes.

The purpose of this study was to evaluate anterior cruciate ligament reconstructions performed in adolescents with open physes and a skeletal age of at least 14 years. At one center, from 1992 to 1996, 19 adolescents (ages, 11 to 15 years) with open physes and a skeletal age of at least 14 years underwent arthroscopic anterior cruciate ligament reconstruction using an Achilles tendon allograft placed through drill holes across the open physes in both the distal femur and proximal tibia. Fifteen patients returned for reevaluation at an average of 25 months postoperatively (range, 12 to 60 months); the remaining four patients were interviewed by telephone. There were no significant leg-length discrepancies or angular deformities as determined by scanograms and anteroposterior and lateral radiographs of the femur and tibia. The mean Lysholm knee score was 97 (range, 94 to 100) and the mean KT-1000 arthrometer side-to-side difference at 20 pounds of anterior force was 1.7 mm (range, 0.0 to 3.0). All patients were satisfied with the results of surgery, and 16 of 19 patients returned to the same sport they were participating in before the injury. This study demonstrates that anterior cruciate ligament reconstruction using an Achilles tendon allograft is a viable treatment option for skeletally immature patients with a skeletal age of 14 years who have sustained midsubstance tears of the anterior cruciate ligament.

Radial polydactyly: an outcome study.

Radial polydactyly is a relatively common congenital disorder that frequently occurs as thumb duplication. A paucity of information exists on outcomes of Bilhaut-Cloquet procedures. To evaluate clinical outcomes, the results of various operative and nonoperative treatments were reviewed. Follow-up by retrospective chart review was performed on 21 patients treated between 1979 and 1994 at the Shriners Hospital for Crippled Children in Erie, Pennsylvania. Patient interview or physical examination, or both, was performed on 16 of these patients. The study was comprised of 9 boys and 12 girls (average age, 7.8 years; range, 1.5-15.8 years) and included 26 thumbs. Ablation alone was performed in 6 thumbs (6 patients), a combined procedure consisting of ablation with radial collateral ligament reconstruction and shaving of the metacarpal in 10 thumbs (9 patients), and a Bilhaut-Cloquet procedure in 5 thumbs (4 patients). Five thumbs (4 patients) with Wassel type I classification were managed without surgical intervention and simply observed. Of the 6 thumbs treated with ablation alone, 5 required subsequent procedures (radial collateral ligament reconstruction). Ablation with collateral ligament reconstruction and articular surface shaving improved clinical alignment and stability but did not return normal interphalangeal joint motion. The Bilhaut-Cloquet procedure improved the overall cosmetic and functional appearance but likewise did not restore normal joint motion. Our findings support current literature that finds that ablation of the thumb without reconstruction is contraindicated because of the high reoperation rate. Although techniques have evolved that improve alignment and stability or appearance, none guarantee normal joint motion. All patients were satisfied, however, that the thumb was significantly improved compared with the preoperative condition.