Osteomyelitis of the calcaneus in children.

Eleven cases of calcaneal osteomyelitis in children are reported. Seven were hematogenous cases, and the remaining four were related to puncture wounds. The clinical presentation was less dramatic than that seen in typical long bone osteomyelitis. Laboratory findings were also less striking. A mixture of organisms was isolated from patients in the hematogenous group. In contrast, all puncture-related cases had cultures positive for Pseudomonas aeruginosa. Plain radiographic findings were noted at the time of presentation in 63%. Those findings were characteristically different in hematogenous and puncture-related cases. Oblique lateral radiographs can be important for diagnosis in puncture-related cases. Radionuclide bone scanning was an important diagnostic test in the absence of plain radiographic changes and in the very young patient. Surgery was performed in 82% of the cases. There were no recurrences or chronic infections. Two complications occurred in one patient, including residual scar sensitivity and early fusion of the calcaneal apophysis.

Lawn mower injuries of the pediatric foot and ankle: observations on prevention and management.

We reviewed 32 children with lower extremity injuries caused by power lawn mowers. Functional outcome of 21 patients was evaluated. Anatomical injury patterns provide some guidelines in management and prediction of functional outcome. Consistently, the most severe injuries result from ride-on mowers and wounds to the posterior/plantar foot and ankle. Our experience with pediatric foot and ankle lawn mower injuries permits recommendations for maximum functional outcome with minimal intervention. Public awareness and mower safety devices may be required to decrease the rate of accidents in the future.

Adolescent femoral shaft fractures: rigid versus flexible nails.

Twenty-one skeletally immature patients between 11 and 16 years of age were treated operatively for a unilateral femoral shaft fracture. Eleven patients underwent fixation with flexible nails and 10 with rigid nails. The patients were studied retrospectively to determine the similarity of the groups. Each method of fixation was then compared to determine the technical ease and final outcome. Both methods gave excellent final radiographic alignment with minimal complications. Flexible nailing required much less operative time and less fluoroscopy time. Estimated cost of using Ender nails is much less than using Russell-Taylor interlocking nails.

A comparison of Wisconsin instrumentation and Cotrel-Dubousset instrumentation.

Twenty-six patients who underwent Wisconsin instrumentation and 36 patients who underwent Cotrel-Dubousset instrumentation (CDI) for idiopathic scoliosis were studied. Inclusion in the study required at least 24-month follow-up. Variables compared included operating time, blood loss, frontal plane correction, axial and sagittal plane changes, effects on compensation, and complications. In general, operating time, blood loss, and instrumentation problems were greater with CDI. Thoracic curve correction in King II curves was better with CDI. There was no advantage to either system with respect to sagittal plane alignment or rotation. When all factors were considered, a significant advantage to use of CDI could not be demonstrated.

Is pinning in situ a safe procedure for slipped capital femoral epiphysis?

This report reviews the results of 37 patients with 46 involved hips treated with pinning for slipped capital femoral epiphysis. Particular attention was given to incidence of complications, including avascular necrosis, chondrolysis, and penetration of the joint. Of 46 hips with 1-year follow-up, there were no cases of chondrolysis. Of 23 hips with 2-year follow-up, there was only 1 case of avascular necrosis. Pin penetration, recognized at the time of surgery, produced no significant sequelae. Pinning can produce satisfactory results without a significant incidence of major complication.

Hip stabilization in severely involved cerebral palsy patients.

Thirty-two patients (48 hips) with total body involved cerebral palsy (CP) underwent medial release and proximal femoral osteotomy for hip subluxation or dislocation. Twenty-eight hips were rated good, 15 were rated fair, and five were rated poor at follow-up. The better located the hip preoperatively and the better the reduction obtained at operation, the better the final result. The major factor that correlated with a good result was early operation, performed before significant deformity had occurred.

Management of femoral shaft fractures in the adolescent.

Forty-four patients (45 fractures) with open physes (age range 11-16 years) underwent treatment for femoral shaft fractures. Seven malunions occurred in the 24 fractures in the nonoperative group; none occurred in the 21 fractures treated by intramedullary nailing. Hospital stay was significantly shorter in the operatively treated patients. There was no premature growth arrest in the surgical group.

Clinical and radiological evaluation of lumbosacral motion below fusion levels in idiopathic scoliosis.

The purpose of this study was to evaluate the unfused segments of the lumbar spine in patients who had Harrington instrumentation and fusion for idiopathic scoliosis. Forty-eight patients, with an average follow-up of 11 years, were evaluated. The translational motion in the unfused segments below the instrumented levels was measured, using lateral flexion and extension radiographs of the lumbar spine. This motion was compared with values obtained from an earlier study of asymptomatic nonscoliotic individuals. The amount of disc space narrowing, retrolisthesis, length and level of the fusion, and the presence of traction spurs also were recorded. The incidence of low-back pain was highest in those patients fused to L4 (62%). Individuals instrumented and fused to L3 or L4 had significantly more translational motion in the adjacent lower interspace when compared with the control group (P = 0.05 and P = 0.001, respectively). Increased translational motion correlated with the presence of low-back pain in patients fused to L4. Retrolisthesis occurred in 81% of patients instrumented to L4, in 40% of those fused to L3, and was not found in patients fused to high levels. Its presence was strongly associated with low-back pain. There was no relationship between low-back pain and traction spurs, length of the fusion mass, lumbar lordosis, or width of the disc space in the unfused lower levels. The authors conclude that retrolisthesis and increased translational motion are important factors in determining low-back pain following surgery for idiopathic scoliosis. Instrumentation to L4 should be avoided if possible.

Neurologic return versus cross-sectional canal area in incomplete thoracolumbar spinal cord injuries.

Twenty-four patients with incomplete spinal cord injuries secondary to burst fractures of the thoracolumbar spine were reviewed an average of 26 months after their injury. No patient had had a specific attempt to decompress neural elements but the majority had posterior instrumentation and fusion for spine realignment and stabilization. The amount of neurologic recovery in each patient was compared to the final area of the spinal canal as determined by CT scan. It was concluded that there was no correlation between neurologic improvement and the amount of spinal canal encroachment. In addition, posterior instrumentation to realign the spine will usually restore canal patency to greater than 50% of normal.

Spinal cord injury without osseous spine fracture.

Sixteen patients with spinal cord injury without osseous spine fracture and 55 patients with spinal cord injury with osseous spine fracture aged from birth through 18 years were studied. Those without osseous fracture were younger (mean age 6 years) than were those with osseous fracture (mean age 16 years). Extravasation of myelographic dye from the spinal canal was a poor prognostic sign. All three in the group with this finding without osseous fracture had complete spinal cord lesions. Those without osseous fracture should be followed for the development of late spinal deformity that may require orthotic support or surgical stabilization.

Operative treatment of Medial epicondyle fractures in children.

Thirty-one patients with fractures of the medial epicondyle displaced more than 2 mm were evaluated an average of four years after their injury. Twenty-three patients had good results regardless of the degree of displacement or the presence of an elbow dislocation. One patient, had a poor result due to a technical error in pin placement. The remaining seven patients had the fracture fragment trapped in the joint and did worse, with three poor results. There was no correlation between range of motion and degree of displacement, length of immobilization, time from injury to surgery, presence of a dislocation, or open versus percutaneous treatment. Operative treatment of medial epicondyle fractures displaced greater than 2 mm gave consistently good results with a good range of motion, good stability, no ulnar nerve symptoms, and no deformity.

Segmental spinal instrumentation with sublaminar wires. A critical appraisal.

Fifty-eight patients who had scoliosis or kyphosis of varying etiologies were followed for a minimum of two years (average, forty-four months) after segmental spinal instrumentation using sublaminar wires. In eight (19 per cent) of the patients who had been operated on for scoliosis one or both rods broke. The average time that had elapsed before the breakage was discovered was twenty-three months. None of the patients in whom a rod had broken had had postoperative immobilization or a first-stage anterior fusion, and only one had had supplementary grafting with banked bone. Instrumentation to the pelvis was also associated with a greater incidence of broken rods. The use of supplementary grafting with banked bone or the use of postoperative immobilization significantly decreased the loss of postoperative correction. Preliminary anterior spinal fusion helped prevent breakage of rods but not loss of correction. It was concluded that postoperative immobilization and use of large amounts of supplementary bone graft lead to better results when using this implant system.

Effects of neurodevelopmental treatment on movement patterns of children with cerebral palsy.

Twelve children with mild, moderate, or severe cerebral palsy were examined and videotaped before and after an intensive course of physical therapy in a neurodevelopmental treatment course. These tapes, demonstrating various predetermined movement patterns, were then randomized and viewed by six evaluators. None of the evaluators could tell the difference between before and after films. This demonstrated that significant changes were not seen in children with cerebral palsy after 6 weeks of therapy.

Mechanical consequences of rod contouring and residual scoliosis in sublaminar segmental instrumentation.

The mechanical performance of contoured Luque rods in a neuromuscular model of spine deformity was examined to define an upper limit of deformity above which rod stresses would exceed the endurance limit for 316L stainless steel and therefore predict fatigue failure. Bovine constructs varying from 0-120 degrees scoliosis were loaded axially, with strain recordings obtained at the apex of the curve. Relatively low loads produced enough tensile stress to contemplate implant fatigue in all except the nondeformed (0 degrees) construct. Construct stiffness was found to decrease rapidly in spines with greater than 38 degrees deformity. In addition, data on patients who had suffered rod fracture from four different centers were found to compare favorably with experimental observations. We conclude that the vulnerability of Luque rod constructs to implant failure, from a mechanical standpoint, is greater than is generally assumed. Cross-linking of rods was found to increase stiffness. Methods to decrease tensile stresses in the implants and increase stiffness include external immobilization, larger diameter rods, and procedures to enhance correction.

Distal tibial physeal injuries in children: a different treatment concept.

Fifty-six patients with Salter-Harris type II physeal fractures of the distal tibia were treated with a weight-bearing long leg cast for 4 weeks. Forty patients were followed clinically and radiographically for an average of 22 months. There were no nonunions or angular deformities. There was one case of clinically insignificant premature physeal closure. Premature physeal closure results from the trauma to the physis that occurs at the time of injury and is not affected by early weight-bearing. Four weeks of immobilization in a long leg weight-bearing cast allows adequate healing and faster rehabilitation without an adverse effect on the growth of the distal tibia.