Slipped capital femoral epiphysis associated with radiation therapy.

We reviewed 32 children with 41 radiation-therapy associated slipped capital femoral epiphyses (RTASCFE). Ten were from the authors' institutions and 22 from the literature. Gender distribution was equal. The age at diagnosis of the malignancy was 4.3 +/- 3.1 years; the amount of radiation was 4,240 +/- 1,445 rads. Children with RTASCFE presented younger (10.4 +/- 3.2 years) than a routine SCFE. The average symptom duration was 5 +/- 6 months. Children with RTASCFE are usually thin (median weight, 10th percentile) in contrast to children with typical SCFE, who are usually obese (<95th percentile). The majority (82%) of the slips were mild, compared to routine SCFEs (approximately 50%); 28% were bilateral. There was a positive linear relationship between the age at presentation of the SCFE and the age at diagnosis of the malignancy; there was a negative linear relationship between the age at presentation of the SCFE and the amount of radiation therapy.

Slipped capital femoral epiphysis. The prevalence of late contralateral slip.

We evaluated the prevalence of slipped capital femoral epiphysis in the contralateral hip of 169 children who had been managed with pinning in situ and thirty who had been managed with immobilization in a spica cast. Only children who had initially been seen with a unilateral slip and had been followed for a minimum of two years or until skeletal maturity were included in the study. The average duration of follow-up was 3.6 years (range, 0.5 to 9.5 years) for the group that had been managed with a cast and 2.8 years (range, 1.0 to 8.3 years) for the group that had been managed operatively. In sixty-one (36 per cent) of the 169 patients who had had operative treatment and two (7 per cent) of the thirty who had been managed with a spica cast, a slip subsequently developed in the contralateral hip; this difference was significant (p = 0.001). On the basis of these findings, we recommend that closer attention be paid to the potential development of a slip in the contralateral hip after pinning.

Both-bone forearm fractures in children.

Treatment of both-bone forearm fractures remains a difficult dilemma for the orthopedist. We assessed the results of 33 children treated with closed reduction and a long-arm cast using traction with finger traps in neutral rotation. Patients were grouped according to age and analyzed for residual angulation and range of motion (ROM). Despite some residual angulation and loss of rotation, all patients were fully active with no functional restriction at follow up. For patients 10 years old or younger with less than 30 degrees of post-casting angulation, full ROM and minimal residual angulation on radiograph can be expected. For patients ages 11 to 15 years (the oldest patient in this series was 15), residual angulation is likely and approximately 60% of patients will have residual loss of less than or equal to 30 degrees of rotation. In spite of this, we found no evidence of functional loss at follow up. Our series supports the continued use of closed manipulation as an effective treatment in children with both-bone forearm fractures.

Supracondylar fractures of the humerus in children.

We undertook a retrospective study of 39 children with displaced supracondylar fractures treated by delayed closed reduction with fluoroscopic guidance. After 3-5 days of side-arm traction, swelling had usually diminished sufficiently to allow the elbow to be safely hyperflexed to stabilize the fracture after elective closed reduction. This method yielded 92% good or excellent results. There were no vascular problems or Volkmann's contractures.

Intraoperative venous dilation and subsequent development of deep vein thrombosis in patients undergoing total hip or knee replacement.

This patient study was based on the observation of characteristic intimal lesions in jugular and femoral veins removed from dogs a few hours following total hip replacement. The lesions, small localized intimal tears, suggested that smooth muscle and connective tissue, might have dilated beyond the ability of intima to accommodate. Intraoperative venous dilation correlated with the incidence of intimal lesions. It was postulated that surgical trauma resulted in circulating vasoactive substances which caused venous dilation and that dilation of smooth muscle and connective tissue beyond the yield point of intima resulted in intimal rupture. Similar intraoperative dilation and lesions, in patients might predispose to development of deep vein thrombosis (DVT). Total hip (THR) and total knee (TKR) replacement patients were selected for study because: (a) of the high incidence of DVT and (b) blood circulation is present in THR but not in TKR patients during operation. Ultrasound was used to monitor cephalic vein diameter during the perioperative period. Development of DVT postoperatively was compared with intraoperative venous dilation. In THR patients, intraoperative venous dilation ranged from 6%-56%. One of nine patients with dilation less than or equal to 17% developed DVT while 12 patients with dilation of greater than or equal to 22% developed DVT, giving a correct prediction of 95%. Of four patients in the intermediate range (19%, 20%), two developed DVT and two did not. The sharp demarcation was to be expected because of abrupt rupture of viscoelastic material when the critical point of elongation is exceeded.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis.

Intraoperative venodilation in veins distant from the site of operation has been shown to occur in animals and has been directly correlated with focal venous endothelial damage. This exposure of subendothelial collagen could serve as initiation sites for thrombus formation. This study tests the hypothesis that human beings (1) significant operative venodilation occurs and that it correlates with postoperative deep venous thrombosis (DVT); (2) operative venodilation can be pharmacologically controlled; and (3) this control reduces the incidence of postoperative DVT. Twenty-one patients undergoing total hip replacement had their contralateral cephalic vein continuously monitored with modified ultrasonographic instrumentation, with a continuous on-line recorder graphing venous diameter. Patients were randomly assigned to receive 0.5 mg of dihydroergotamine and 5000 U of heparin (DHE/Hep) for prophylaxis or placebo, with investigators "blinded" Postoperatively, all patients underwent ascending phlebography. Patients in whom postoperative DVT developed (11) had a mean operative venodilation of 28.9% +/- 3.93%, and those in whom DVT did not develop (10) had a mean venodilation of 11.6% +/- 1.55% (p = 0.001). Only 17% (2/12) dilating less than 20% baseline diameter had DVT compared with 100% (9/9) dilating greater than 20% of baseline diameter (p = 0.002). Patients receiving venotonic agent DHE had significantly less venodilation and DVT (p less than 0.001) compared with patients receiving the placebo. Patients who had DVT and whose veins dilated greater than 20% were older than patients who did not have DVT and whose veins minimally dilated: p = 0.04 and p = 0.07, respectively. Although there was a trend toward increased venoconstriction in patients receiving DHE/Hep (p = 0.09), there was no correlation of venoconstriction with ultimate thrombotic outcome. Maximal venodilation occurs during handling of soft tissue (muscle), and this occurs significantly sooner than maximal venoconstriction, which occurs during bone manipulation. We conclude that excessive operative venodilation is a new and important etiologic factor that leads to postoperative DVT. Operative venodilation can be pharmacologically controlled with the venotonic agent DHE. The combination DHE/Hep reduces postoperative DVT by the reduction of operative venodilation in the presence of low doses of an anticoagulant. These findings offer a new approach for predicting postoperative DVT and an object rationale for developing effective prophylaxis.

Osteochondritis dissecans: analysis of mechanical stability with radiography, scintigraphy, and MR imaging.

Twenty-one joints with stable (n = 9) or loose (n = 12) osteochondritis dissecans (OCD) lesions were examined in 15 subjects with plain radiography, three-phase bone scintigraphy, and magnetic resonance (MR) imaging. The lesion size and the thickness of the sclerotic margin as measured on plain radiographs were good parameters for predicting loosening. However, bone scintigraphy was more sensitive and specific in determining the mechanical stability of OCD lesions. MR imaging permitted direct visualization of loosening and fragment displacement; the latter permits differentiation of in situ loosening from a grossly unstable lesion. The noninvasive nature of bone scintigraphy and MR imaging makes them potentially preferable diagnostic modalities to arthrography for evaluating the mechanical status of OCD lesions.

Agenesis of the corpus callosum and limbic malformation in Apert syndrome (type I acrocephalosyndactyly).

Agenesis of the corpus callosum and malformation of limbic structures are described in a patient with Apert syndrome, a disorder characterized by acrocephaly, severe syndactyly, and often, mental retardation. Including the present case, malformation of the corpus callosum and/or limbic structures apparently has been reported in a total of ten patients with the syndrome. Complete or partial agenesis of the corpus callosum was found in six patients, septal defects in three, and arhinencephaly and ammonic hypoplasia in one. Since malformation or limbic structures are, to our knowledge, a consistent feature of agenesis of the corpus callosum, it seems that limbic abnormalities could be important for the pathogenesis of mental retardation not only in Apert syndrome, but also in other acallosal patients.

Pyogenic arthritis in infants and children: a review of 95 cases.

The clinical and laboratory findings of 95 children with pyogenic arthritis were reviewed to assess etiologic agents, diagnostic tools and results of therapy. Despite obtaining specimens from multiple sites for culture and using antigen detection tests only 64% of patients had an etiologic agent determined. Haemophilus influenzae type b was the most common causative agent identified and 82% of such cases occurred in children between 6 and 24 months of age. Infection due to Staphylococcus aureus was not confined to any age group. Results of laboratory tests which measure inflammatory response were not always abnormal. Platelet count and sedimentation rate frequently rose as clinical improvement occurred. Roentgenograms and radionuclide studies were of little benefit. Therapy included immediate decompression of the joint space, articular rest and use of antibiotics delivered parenterally. Ninety percent of 70 patients who were followed for 1 month to 5 years (mean, 15.5 months) were cured. Eight children had clinically significant sequelae which affected length of extremity, stability of articulations and range of movement. Development of sequelae was significantly associated with infection at age less than 6 months, delay of 4 or more days in institution of medical or surgery treatment, infection due to S. aureus and most strikingly the involvement of the hip or shoulder with concomitant presence of osteomyelitis.

Total hip replacement induces injury to remote veins in a canine model.

The effects of total hip replacement on the condition of the luminal surface of the jugular and femoral veins and the carotid and femoral arteries were studied in healthy dogs. Four hours after the completion of surgery, most of the blood was removed by whole-body perfusion and the vessels were partially fixed in situ by glutaraldehyde perfusion, harvested, and prepared for scanning electron microscopy. In control dogs (held under anesthesia) the luminal surfaces of the veins (including valves and confluences) and arteries were covered by intact endothelium and were free of adhering blood cells. The arteries from dogs that were operated on were also free of damage. In contrast, the veins from dogs that were operated on showed a series of roughly parallel microtears around 70 to 80 per cent of the confluences of the side branches with the jugular or femoral vein. The basement membrane as well as the endothelial sheet was torn, thereby exposing underlying connective-tissue fibers and smooth muscle cells. The endothelium separated along intercellular junctions. The tears were infiltrated with many leukocytes and platelets and some erythrocytes. Subtle endothelial changes and patchy leukocyte adhesion occurred away from the side branches. The mechanism or mechanisms remain to be elucidated.