Long-term outcome of lumbar discectomy in children and adolescents sixteen years of age or younger.

We retrospectively reviewed the cases of seventy-two consecutive patients who had a lumbar discectomy, between 1950 and 1983, when they were sixteen years of age or younger. There were forty boys and thirty-two girls. At the time of the lumbar discectomy, twelve patients (17 per cent) also had a spinal arthrodesis. The mean duration of follow-up was 27.8 years (range, twelve to forty-five years). Twenty patients (28 per cent) had one reoperation or more, with the first reoperation performed at a mean of 9.7 years after the initial discectomy. Fourteen patients had one reoperation, four had two reoperations, one had three, and one had five. Fifty-two patients (72 per cent) did not need a reoperation. At the time of the latest follow-up, forty-eight (92 per cent) of the fifty-two patients either had no pain or had occasional pain related to strenuous activity and fifty-one (98 per cent) could participate in daily activities with no or mild limitations. Survivorship analysis showed that the overall probability that a patient would not need a reoperation was 80 per cent at ten years and 74 per cent at twenty years after the initial operation. With the numbers available for study, we could not show that age, gender, or an arthrodesis performed at the time of the initial operation were risk factors for a reoperation. We could not detect a difference, with respect to pain or the level of activity, between the patients who had had an arthrodesis at the initial operation and those who had not or between those who had a coexisting structural abnormality of the lumbar spine and those who did not.

Total hip arthroplasty with cement in patients less than twenty years old. Long-term results.

Sixty-three consecutive total hip arthroplasties were performed with cement in fifty adolescent patients from 1972 through 1980, and the results were determined after a minimum of ten years. A polyethylene cup without a metal backing and a non-modular femoral component with a collar and a fixed neck length were inserted, with use of so-called first-generation cementing techniques, in each hip. Kaplan-Meier survival analysis of all sixty-three hips demonstrated that the probability of failure (defined as revision or symptomatic loosening) increased steadily over time and reached 45 per cent after fifteen years. A number of specific variables were associated with a significantly higher probability of failure: a history of more than one previous procedure involving the hip (p = 0.0002), unilateral arthroplasty (p = 0.006), previous trauma involving the hip (p = 0.01), the absence of other disease that limited function of the ipsilateral lower extremity (p = 0.03), a high postoperative level of activity (involving moderate or strenuous manual labor) (p = 0.03), and a preoperative weight of more than sixty kilograms (p = 0.03). The probability of failure in the patients who had inflammatory arthritis (11 per cent) was significantly lower than that in those who had previous trauma involving the hip (47 per cent) (p = 0.0006). Fifty-two hips (forty patients) were followed for a minimum of ten years or until revision. The mean duration of follow-up for these fifty-two hips was 12.6 years (range, 1.6 to 18.6 years). The result was evaluated clinically and radiographically with use of the Mayo hip-scoring system and was graded as excellent in ten hips (19 per cent), good in sixteen (31 per cent), fair in one (2 per cent), and poor in twenty-five (48 per cent). Most of the poor results were due to symptomatic loosening of the acetabular component. The probability of radiographic loosening after fifteen years was 60 per cent for the acetabular component and 20 per cent for the femoral component. Radiographic evidence of polyethylene wear was associated with probable loosening of the acetabular component (p = 0.03). The findings of the present study suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. Fixation of the acetabular component with cement is not recommended in this setting.

Tibia vara in a patient with Bardet-Biedl syndrome.

The Bardet-Biedl syndrome is characterized by polydactyly, hypogonadism, obesity, mental retardation, and retinitis pigmentosa. Several other skeletal findings include hip dysplasia, short stature, and skull deformities. The patient described in this report has the classic findings of Bardet-Biedl syndrome in conjunction with tibia vara and irregular physes of the lower extremities.

Chronic posterior subluxation and dislocation of the radial head.

The clinical and radiographic features of chronic posterior subluxation or dislocation of the radial head were studied in thirty-four elbows of twenty-seven patients. Three characteristic radiographic types were noted: Type I, subluxation; Type II, posterior dislocation with minimum displacement; and Type III, posterior dislocation with substantial proximal migration of the radius. Follow-up of eighteen patients (twenty-one elbows) revealed that posterior displacement did not usually cause serious functional impairment except for loss of rotation of the forearm. The least common presentation, Type-I subluxation, caused pain and clicking and was associated with late degenerative arthritis. Cosmetic deformity due to prominence of the radial head was also a cosmetic problem, particularly with Type-III dislocation.

Bipartite patella in the adolescent: results of surgical excision.

We evaluated the results of excision of the fragment in 16 patients with symptomatic bipartite patellae. In nine, the pain began following trauma; in seven, the onset was insidious. The pain was aggravated by activity in all patients. The average age at surgery was 14 years, 6 months, and the average postoperative follow-up was 7 years. Fifteen of the patients were markedly improved; one was not.

Results of lumbar discectomy in the pediatric patient.

To determine the results of lumbar discectomy in pediatric patients, a review was conducted of the medical records of 74 consecutive patients (40 males and 34 females) younger than 17 years who underwent lumbar disc surgery between 1950 and 1983. During this period, only 3% of patients younger than 17 years who presented with the chief complaint of low-back pain eventually had lumbar disc operation. In 43 patients it was thought that an injury had precipitated the symptoms. Thirty-seven patients had a nerve deficit at the time of initial evaluation. Water-soluble contrast myelography with repeated postmyelographic computerized tomography is currently used to confirm the diagnosis. The disc operations were performed at the L4-5 level in 47% of patients, the L5-S1 level in 45%, the L3-4 and L4-5 level in 4%, and the L4-5 and L5-S1 level in 4%. Fourteen of the 74 patient underwent spinal fusion with their first operation. At 9 months postoperatively, 95% had good or excellent results. During an extended follow-up period of up to 34 years, 16 of the patients with early successful results required further back procedures. After all medical and surgical treatment in this group of patients, the results were excellent in 57%, good in 38%, and poor in only 4%.

Surgical implications of Klippel-Trenaunay syndrome.

Between January 1956 and July 1981, 40 patients with Klippel-Trenaunay syndrome were seen at the Mayo Clinic. Twenty male and 20 female patients presented with the classic triad of soft tissue and bony hypertrophy of the extremity, hemangioma, and varicosity without evidence of functional arteriovenous fistulae. The lower extremity was involved in 38 patients (95%), the upper extremity in six patients (15%). In four of these cases (10%), both the upper and lower extremities were affected. The disease was unilateral in 34 patients (85%), bilateral in five cases (12.5%), and crossed-bilateral in one case (2.5%). Surgery was done in 13 patients (32.5%), nine of whom were operated on at the Mayo Clinic and four of whom had had previous surgery elsewhere. Excision and stripping of varices were performed in three patients; of these three, a deterioration of symptoms was observed in one, but the procedure was beneficial in the other two. Partial varicectomy was performed in four cases, while resection of the angioma was attempted in eight cases, with good results in three cases of small angiomas. Femoral and tibial epiphysiodesis stopped the overgrowth and produced an excellent result in one case. In four cases of epiphysiodesis at the foot level and two cases of derotational tibial osteotomy, moderate improvement was achieved. The indication for vascular or orthopedic surgery should be carefully considered in each patient who has this syndrome. One patient (2.5%) died of a severe form of the disease, but the relatively benign course is documented by the 21 patients (52.5%) who are free of complaints without any treatment or with elastic support only.

Lumbar disc excision in children and adolescents.

Fifty patients, all of whom were sixteen years old or younger, underwent discectomy for a herniated lumbar disc at the Mayo Clinic between 1950 and 1976. Ninety-four per cent of the patients had had excellent or good initial relief of symptoms after the initial operation. Subsequently, however, twenty-eight of the thirty-seven patients who initially had undergone disc excision only required additional treatment for low-back pain or sciatica. Twelve of them required a second operation, consisting of nine discectomies (six with a concomitant spine fusion), two spine fusions alone, and one re-fusion. Of the thirty-seven patients who initially had had disc excision alone, three had a recurrent disc protrusion and five had a disc protrusion at another level. Of sixteen patients who had had multiple subtotal hemilaminectomies at the initial operation, either for involvement of multiple discs or for exploration, seven required reoperation. In the twelve patients who had had both a disc excision and a lumbar spine fusion as the initial operation, there were no recurrent disc protrusions and only one patient had a protrusion at another level. Follow-up on all patients ranged from five to thirty years (average, nineteen years). Ninety per cent of the patients stated that the condition of the back had little or no effect on their current way of life, despite the presence of continuing back complaints in some. However, we rated the results of the initial discectomy at follow-up as excellent or good in 73.5 per cent and poor in 26.5 per cent of the patients.

Osteochondritis dissecans of the capitellum.

A retrospective study was done of 84 patients with osteochondritis dissecans of the capitelum who were seen during a 43-year period; followup of 57 patients could be obtained, nine of whom had involvement in both elbows. Most of the osteochondral lesions could be classified either as those still attached to the capitellum (type 1) or as loosened fragments lying free and floating within the joint (type 2): 24 were of type 1 and 37 were of type 2. Residual limitations were highest in the type 2 lesions that were treated either nonsurgically or surgically after a long delay. The best surgical results occurred with excision of the osteochondral defect and drilling or curettage of subchondral bone.

Multiple endocrine neoplasia with skeletal manifestations.

There are three types of familial multiple endocrine neoplasia, but type 2b, which is characterized by medullary thyroid carcinoma, pheochromocytoma, and ganglioneuromatosis, is the only one in which patients also have skeletal anomalies. These musculoskeletal abnormalities include marfanoid habitus, pes cavus, talipes equinovarus, slipped capital femoral epiphysis, kyphosis, scoliosis, lordosis, increased joint laxity, and weakness of the proximal muscles of the extremities. Affected patients have several facial abnormalities as well, the most striking being enlargement of the lips. Therefore, when a patient is seen with one or more of these musculoskeletal defects, the diagnosis of type-2b multiple endocrine neoplasia should be considered. If the characteristic facial features of the disorder are present, the patient should have a prompt examination for medullary thyroid carcinoma and pheochromocytoma.

Total joint arthroplasty. Applications in children and adolescents.

Sixty total hip arthroplasties were performed in 47 severely disabled children and adolescents. Follow-up was from 1 to 5 years. The complication rate was 22%. Loss of the prosthesis occurred in only one patient, who had had multiple operations. Eighty-five percent of these patients had good to excellent results.

Hematogenous osteomyelitis at uncommon sites in children.

The diagnosis of hematogenic osteomyelitis is often delayed in children if it involves uncommon sites such as the pelvis, clavicle, or calcaneus. Although parenterally administered antibiotics may control the disease process in the acute stage, abscess formation requires incision and drainage. Staphylococcus aureus was the most common organism in this series, and it usually was penicillin resistnat. When the condition is diagnosed early and is properly treated with at least 3 weeks of antibiotic therapy and judicious surgical intervention, recurrences are rare and morbidity is minimal.

Femoral shortening.

Femoral shortening is a well proven method of correcting a leg length discrepancy once growth has ceased. The discrepancy should be significant enough to justify the procedure, and should be ideally confined to the femurs. The musculature of the femur to be shortened should be normal. A segment of femur equal to the discrepancy is excised at either the midshaft, subtrochanteric, or supracondylar levels. Secure internal fixation of the osteotomy is essential. Equalization of the femurs (femoral shortening combined with femoral lengthening of the opposite leg) can be performed for femoral discrepancies of over 8 cm.

Hematogenous osteomyelitis of the clavicle in children.

Recognition of acute hematogenous osteomyelitis of the clavicle can be difficult. The condition may even to confused with fracture or malignancy. Treatment with parenteral antibiotics must be continuous for at least three weeks. If there is evidence of abscess formation, incision and drainage is indicated. If surgery is performed, a thorough debridement or partial resection may be required to prevent recurrence. If inadequately treated, the process becomes chronic. Resection of involved portion of the clavicle has been effective in the chornic stage of the disease. In the young child the resected segment often regenerates and the clavicle completely reconstitutes itself.

Suppurative arthritis of the hip in children.

Of thirty-seven children treated at the Mayo Clinic for suppurative arthritis of the hip and followed for at least one year (average, 8.3 years), nineteen had a satisfactory result and eighteen, an unsatisfactory result. An analysis of the records of the thirty-seven children revealed the following: (1) duration of symptoms was the most important prognostic feature, there being no unsatisfactory results if treatment was instituted less than four days after onset of symptoms; (2) fourteen of sixteen patients with associated osteomyelitis and six of eight with so-called penicillin-resistant Staphylococcus aureus had unsatisfactory results; (3) if symptoms had been present for more than ten days or if there was osteomyelitis, at least two weeks of parenteral antibiotics with arthrotomy and continuous irrigation offered the best prognosis; and (4) the prognosis has improved in recent years, possibly due to a move vigorous policy of early arthrotomy.

Disk space infections in children.

The present review of disk space infection in children agrees with that carried out in 1962.12 The physician who encounters a child with back or hip pain, irritability, and a change in walking pattern should always suspect an infection of the vertebral column, particularly in the presence of limited spine motion, spasm, and an elevated sedimentation rate. S. aureus still is the usual primary infecting agent. Treatment consisting of rigid immobilization of the spinal column during the acutely painful phase appears to be adequate therapy. The use of antibiotics is not generally recommended. Because of this, hospitalization is usually not prolonged unneccessarily. The rationable for the use of antibiotics in one atypical case included recurrence of clinical signs and symptoms despite immobilization. These included persistent pain and spasm associated with a high sedimentation rate. Disk space aspiration probably is no longer necessary or desirable in the usual patient in whom immobilization is generally effective. The prognosis for most patients is good. Occasionally spinal fusion should be considered in this young age group if mechanical backache persists after the infection has been cured. The findings and recommendations regarding management of this disease in children should not be applied to the adult.

Septic arthritis in children.

When septic arthritis involves the hip, the prognosis is much worse than with any other joint. Approximately 50 per cent of the results were unsatisfactory with hip involvement compared to 12 per cent unsatisfactory results with involvement of the other joints. The erythrocyte sedimentation rate is a much more helpful diagnostic test than the leukocyte count or differential cell count. The most important prognostic factors are the duration of symptoms prior to treatment, a penicillinase-producing organism (penicillin-resistant) as the etiologic agent, and evidence of associated metaphyseal osteomyelitis. Early decompression and cleansing of the joint by aspiration or arthrotomy are essential for a good result. Long-term parenteral antibiotic therapy improves the prognosis when osteomyelitis is an assoicated feature. Arthrotomy with continuous irrigation appears to be more effective in decreasing long-term residual effects than arthrotomy alone. Almost all secondary surgical procedures are directed toward correcting the sequelae of septic arthritis of the hip.

Osteochondritis dissecans of the elbow.

The clinical findings, roentgenographic findings, and results of various forms of treatment of osteochondritis dissecans in 50 elbows were reviewed in a study of the records of 42 patients. All the patients were males; two-thirds were between 9 and 15 years of age when they first had symptoms. Pain, loss of motion, locking, and clicking were the most common symptoms. Roentgenographically, rarefaction and flattening of the capitellum were common features. Some form of surgical treatment was used for 38 elebows; removal of loose bone and curettage and trimming of the crater were the most frequent procedures. The results of treatment were generally satisfactory. This review suggests that loose bodies should be removed and that, in most instances, no other procedures are indicated.