Acute abdominal symptoms and signs in children and young adults with spina bifida: ten years' experience.

BACKGROUND/PURPOSE: Diagnosis and management of the acute abdomen in patients with spina bifida (SB) can be problematic. There are at least 4 clinical factors that can predispose to the development of acute abdominal symptoms and signs, and patients with a thoracic level lesion can have a partially insensate abdomen. The authors analyzed their accumulated experience to determine the annual incidence of acute abdominal signs and symptoms in children and young adults with spina bifida, the differential diagnosis, the operative management, and the outcome. The pertinent literature was reviewed. METHODS: Cases were ascertained during a 10-year period at 1 institution and reviewed retrospectively. RESULTS: Twenty-two episodes of acute abdominal symptoms and signs in 19 children and young adults with SB were ascertained over 10 years at 1 institution, for an annual incidence of 0.74%. More patients had a thoracic level lesion (n = 12; 60%) than in the clinic population as a whole (27%; P =.04), but the gender distribution was similar (58% girls), as was the prevalence of ventriculoperitoneal shunts (VPS; 95%). The median age was 13 years (range, 1 year to 26 years). Hospitalization was necessary for 19 (86%) of the 22 episodes. The duration of symptoms before diagnosis was a median of 3 days (range, 1 to 14 days). Most patients (82%) presented with abdominal pain. Fever was present in 27%, shock in 23%, and peritoneal signs in 23%. There were 14 different final diagnoses, 10 (71%) of which were associated with a predisposing factor. Of the 22 episodes, 18 (82%) could be attributed to an underlying factor: (1) neurogenic bladder (9; 41%); (2) neurogenic bowel (3; 14%); (3) VPS (4; 18%); (4) complications from previous surgery (2; 9%). Thirteen patients (59%) underwent a total of 20 surgical procedures of 12 different kinds. Despite awareness of the complexities involved, 3 patients (14%) died: 1 from complications resulting from bladder perforation; 1 from urosepsis and shock; and 1 from peritonitis caused by VPS infection. CONCLUSION: The differential diagnosis of the acute abdomen in patients with SB is broad, conditions requiring surgery are frequently diagnosed, and the mortality rate is substantial, despite aggressive management.

Pediatric traumatic atlanto-occipital dislocation: five cases and a review.

Traumatic atlanto-occipital dislocation (AOD) has been thought to be a rare and fatal injury. Recently, more survivors, especially children, have been reported. During a 10-year period, the authors have encountered five children with traumatic AOD. A retrospective review of traumatic AOD in children from 1985 to 1995 was performed. Clinical presentation, initial radiologic findings, and final outcome were emphasized. Distance from the dens to the basion and the ratio of Powers were measured from initial lateral cervical spine radiographs. The average distance from the dens to the basion was 9.8 mm. The average ratio of Powers was 1.38. There were three survivors, two having a concomitant spinal cord injury. All survivors underwent a posterior occipitovertebral fusion. Three cases initially went undiagnosed. The diagnosis of AOD by lateral cervical spine radiographs can be difficult. The authors recommend detailed measurements of the initial cervical spine radiographs in pediatric patients at risk for traumatic AOD.

Treatment of osteonecrosis in the hip of pediatric patients by free vascularized fibular graft.

The purpose of the current study was to review the demographics and etiologies of symptomatic femoral head osteonecrosis in the pediatric and adolescent population and to assess the results of treatment using free vascularized fibular grafting. A group of patients with femoral head osteonecrosis who were treated with free vascularized fibular grafting was reviewed. Patients who were studied were 18 years of age or younger at the time of surgery. Records were examined for demographic data, etiology of osteonecrosis, stage of the disease at time of surgery, and results of treatment including preoperative and postoperative Harris hip scores. Eighty-two pediatric and adolescent patients with osteonecrosis of the femoral head underwent 90 free vascularized fibular grafting procedures. Fifty patients (54 hips) who have been followed up at least 2 or more years (average, 4.3 years) constituted the study group. At the last followup, total hip arthroplasty was performed in seven hips (seven patients) and hip fusion was performed in one hip (one patient). The average Harris hip scores in patients who did not undergo total hip arthroplasty improved from a preoperative average of 55.3 points to 90.2 points at the latest followup. Treatment of patients with osteonecrosis with free vascularized fibular grafting resulted in a lower rate of conversion to total hip arthroplasty or fusion (16%) in pediatric and adolescent patients when compared with conversion to total hip arthroplasty in adults (25%). The quality of life as evidenced by the increased Harris hip scores was improved significantly in this group of pediatric and adolescent patients.

Knee arthrodesis with circular external fixation.

Knee arthrodesis can enable limb salvage in patients with disability secondary to trauma, infected total knee arthroplasty, pyarthrosis, and other complications. Historically, intramedullary nailing has resulted in the highest overall knee fusion rates. However, intramedullary nailing is relatively contraindicated in the presence of active infection. Nineteen patients who underwent knee arthrodesis with circular external fixation were studied retrospectively. Postoperative radiographs were evaluated for evidence of bony fusion, which was defined as trabecular bridging between the femur and tibia. Patients were interviewed and graded using the functional assessment portion of the Knee Society clinical rating system. Fusion was successful in 13 of 19 (68%) patients. Overall, patients spent an average of 4 months 8 days wearing the circular external fixator. Average time to radiographic and clinical evidence of arthrodesis (defined as lack of motion across the fusion site) was 4 months 18 days. No patient with successful fusion considered himself or herself housebound. All but one of these patients require some form of assistive device for ambulation. Complications occurred in 16 of 19 (84%) patients overall. Superficial pin tract infection (55%) and nonunion (32%) were the most common. Circular external fixation is an effective method for obtaining knee arthrodesis in patients who are not good candidates for intramedullary nailing.

Severin classification system for evaluation of the results of operative treatment of congenital dislocation of the hip. A study of intraobserver and interobserver reliability.

The Severin classification system frequently is used to evaluate the radiographic results of operations performed for the treatment of congenital dislocation of the hip. However, the reliability of this classification scheme has not been established, to our knowledge. Ideally, a classification system should be validated before it is used to promote therapeutic guidelines or to compare results of treatment; the purpose of the present study was to establish the intraobserver and interobserver reliability of the Severin classification system. Four blinded raters and the operating surgeon independently used the Severin system to evaluate the most recent radiographs of thirty-seven children (fifty-six hips) who had been managed, an average of nine years previously, with a medial open reduction for congenital dislocation of the hip. Three of the raters evaluated the same radiographs again under similar testing circumstances eight weeks later. Ten paired interobserver and three intraobserver comparisons then were analyzed with use of the Cohen kappa coefficient (kappa). The average kappa coefficient for the six pairwise comparisons between the four blinded raters was 0.15 (range, -0.05 to 0.42) when all Severin classes were analyzed independently. The average kappa coefficient for the four pairwise comparisons between the blinded raters and the operating surgeon was even lower (0.02). The kappa coefficients for the three intraobserver comparisons were 0.20, 0.38, and 0.44 (average, 0.34). Kappa analysis demonstrated variable and low levels of agreement when the Severin system was used to rate the results of operations performed for the treatment of congenital dislocation of the hip. We believe that the unadjusted kappa coefficient should indicate excellent agreement (kappa > 0.75) for all comparisons if this system is to be used for the evaluation of clinical results. The unacceptably low levels of intraobserver and interobserver reliability call into question the clinical conclusions of reports in which the Severin system has been used as the basis of proof.

Treatment of adolescent Blount disease with the circular external fixation device and distraction osteogenesis.

The purpose of this study was to review both the anatomic and functional results of treatment of adolescent tibia vara with distraction osteogenesis by using the circular external-fixation device. Twelve tibias in eight patients were treated. Preoperative proximal tibial varus averaged 18 degrees (range, 7-26 degrees). Postoperatively the mean deviation from standard anatomic alignment of the proximal tibia was 2.5 degrees (range, 0-7 degrees). All patients were allowed to weight bear as tolerated throughout the 12 weeks of frame wear. Function was assessed by knee score and was improved in all patients at a mean follow-up of 23 months. There were no neurovascular complications or delayed unions. One patient required return to the operating room because of premature consolidation of his regenerate.

The effects of the Ilizarov distraction technique on bone and muscle in a canine model: a preliminary report.

This study examined the functional and morphological changes experienced by bone and muscle during Ilizarov distraction osteogenesis. Although extensive research has been conducted in the area of regenerate bone formation, the effect of limb lengthening on the biomechanical properties of bone and muscle has not been thoroughly addressed. In this study, an Ilizarov external fixator was applied to one tibia of nine skeletally mature dogs, and distracted 3 cm over thirty days. The contralateral tibia served as control. Histology and weekly radiographs assessed muscle morphology and bone growth. The contractile capabilities of the gastrocnemius muscles from the experimental and control limbs were measured prior to sacrifice, and the bending stiffness of the tibias of five dogs was determined. All dogs experienced loss of knee extension secondary to muscle contracture and/or stiffness about the joint. These dogs did not bear weight on the experimental limb. In one dog, spontaneous resolution of the muscle contracture allowed partial weight bearing during the last three weeks of consolidation. Despite 3 cm distraction, tibial lengthening ranged from 1.7 to 3 cm. Biomechanical testing revealed a significant reduction in the bending stiffness of the lengthened bones when compared with control values (p < 0.003). The weight of the lengthened muscles was 35% less than control values, a finding consistent with the histology which showed mild muscle fiber degeneration in all dogs. The contractile capabilities of the lengthened muscles were reduced to 29-80% of control values (p < 0.005). In contrast, the lengthened muscle from the weight bearing dog retained 85% of the weight and 104% of the maximum contractile force of the control muscle.

Results after replantation and revascularization in the upper extremity in children.

The rates of survival of the amputated part and the functional outcomes were studied retrospectively after seventy-three replantations and eighty-nine revascularizations in the upper extremity in 120 children. All operations were performed between January 1974 and December 1988 after partial and complete amputations at various levels. The ages of the patients ranged from three days to sixteen years. The average duration of follow-up was thirty-six months (range, fourteen months to seven years) for the patients who had had a replantation and thirty months (range, fourteen months to eight years) for the patients who had had a revascularization. The rate of survival of the amputated part was significantly higher (p < 0.0002) after revascularization (seventy-eight parts [88 per cent]) than after replantation (forty-six parts [63 per cent]). There was no association, for either group, between survival and the preoperative duration of ischemia, the level of the injury, the digit that had been injured, the number of arteries that had been repaired, or the use of venous grafts. The rate of survival after replantation of completely amputated parts was 72 per cent (twenty-eight of thirty-nine parts) when the amputation had resulted from a laceration injury and 53 per cent (eighteen of thirty-four parts) when the amputation had resulted from a crush or an avulsion injury. The rate of survival after revascularization of incompletely amputated parts was 100 per cent (all forty-five parts) when the injury had been the result of a laceration and 75 per cent (thirty-three of forty-four parts) when it had been the result of a crush or an avulsion. We did not find any relationship between the age of the patient and the rate of survival of the amputated part after revascularization; however, there was a significantly higher rate of survival (p , 0.02) after replantation in children who were less than nine years old (77 per cent [twenty-four of thirty-one parts]) compared with the rate in those who were nine to sixteen years old (52 per cent [twenty-two of forty-two parts]). The viability of the digit was in jeopardy after twenty-nine (40 per cent) of the seventy-three replantations and nineteen (21 per cent) of the eighty-nine revascularizations. Immediate reoperation resulted in the salvage of only two of the twenty-one replanted parts and six of the twelve revascularized parts that had a reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)

Hip fusion in young adults. Using a medial displacement osteotomy and cobra plate.

Eight consecutive patients, mean age 17.25 years, underwent a medial displacement osteotomy and hip arthrodesis with a nine-hole Cobra plate. A transverse innominate osteotomy facilitated medial displacement of the femoral head and acetabulum. Alignment of the lower limb at 25 degrees flexion, neutral abduction, and neutral rotation was assisted by a long-limbed protractor and Steinmann pins placed in both anterior superior iliac spines. The greater trochanter was reattached to the Cobra plate so that hip abductor function could be restored should the fusion ever be converted to an arthroplasty. No postoperative immobilization was required. All patients had radiographic evidence of union by 12 months. One patient had a postoperative brachial plexus neuropraxia that resolved at three months. One patient required an ipsilateral femoral lengthening for limb-length inequality secondary to collapse of his femoral head before hip fusion. At a mean follow-up interval of 2.8 years (range, one to 4.5 years), all patients had significant improvements in pain (p < 0.05), function (p < 0.01), and gait (p < 0.01). The average preoperative Harris Hip Score of 45 points +/- 8 points (mean +/- SEM) improved to 84 points +/- 2 points (p < 0.01).

An assessment of the reliability of the Scoliometer.

Accurate noninvasive measurements of spinal curvature are crucial in planning treatment and assessing curve progression in adolescent idiopathic scoliosis. An inter-rater agreement trial and an intrarater agreement trial were undertaken to estimate the reliability of axial rotation measurement using the Scoliometer (Orthopedic Systems, Inc., Haywood, California). In the inter-rater trial, two orthopedic surgeons and two orthopedic surgery residents independently measured the thoracic and lumbar axial rotations of 22 patients with idiopathic scoliosis using the Scoliometer. In the intrarater, trial a single orthopedic surgeon measured the thoracic and lumbar axial rotations of 25 patients on four separate occasions with the Scoliometer. Inter-rater agreement using the Scoliometer to estimate the magnitude of the hump (in centimeters) in the thoracic and lumbar regions was poor (intraclass correlation coefficient, Rho = 0.57 and Rho = 0.76 for the thoracic and lumbar regions, respectively). Inter-rater agreement using the Scoliometer to estimate the degree of axial trunk rotation was better (Rho = 0.81 and Rho = 0.82 for the thoracic and lumbar regions, respectively). Intrarater agreement using this device to estimate the magnitude of the hump (in centimeters) in the thoracic and lumbar regions was good (Rho = 0.90 and Rho = 0.84 for the thoracic and lumbar regions, respectively). Intrarater agreement using the Scoliometer to estimate the degrees of curvature was outstanding (Rho = 0.995 and Rho = 0.998 for the thoracic and lumbar regions, respectively). These results indicate that the Scoliometer can be a reliable noninvasive method for repetitively assessing spinal axial rotation when used by a single trained observer.

The medial approach to the hip revisited.

Several muscular intervals have been described to approach the hip through a medial incision. We studied in detail the original descriptions of these surgical planes and found that several of them are nearly identical. We attempt to clarify the anatomic intervals available to the surgeon in hope of eliminating ambiguity in future reporting.

Bilateral transpedicular decompression and Harrington rod stabilization in the management of severe thoracolumbar burst fractures.

Fifty-eight patients with severe thoracolumbar burst fractures were treated with bilateral transpedicular decompression, Harrington rod instrumentation, and spine fusion. Spinal realignment and stabilization was achieved by contoured dual Harrington distraction rods supplemented by segmental sublaminal wiring. Posterior element fractures were noted in 25 patients, 9 of whom had associated dural tears. Computed tomography was performed to assess the cross-sectional area of the spinal canal before surgery and after decompression. Patients at initial evaluation averaged greater than 67% spinal canal compromise. After surgery, successful decompression was accomplished in 57 patients. One patient required staged, anterior thoracoabdominal decompression and fibula strut grafting. At follow-up (average, 43 months; range, 25-70 months), neurologic improvement was found in 77% of the patients who initially presented with neurologic deficits. Thirty-four of 40 patients with incomplete paraplegia improved one or more subgroups on the Frankel scale. A solid fusion was attained in all 58 patients. No patient had a significant residual kyphotic deformity. Single-stage bilateral transpedicular decompression and dual Harrington rod instrumentation reliably provides decompression of the spinal canal and restores spinal alignment. The procedure allows early mobilization and provides an environment for solid fusion and maximum neurologic return.

Replantation in children.

The authors have replanted 162 parts in 120 children over the past 15 years. The youngest patient, undergoing successful replantation, was aged 7 months, 3 weeks. Unlike an adult, any child suffering a traumatic amputation should be considered for a possible replantation. Replantation should consist of minimal bone shortening to preserve epiphyseal plates, with repair of all severed structures. Longitudinal K-wires usually provide adequate fixation. Our survival rate for complete replantation in children under the age of 16 years is 77%. Long-term study showed that continued skeletal growth occurred and the digit attained 81% of normal longitudinal length at maturity. Recovery of sensibility in the replanted digit is nearly as good as for isolated digital nerve repair. Patient and parent satisfaction is high when replantation is successful, with uniform approval of the extensive effort required.

One hundred eleven thumb amputations: replantation vs revision.

One hundred eleven patients who sustained isolated, complete thumb amputation between 1971 and 1985 were reviewed to assess results of replantation and to compare these with results of amputation revision. Routine postoperative evaluation was performed in 69 successful replant patients and in 42 with revision. Twenty-five of the replant group and 18 of the revision group returned for additional testing that consisted of interview and physical examination, test of activities of daily living, Jebsen test of hand function, and both static and dynamic testing on the BTE work simulator. Ninety percent of replantations were between the metacarpophalangeal (MCP) joint and the proximal third of the distal phalanx. Shortening averaged 11 mm, and range of motion was 42% +/- 28% that of the uninjured thumb. One-half of the patients could touch the MP of their ring finger, and one-fourth could touch the proximal interphalangeal (PIP) joint. Twenty-one percent had 7 mm or less two-point discrimination, and 38% had between 8 and 20 mm. Eighty percent of both groups were able to perform activities of daily living at 80% of their uninjured side. Grip strength was approximately 84% of that of the uninjured hand in each group. Lateral pinch averaged 68% +/- 26% of that of the normal side in the replant group and 91% + 9% in the amputation group. Work simulator assessment of lateral and three-point pinch was better in the revision group. Scores on Jebsen testing were slightly better for those with replanted thumbs, but in general neither replant nor revision patients functioned as well as did Jebsen's normals.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of Cotrel-Dubousset and Harrington rod instrumentations in idiopathic scoliosis.

An analysis of the efficacy of two techniques of posterior spinal instrumentation in patients with idiopathic scoliosis was performed. Thirty-two consecutive patients treated with Cotrel-Dubousset instrumentation and no external bracing were compared with 30 consecutive patients treated with Harrington rod instrumentation supplemented by Bobechko hooks, sublaminar wires, and postoperative bracing. The groups were similar in age, curve magnitude, and type. Cotrel-Dubousset instrumentation demonstrated significantly improved immediate frontal plane correction. It was also more effective in improving thoracic kyphosis, particularly in patients with preoperative hypokyphosis. Both procedures were performed with similar operative time, blood loss, and minimal complication rates.

Plastic deformation in pediatric fractures: mechanism and treatment.

The plastic deformation often observed in children's long bone fractures is due largely to the complex nature of the molecular and histologic aspects of pediatric bone. Pediatric cortical bone has a lower mineral content than adult bone, accounting in part for its different material properties. Although plasticity allows children's long bones to absorb more energy prior to fracture, a significant deformity may persist after injury. An algorithm and technique for treatment of plastic deformation of the radius and ulna, the two most commonly involved bones in plastic deformation, are reviewed.

Neisseria gonorrhoeae foot abscess. A case report.

A cutaneous abscess involving Neisseria gonorrhoeae is extremely rare outside the perineum. Such remote lesions are a result of disseminated gonococcal disease. A 12-year-old girl with arthrogryposis multiplex congenita developed a gonococcal abscess on the plantar aspect of her lateral forefoot after a two-week prodrome of pain, erythema, and swelling. The infection was successfully treated with open drainage, acetic acid dressing changes, and the administration of penicillin.

Demographics and replantation.

We reviewed demographic data on 761 patients who had one or more amputated parts replanted at Duke University Medical Center between 1972 and 1984 to learn more about the population that sustained amputation and replantation. Ninety-four percent were from North Carolina and its border states. Persons between ages 21 and 30 years were the most frequently injured. Eighty-five percent of patients were men. Seventy-eight percent of amputations occurred between 6:00 AM and 6:00 PM. No significant difference in the number of replantations was noted at various months of the year. Fifty-eight percent of amputations were job related, and laceration was the most frequent type of amputation. Time between injury and operation averaged 5 hours 50 minutes. Average operating time was 6 1/2 hours. Thumbs were replanted most frequently, the index and small finger least frequently. Length of hospital stay averaged 9 days. Time out of work averaged 3 months. This data suggest that efforts directed toward employee education, safety, and prevention of injury on the job have the potential of decreasing the largest single cause of amputations in the upper extremities of patients in our area of the United States.