Multispecialty tracheostomy experience.

INTRODUCTION: Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK. METHODS: A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously. RESULTS: A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days. CONCLUSIONS: This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

Wedge-shaped distal tibial epiphysis in the pathogenesis of equinovalgus deformity of the foot and ankle in tibial lengthening for fibular hemimelia.

Fibular hemimelia is associated with an equinovalgus deformity of the foot and ankle and different degrees of wedging of the distal tibial epiphysis. This deformity is often a major problem during lengthening of the shortened tibia. To determine the significance of the wedge-shaped distal tibial epiphysis in the pathogenesis of the equinovalgus deformity of the foot and ankle during and after lengthening, we reviewed 20 patients who had undergone tibial lengthening by either the Wagner or the Ilizarov technique. The mean duration of follow-up after removal of the fixator was 5.2 years (range, 2.3-9.7 years). Three types of wedge-shaped distal tibial epiphyses were identified. A mildly wedged (type I) epiphysis was found in seven patients, a moderately wedged (type II) epiphysis was found in seven patients, and a severely wedged (type III) epiphysis, in six patients. Premature fusion of the lateral part of the distal tibial physis and growth retardation of the tibia were common after lengthening in patients with the type II or type III epiphysis. After lengthening, all patients with a type II or type III epiphysis had a recurrence or aggravation of foot deformities that existed before lengthening. This usually necessitated various secondary operative procedures to obtain a plantigrade foot. We believe that after lengthening, one should anticipate varying degrees of mild growth retardation and minimal foot deformity in patients with type I epiphysis, worsened asymmetric growth retardation and progressive foot deformity in patients with type II epiphysis, and severe growth retardation and severe foot deformity in patients with type III epiphysis.

Computer modeling of the pathomechanics of spastic hip dislocation in children.

Spastic muscles about the hip cause subluxation, dislocation, and lead to acetabular dysplasia. Spastic hip disease occurs when the muscles about the hip exert forces that are too high or in the wrong direction or both. To determine the role of the hip forces in the progression of spastic hip disease and the effect of both muscle-lengthening and bony reconstructive surgeries, a computerized mathematical model of a spastic hip joint was created. The magnitude and direction of the forces of spastic hips undergoing surgery were analyzed preoperatively and postoperatively to determine which procedure is best suited for the treatment of spastic hip disease. The muscle-lengthening procedures included (a) the adductor longus, (b) the psoas, iliacus, gracilis, adductor brevis, and adductor longus, and (3) the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus. The bony reconstructive and muscle-lengthening procedures included (a) lengthening the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing femoral neck anteversion from 45 to 10 degrees , (b) lengthening of the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing neck-shaft angle from 165 to 135 degrees , and (c) lengthening of the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing femoral neck anteversion from 45 to 10 degrees and neck-shaft angle from 165 to 135 degrees . Results show that a child with spastic hip disease has a hip-force magnitude 3 times that of the a child with a normal hip in the normal physiologic position. Based on this mathematical model the best to normalize the magnitude of the hip-joint reaction force, the muscles to be lengthened should include the psoas, iliacus, gracilis, adductor brevis, and the adductor longus. To normalize the direction of the hip force, the extremity should be positioned in the normal physiologic position. The impact of decreasing the femoral anteversion or femoral neck-shaft angle or both had little additional effect on the direction or magnitude of hip forces.

Factors predicting postoperative complications following spinal fusions in children with cerebral palsy.

A retrospective review of 107 patients with cerebral palsy who had undergone a posterior spinal fusion with unit rod instrumentation by the same two surgeons was done to determine what factors cause complications that lead to delayed recovery time and a longer than average hospital stay. The operative risk score was developed with scores for the child's ability to walk and talk, oral feeding ability, cognitive ability, and medical problems within the year prior to surgery. Operative risk score is primarily a measure of degree of neurologic involvement. The postoperative complication score (POCS) is a combined measure of all postoperative complications including factors for prolonged intubation, intensive care unit stay, hospital stay, and delayed feeding. The mean age at surgery was 14.3 years. The mean weight was 29.5 kg, with 89 of 107 patients below the fifth percentile for weight compared with age. The mean degree of spinal deformity was 75.2 degrees (range 43-120 degrees ). The mean weight for age was -1.96 SD below the normal. The mean operative time was 4.3 h, with estimated blood loss of 1.2 blood volumes. The mean length of hospitalization was 23 days 2 h, with 5 days 2 h in the intensive care unit. The operative risk score and weight for chronological age below the fifth percentile showed statistical significance (p = 0.05) in regard to increased POCS. The weight for height-age and deficient total lymphocyte count, both factors that measure nutritional status, showed no statistical significance (p > 0.05) compared with POCS. Curves with deformity of >70 degrees had statistically significant high POCS (p = 0.03). Complications for patients having a posterior and an anterior surgery versus those who had a posterior fusion alone were not statistically different (p > 0.05). The factors that led to a greater rate of complications were the severity of neurologic involvement, severity of recent history of significant medical problems, and severity of scoliosis.

Wound infection after spinal fusion in children with cerebral palsy.

One hundred and seventy-two children with cerebral palsy were operated on for neuromuscular scoliosis by spinal fusion with unit rod instrumentation between January 1988 and June 1996. There were 15 (8.7%) postoperative wound infections (seven deep, eight superficial) in 15 patients (five males, 10 females) who had a mean age of 13.9 years. The mean follow-up after diagnosis of infection was 3.3 years (range, 1-7.2). Twelve of the 15 infected cases, including all seven deep infections, occurred in the distal portion of the incision. In 14 patients, the wound infections were diagnosed within the first 2 months of the original spinal fusion. All the superficial wound infections were treated successfully by local wound care and intravenous antibiotics. The removal of hardware was necessary in the one late deep wound infection that occurred 2 years after the spinal fusion. The remaining six deep infections were treated by irrigation and debridement with the wound left open, allowing it to heal by secondary intention. One patient's wound was closed over suction-irrigation drains; however, due to a recurrent abscess, the wound was reopened and allowed to granulate. All the wound infections occurred in severely neurologically involved spastic quadriplegics who were nonambulatory and severely mentally retarded and had seizure disorders.

A method of dynamic foot-pressure measurement for the evaluation of pediatric orthopaedic foot deformities.

Dynamic foot-pressure measurements are time-sensitive measurements of the pressures under the foot while walking. Historically, many methods are used to measure these pressures; however, current medical literature does not contain a method suitable for the evaluation of pediatric orthopaedic foot deformities. A method for the measurement of dynamic foot pressure for the treatment of pediatric orthopaedic foot deformities was defined in this study. We established the dynamic foot-pressure pattern of a normal population using this method. Dynamic foot-pressure measurements were collected from 54 normal subjects (108 feet). These measurements were divided into the following five segments: the heel, the lateral midfoot, the medial midfoot, the lateral forefoot, and the medial forefoot. Standard tables and graphs were created describing the normal progression of pressure across each segment of the foot while walking. These standard tables and graphs can be used as a reference with which clinical measurements can be compared. This method may be useful as a diagnostic measure of foot deformities and may increase the clinician's ability to measure changes in foot deformity resulting from treatment intervention.

Legg-Calvé-Perthes disease in girls. A comparison of the results with those seen in boys.

We reviewed the records and roentgenograms of all patients with Legg-Calvé-Perthes disease who had been seen at our institution between 1940 and 1996. One hundred and five girls (122 hips) and 470 boys (531 hips) were identified. Thus, 18 per cent of the 575 patients in the present series were girls. Seventeen (16 per cent) of the girls and sixty-one (13 per cent) of the boys had bilateral involvement. Although more girls than boys had severe involvement of the femoral head and the lateral pillar, we could not detect a significant difference between the two groups with respect to the distribution of the involvement of the hips according to the system of Catterall or the lateral pillar classification (p > 0.05, beta = 0.99). Serial roentgenograms that showed all four stages of the disease according to the system of Waldenström were available for fifty-two hips in girls and 184 hips in boys. A review of these roentgenograms revealed that the average ages of the girls at the stages of necrosis, fragmentation, reossification, and remodeling were 6.8, 7.3, 7.9, and 9.5 years, respectively, whereas the average ages of the boys were 6.8, 7.3, 7.9, and 9.9 years, respectively. Girls, however, had closure of the affected proximal femoral physis at an average age of 12.9 years, whereas boys had closure at an average age of 15.8 years. Therefore, girls had a shorter potential period for remodeling of the femoral head (average, 3.4 years) compared with boys (average, 5.9 years). Sixty-four girls (seventy-eight hips) and 363 boys (416 hips) had reached skeletal maturity by the time of the latest follow-up and were evaluated according to the system of Stulberg et al.; we could not detect a significant difference between boys and girls with respect to the distribution of the hips according to this system (p > 0.05, beta = 0.99). Although the numbers were too small for statistical analysis, our findings suggest that boys and girls who have the same Catterall or lateral pillar classification at the time of the initial evaluation can be expected to have similar outcomes according to the classification system of Stulberg et al.

Operative treatment for hallux valgus in children with cerebral palsy.

All patients with cerebral palsy who had hallux valgus and bunion deformities surgically corrected between 1986 and 1995 were reviewed to determine whether techniques other than arthrodesis of the first metatarsophalangeal joint would adequately correct these deformities. Twenty-six feet of 17 patients were surgically corrected for their bunions and/or their hallux valgus deformity. The mean hallux valgus angle for all children was 30 degrees, preoperatively, with 70% correction achieved. Four techniques of surgical correction were used. A first metatarsophalangeal joint arthrodesis on eight feet gave excellent outcomes for all using the duPont Bunion Rating Score and a mean of 89% correction of the hallux valgus angle. A proximal first metatarsal osteotomy, distal soft tissue release, and exostectomy of the bunion on five feet gave three excellent and two fair outcomes, with a mean of 83% correction of the hallux valgus angle. A distal soft tissue release and exostectomy on eight feet gave four excellent outcomes, two good outcomes, and two fair outcomes, with a mean of 53% correction of the hallux valgus angle. An osteotomy of the first proximal phalanx, metatarosphalageal soft tissue release, and exostectomy on five feet gave three excellent outcomes, one good outcome, and one fair outcome with a mean of 36% correction of the hallux valgus angle. All patients who met the criteria for the procedures were satisfied with the outcomes; however, the first metatarosphalageal joint arthrodesis gave the best results with the highest percent correction and bunion score.

Delayed union following stress fracture of the distal fibula secondary to rotational malunion of lateral malleolar fracture.

We present a case of delayed union following stress fracture of the distal fibula secondary to rotational malunion of a lateral malleolar fracture. The patient underwent operative excision of the nonunion, plating with autogenous iliac bone grafting, and correction of the malrotation of the distal fibular fragment. The fracture healed, and the patient was asymptomatic with full range of motion at follow-up. This report documents an unusual etiology, "external malrotation," for delayed union of a fibular stress fracture.

Revision spine surgery in children with cerebral palsy.

Ten children with neuromuscular scoliosis and pelvic obliquity had revision spinal instrumentations and fusions performed at an average age of 14.7 years. The initial spinal deformity in all children was the result of static encephalopathy with nine children diagnosed as having spastic cerebral palsy without another specific diagnosis and one child diagnosed as also having Noonan syndrome. All 10 children had a revision performed after the first surgery, and two of the 10 children underwent a second revision because of failure of rod cross-links. The indications for revision surgery were symptomatic recurrent deformity, symptomatic pseudoarthrosis, or perforation of one leg of the unit rod through the pelvis. The average time between the first and second surgery was 2.7 years, and from revision to final follow-up was 2.5 years. The goal of providing symptomatic relief and correction of deformity was accomplished in nine of 10 children; however, two of the nine required two revisions. One patient continues to have a residual painful pseudoarthrosis. The two postoperative complications requiring further surgery were related to the failure of rod connectors.

Measurement of acetabular index intraobserver and interobserver variation.

Pelvic radiographs of 25 children aged 6 months to 2 years had the acetabular index measured 3 times by each of five pediatric orthopaedists. Interobserver measurements were found to vary +/-3.0 degrees, whereas the intraobserver variation was +/-3.6 degrees. This error reflects only measurement error and does not consider error introduced with different positioning of the pelvis.

Cerebral palsy.

Cerebral palsy is caused by a static lesion to the cerebral motor cortex that is acquired before, at, or within 5 years of birth. Multiple causes for the condition exist and include cerebral anoxia, cerebral hemorrhage, infection, and genetic syndromes. Cerebral palsy is commonly classified according to the type of movement problem that is present (spastic or athetoid) or according to the body parts involved (hemiplegia, diplegia, or quadriplegia). To care for children with cerebral palsy, a team approach is most effective; the team should include the pediatrician and orthopedist, among others. In the nonambulatory patient, good sitting posture, the prevention of hip dislocation (spastic hip disease), and the maintenance of proper custodial care are prime concerns. Careful monitoring and treatment of spastic hip disease and the correction of scoliotic spinal deformity are also important. In the ambulatory patient, the main goal is to maximize function. Computerized gait analysis in patients with complex gait patterns helps to show whether orthotic or surgical treatment is indicated. In this paper, we also review both the proper indications for orthopedic intervention in patients with upper extremity involvement and recent methods to control spasticity, such as selective dorsal rhizotomy and administration of botulinum toxin or intrathecal baclofen.

Soft-tissue release for spastic hip subluxation in cerebral palsy.

Children with spastic hip subluxation secondary to cerebral palsy were treated with a standard protocol that focused on early detection of the subluxation using physical examination and anteroposterior pelvis radiographs. Using limited hip abduction of < or =30 degrees and subluxation of > or =25% migration percentage as indications, patients had open adductor and iliopsoas lengthenings with immediate postoperative mobilization and no abduction bracing. The protocol was applied to 74 children with a mean age of 4.5 years and had 147 hips surgically addressed. Of these hips initially, 20% were normal (migration percentage <25%), 52% were mildly subluxated (migration percentage 25-39%), 22% were moderately subluxated (migration percentage 40-59%), and 6% were severely subluxated (migration percentage > or =60%). At a final postoperative follow-up of 39 months, 54% of these hips were classified as good (migration percentage <25%), 34% were fair (migration percentage 25-39%), and 12% were poor (migration percentage > or =40%). Of this patient population, 69% were nonambulators and their outcomes were not statistically different from children who could walk. No child developed an abduction contracture or wide-based gait that required treatment. With early detection and applying this treatment algorithm, 80% of children with spastic hip disease should have good or fair outcomes. Longer follow-up will be required to determine how many children will need bony reconstruction to maintain stable and located hips at the conclusion of growth.

The effect of rectus EMG patterns on the outcome of rectus femoris transfers.

Rectus femoris transfer to the sartorius is performed in children with cerebral palsy to treat stiff-knee gait. To determine whether preoperative electromyographic (EMG) activity of the rectus femoris is predictive of outcome, we studied 25 children with stiff-knee gait who had preoperative EMG gait analysis before rectus femoris transfer. Fifteen patients had bilateral surgery, and 10 patients had unilateral surgery. The mean age at surgery was 9.6 years for the retrospective review. Patients were divided into three groups based on the recorded EMG patterns of the rectus femoris during the gait cycle. Group I patients had predominant swing-phase activity only. Group II patients had constant rectus activity through the entire gait cycle. Group III patients had normal rectus, defined as minimal EMG activity in the last 75% of swing phase. A repeated gait analysis at a mean of 1.5 years after surgery was available for comparison. In group I, mean peak knee flexion increased 26 degrees after surgery from 44 to 70 degrees. In group II, mean peak knee flexion increased 18 degrees after surgery from 51 to 69 degrees. In group III, mean peak knee flexion increased 12 degrees from 54 to 66 degrees. Results of this study show the greatest improvement in outcome, as measured by knee flexion, occurred in group I in which the rectus fired predominantly in swing phase. Preoperative EMG patterns are therefore useful in determining the outcome after rectus femoris transfer to the sartorius.

Reconstruction of the dysplastic spastic hip with peri-ilial pelvic and femoral osteotomy followed by immediate mobilization.

All children with cerebral palsy who had a pelvic osteotomy performed by the senior author (F.M.) from 1989 through 1991 were reviewed. Indications for operative reconstruction were failed muscle lengthening in a child younger than 8 years or a painful hip. The operative procedure included adductor muscle lengthening, varus shortening femoral osteotomy, and peri-ilial pelvic osteotomy. Patients were immediately mobilized after surgery by physical therapy. Fifty-one children had reconstruction of 49 subluxated and 21 dislocated hips. Femoral and pelvic osteotomies were performed on 59 hips, and 11 hips had only a femoral osteotomy. Forty-nine hips had adductor muscle lengthening, and 27 hips had femoral osteotomy to provide for relief of contractures. At mean follow-up of 34 months, two hips in two patients had redislocated, requiring repeated surgery. Two hips remained subluxated and asymptomatic. Twenty-three hips in 18 patients were painful before surgery. One hip continued with severe pain after surgery, requiring further surgery. Three hips continued with mild pain not requiring surgery, and 14 (82%) hips had complete pain relief. Of 37 caretakers interviewed, 80% felt the procedure was beneficial and would recommend it to others. Eight percent were uncertain, and 6% (two caretakers) thought it was not helpful.

Surgical correction of spinal deformity using a unit rod in children with cerebral palsy.

Thirty-one patients with cerebral palsy and neuromuscular scoliosis underwent instrumentation with a unit rod fixed with sublaminar wires and posterior spine fusion. The mean curve measured 79 degrees preoperatively, 19 degrees immediately postoperatively, and 18 degrees at final follow-up of 2.8 years, excluding two patients who died and four who were lost to follow-up after < 12 months. The preoperative pelvic obliquity was 25 degrees, which was initially corrected to 3 degrees and remained unchanged at 4 degrees at final follow-up. Twenty-four patients underwent a one-stage posterior fusion, and seven patients underwent both anterior and posterior fusions. Complications included one acute deep-wound infection and one late deep-wound infection seeded from the urinary tract. No pseud-arthroses or hardware failures have occurred to date. Seven children with open triadiate cartilages had a posterior spinal fusion only and were followed up to skeletal maturity with a 3 degrees loss of correction of the scoliosis and a 0 degree loss of correction of pelvic obliquity. Questionnaires filled out by primary caretakers demonstrated that the objective of improving the child's ability to sit more comfortably was accomplished for the majority (65%) of patients. Spinal fusion was recommended for other children by 86% of interviewed caretakers.

A casemix for mental health services: the development of the mental health and substance abuse components of the Australian national diagnosis-related groups.

OBJECTIVE: To describe the development of the mental health and substance abuse sections of the version of the Australian casemix system, Australian national diagnosis-related groups 3 (AN-DRG 3), released in July 1995. METHOD: The guiding principles and data sources used to construct the mental health and substance abuse components of AN-DRG 3 are described by the group who undertook that task. The group used data sets of patients separating from hospitals throughout Australia, and from hospitals in South Australia, to examine the capacity of existing and revised diagnosis-related groups (DRGs) to predict patients' lengths of hospital stay. They also reviewed the lists of conditions allowed as complicating and comorbid conditions within the AN-DRG system. RESULTS: A variety of recommendations were made including: moving organic mental disorder DRGs to a neuroscience area of the AN-DRG; completely reorganising the mental health section of the casemix; creating a number of narrowly defined DRGs covering areas such as schizophrenia, major affective disorders, anxiety disorders and eating disorders, while allowing for a limited number of more heterogenous DRGs and simplifying substance abuse DRGs into groups covering alcohol and other substances, and differentiating intoxication and withdrawal from abuse and dependency. CONCLUSIONS: A casemix dialect based on clinical diagnosis, which describes mental health and substance abuse problems in terms which should be familiar to clinicians, has been developed. Its applications and limitations are briefly discussed.