Endoscopic pelvic osteotomy for the treatment of hip dysplasia.

Adolescent and adult hip dysplasia can be surgically treated by rotating the acetabulum into a better weight-supporting position; however, open pelvic osteotomies are among the most invasive of all pediatric orthopaedic procedures. Endoscopic pelvic osteotomy offers the theoretical advantages of magnified visualization of the bone cuts, minimized surgical dissection, and rapid postoperative recovery. The technique of endoscopically assisted triple innominate osteotomy requires the combination of endoscopic skills and facility with more standard surgical approaches.

The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children.

BACKGROUND: The purpose of this study was to evaluate the perioperative complication rates associated with early surgical treatment (eight hours or less following injury) and delayed surgical treatment (more than eight hours following injury) of displaced supracondylar humeral fractures in children. METHODS: Fifty-two patients had early surgical treatment and 146 patients had delayed surgical treatment of a displaced supracondylar humeral fracture. The perioperative complication rates of the two groups were compared with the use of bivariate and multivariate statistical methods. RESULTS: There was no significant difference between the two groups with respect to the need for conversion to formal open reduction and internal fixation (p = 0.56), pin-track infection (p = 0.12), or iatrogenic nerve injury (p = 0.72). No compartment syndromes occurred in either group. Power analysis revealed that our study had an 86% power to detect a 20% difference between the two groups if one existed. CONCLUSIONS: We were unable to identify any significant difference, with regard to perioperative complication rates, between early and delayed treatment of displaced supracondylar humeral fractures. Within the parameters outlined in our study, we think that the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

Limited magnetic resonance imaging examination after surgical reduction of developmental dysplasia of the hip.

We evaluated the utility of limited magnetic resonance imaging (MRI) after surgical reduction and spica casting for developmental dysplasia of the hip (DDH) with respect to feasibility, time, need for sedation, and charge. Eighteen limited MRI examinations were performed in 10 children (mean age, 9 months) with a 1.5-T magnet. Twenty-eight dysplastic hips were imaged within 4 hours of surgery. Mean imaging time for two sequences was approximately 3 minutes. All examinations were interpretable, although three were degraded by motion. No child required sedation, additional sequences, or repeat study. Two thirds of the dysplastic hips had no proximal femoral ossification center on MRI. A reduced charge was assigned to the examination. We conclude that using limited MRI to confirm intraoperative reduction for DDH is feasible and desirable. The lack of radiation or need for sedation, the reduced charge that reflects the short time needed for imaging, and the superb visualization of nonosseous structures have made it our preferred method to evaluate surgical reduction of DDH.

Traumatic hip dislocation in children. Long-term followup of 42 patients.

To assess the impact of traumatic hip dislocations in the skeletally immature patient, 42 children younger than 16 years of age (average age, 9 years 10 months) who were treated at the authors' institution were studied. Data were collected from charts and radiographs and by completion of questionnaires. The average followup after injury was 10 years 1 month. The majority of dislocations (64%) were attributable to low energy injuries. Ipsilateral fractures about the hip occurred in 17% of patients. Avascular necrosis of the femoral head developed in 12% of patients, with the amount of time spent dislocated being the only statistically proven risk factor. Patients whose reduction was delayed greater than 6 hours had a 20 times higher risk of having avascular necrosis develop compared with patients whose hips were reduced in 6 hours or less. The use of computed tomography for joint asymmetry of 3 mm or greater and omission of bone scan screening were supported by this study. Functional outcomes were very good in this series with 95% of patients suffering mild (usually weather related) or no pain and 95% of patients suffering mild pain (intermittently noticeable) or no limp. A large percentage of the patients (78%) continued to participate in high demand activities such as football, soccer, and basketball.

Hyphenated history: Knight-Taylor spinal orthosis.

This paper offers some interesting biographic information on the two men from whom the Knight-Taylor spinal orthosis takes its name. James Knight and Charles Taylor were two orthopedists from New York City who were interested in spinal care. They prescribed and fashioned their distinctive braces, aspects of which were combined by others, thus linking these two men in orthopedic hyphenated history.

Hyphenated-history: the Kocher-Langenbeck surgical approach.

The language spoken by orthopaedic surgeons is filled with eponyms. In orthopaedics, perhaps more than any other medical specialty, we speak cryptically to one another using code words and other secret language. Certain hyphenated eponyms are of particular interest because they pique one's curiosity as to how these people came to be partners in orthopaedic history. In this paper, we offer some bits of orthopaedic hyphenated-history, outlining the pertinent work of Theodor Kocher and Bernhard von Langenbeck, as well as associated background information. These two surgeons are linked through a common hyphenated eponym in orthopaedic surgery: the Kocher-Langenbeck surgical approach, a well-known posterior approach to the proximal femur and acetabulum.

The fate of untreated developmental dislocation of the hip: long-term follow-up of eleven patients.

Eleven patients with developmental dislocation of the hip who had no treatment other than observation were followed up for an average of 40 years. Nine of the 11 patients had bilateral hip dislocations. None of the hips developed avascular necrosis. Overall clinical and functional results were very satisfactory despite uniformly unsatisfactory radiographs. These patients achieved a better quality of life than have many patients of similar age who have undergone surgical treatments aimed at reducing such late-presenting hip dislocations.

Pediatric vertebral and spinal cord tumors: a retrospective study of musculoskeletal aspects of presentation, treatment, and complications.

Fifty-two pediatric patients with documented vertebral and spinal cord tumors were reviewed to evaluate the musculoskeletal manifestations of presentation, treatment, and management of complications. Diagnoses included 16 malignant and 36 nonmalignant vertebral and spinal cord tumors. Mean age at diagnosis was 8 years 1 month, and the male-to-female ratio was 1.7:1. Overall, there was an average delay in diagnosis of 12 months for this group of patients. Mean clinical follow-up was 5 years. The two most common reasons for presentation were pain (67%) and spinal deformity (46%). Initial plain radiographs were positive in 82% of patients. Postlaminectomy spinal deformity occurred at a rate of 45% in patients undergoing laminectomies, and 60% of those with deformity required spinal fusion. Overall, 67% of the 52 patients underwent spinal fusion, with a 9% asymptomatic pseudarthrosis rate. Complications were common, with 1.9 complications per patient; 59% of complications required surgical management. There were no perioperative deaths. At follow-up, 19% of patients had neurologic deficits ranging from neurogenic bladder to lower extremity weakness and difficulty walking to quadriplegic. Eighty-six percent of patients were ambulating without difficulty at follow-up. The survival rate was 94% and the local recurrence rate was 27% at most recent follow-up.

Hyphenated history: Osgood-Schlatter disease.

The language of orthopedics is rather interesting in that it often credits the original describers or those who popularized a disease process by attaching their names to the disease process in question. These so-called "eponyms" have become quite commonplace in our literature and offer important orthopedic historical insight. Often throughout history, the simultaneous discovery of a disorder is described by two independent researchers, resulting in a hyphenated eponym. Such is the case in the observations made by two physicians, Robert Bayley Osgood and Carl Schlatter, concerning overuse injuries of the tibial tubercle in adolescents. This disorder subsequently became known as "Osgood-Schlatter disease, and aspects of its hyphenated history are the focus of this paper.

Instability of the patellofemoral joint in Rubinstein-Taybi syndrome.

Twenty-five (3.4%) of 732 individuals with Rubinstein-Taybi syndrome were noted to have instability of the patellofemoral joint. We believe that this is in fact an underrepresentation of the true incidence, as we were able to identify only those patients whose symptoms were most severe. These individuals typically had symptoms before or during their adolescent growth spurt, had bilateral involvement, and in some instances, ceased to ambulate because of their patellofemoral problems. A subset of these individuals underwent patellar realignment surgery, with those whose treatment did not include extensive quadriceps mobilization/quadricepsplasty having a 2.7 times higher risk of requiring revision patellar surgery. Patellofemoral instability associated with Rubinstein-Taybi syndrome demands early recognition and treatment to prevent potentially catastrophic gait disturbances.

Hyphenated history: the Hueter-Volkmann law.

The language that orthopedic surgeons speak is filled with eponyms. Perhaps more than any other medical specialty, we speak cryptically to one another using code words and secret language. Certain hyphenated eponyms are particularly interesting, because they pique one's curiosity as to how these persons came to be partners in orthopedic history. We will offer some bits of orthopedic hyphenated history, outlining the pertinent work of the respective authors as well as associated background information. This paper focuses on the Hueter-Volkmann law, an important orthopedic concept concerning bone growth. This law bears the names of the two men credited with enunciating and popularizing it, Carl Hueter and Richard von Volkmann.

Hyphenated history: the Phelps-Baker test.

The language of orthopedics is filled with eponyms. Orthopedic surgeons speak cryptically to one another using code words and "orthopedic pig-Latin." Certain hyphenated eponyms are particularly interesting, because they represent people who came to be partners in orthopedic history. The derivation of the Phelps-Baker test, an important component of the hip examination of children who suffer from cerebral palsy, named in honor of Winthrop Morgan Phelps and Lenox D. Baker, is described in this report.

Video-assisted thoracoscopic surgery (VATS). Endoscopic thoracoplasty technique.

STUDY DESIGN: The study of two patients whose rib deformity was treated using a new endoscopic thoracoplasty technique is reported. OBJECTIVES: To report a new endoscopic thoracoplasty technique for the treatment of rib deformities associated with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Thoracoplasty has traditionally been performed as an open procedure, often necessitating additional incisions and/or tissue dissection. METHODS: Two children with significant rib humps associated with idiopathic scoliosis were treated with a new endoscopic thoracoplasty technique. RESULTS: Both children showed dramatic cosmetic improvement of their rib deformity. CONCLUSIONS: The indications for the use of video-assisted thoracoscopic surgery in the treatment of pediatric spinal deformity are expanding. We have extended our video-assisted thoracoscopic surgery repertoire to include endoscopic thoracoplasty for treatment of rib deformities associated with idiopathic scoliosis. The technique for endoscopic thoracoplasty is discussed, and illustrative cases are presented.

Radiation exposure to the orthopaedic surgical team during fluoroscopy: "how far away is far enough?".

OBJECTIVES: To correlate the amount of radiation exposure to members of the orthopaedic surgical team based on their relative positions during a simulated fluoroscopically assisted orthopaedic procedure. DESIGN: Experimental study using commercially available fluoroscopic units and dosimetry badges designed to measure "eye" (ocular lens), "shallow" (hands/skin), and "deep" (whole-body) radiation exposure. SETTING: Standard hospital operating room at a level one trauma center. PARTICIPANTS: Dosimetry badge clusters at specified distances from a fluoroscopic x-ray beam. Represented positions were direct beam contact, surgeon (12 in/30.5 cm), first assistant (24 in/70 cm), scrub nurse (36 in/91.4 cm), and anesthesiologist (60 in/152.4 cm). INTERVENTION: Dosimetry badges were systematically exposed by a protocol intended to maximize radiation scatter. A maximum time for continuous fluoroscope use was set at ten minutes. MAIN OUTCOME MEASUREMENTS: Radiation exposure readings from dosimetry badges processed by a commercially available dosimetry service. RESULTS: Maximum readings are reported. Direct beam contact resulted in approximately 4000 mrem/minute (40 mSv/min) of radiation exposure. Deep exposure for the surgeon and first assistant was 20 mrem/min (0.2 mSv/min) and 6 mrem/min (0.06 mSv/min), respectively. Superficial exposure was 29 mrem/min (0.29 mSv/min) for the surgeon and 10 mrem/min (0.1 mSv/min) for the first assistant. Eye exposure was 10 mrem/min (0.1 mSv/min) for the surgeon and 6 mrem/min (0.06 mSv/min) for the first assistant. At the scrub nurse position, no deep or eye exposure was detected. One positive badge for shallow exposure was noted at the scrub nurse position, reflecting a 2 mrem/min (0.02 mSv/min) exposure rate. After ten minutes of continuous exposure, badges assigned to the anesthesiologist position never registered any positive readings. CONCLUSIONS: These results indicate that unprotected individuals working twenty-four inches (70 cm) or less from a fluoroscopic beam receive significant amounts of radiation, whereas those working thirty-six inches (91.4 cm) or greater from the beam receive an extremely low amount of radiation.

Operative treatment of supracondylar fractures of the humerus in children: the Cincinnati experience.

A retrospective review of 115 patients treated surgically for displaced supracondylar humeral fractures was conducted. All patients had a minimum of 2 years' follow-up (range 2 to 7 years). According to a modified Gartland (19) classification system, 18.3% were type II (21/115), 77.4% were type III (89/115), and 4.3% (5/115) type IV supracondylar fractures. Twelve percent (14/115) of patients presented with neurapraxias, with the radial nerve being the most commonly affected. Sixty percent (69/115) of patients were treated with a crossed K-wire configuration, while another 30% (35/115) received two lateral pins as their internal fixation. The remaining 10% (11/115) of patients were treated with a variety of "other" pin configurations, including four lateral pins, three lateral pins, one lateral and one medial pin constructs. Eighty patients were treated in the lateral position with the C-arm horizontal, while 35 were treated supine using the C-arm base as the operating table. There were 23 complications noted, with 5 children with cubitus varus, 4 children with cubitus valgus, 3 pin-tract infections requiring antibiotic therapy, 3 failed closed reductions in the operating room that required formal open reduction and internal fixation, and 2 patients experiencing pin breakage. For a subgroup of 77 patients, satisfactory clinical and radiographic data were available for the purpose of evaluating these patients with Flynn's supracondylar rating scale as well as Baumann's angle (15). Eighty-three percent had good or excellent results, 14- had fair results, and 3% had poor results. At completion of bony healing 9 children fell outside the normal range for Baumann's angle established by Williamson et al. (45). Five children were noted to have cubitus varus (Baumann's angles ranging from 83 degrees to 90 degrees) and 4 children had significant cubitus valgus (Baumann's angles ranging from 60 degrees to 63 degrees).

Rhabdomyolysis. A primer for the orthopaedist.

Orthopaedic surgeons may be confronted with a variety of medical problems that demand recognition and treatment. These may range in severity from a mild case of rheumatoid arthritis to a life-threatening pulmonary embolism. Rhabdomyolysis is a serious problem that must be recognized early to avoid grave renal consequences. This disorder is characterized by significant muscle injury giving rise to nephrotoxic breakdown products in the bloodstream. As many as 33% of these patients will suffer acute renal failure. Many orthopaedic patients may be at high risk for rhabdomyolysis, and the orthopaedic surgeon should be familiar with its diagnosis and treatment.

Fracture of the shaft of the humerus secondary to muscular violence.

Fractures of a normal humeral shaft secondary to muscular violence have been uncommonly reported in the literature since the early 1900s. These injuries have been associated with throwing javelins, hand grenades, and baseballs. We report a case of a similar injury occurring in a healthy young amateur baseball pitcher. Pertinent anatomy, pathomechanics, and electromyographic study results are discussed.

Bilateral hypoplastic calcanei.

A previously undescribed anomaly of the calcaneus occurred in an otherwise healthy 2-month-old girl. There was marked bilateral hypoplasia of the calcanei, involving approximately the posterior half of each. The child stood at 15 months and walked at 22 months. At age 5 years, the child had a slight in-toed gait that corrected with dorsiflexion. Her only problem has been some difficulty with shoeware. The etiology of this anomaly remains conjectural.

Would you recognize celiac axis syndrome?

Since its original description, celiac axis syndrome has been a topic of debate. Clinical findings include postprandial abdominal pain, weight loss, and an epigastric bruit. Diagnosis is often made by exclusion and is confirmed by lateral aortography. The role of surgery in treating celiac axis syndrome is controversial.