Decreased radiation exposure using pulsed fluoroscopy and a detachable pedicle marker and probe to place pedicle screws: a comparison to current fluoroscopy techniques and CT navigation.

STUDY DESIGN: Quality improvement evaluation with retrospective analysis. OBJECTIVES: To compare a technique to place pedicle screws (PS) using a novel detachable pedicle marker and probe (DPMP) and pulsed fluoroscopy (PF) vs. conventional technique utilizing PF with standard instruments (SI) and O-arm. Spinal fusion with pedicle screw instrumentation (PSI) is the mainstay in treatment of spinal deformities. Reports suggest that CT navigated (O-arm) PS placement is more accurate than fluoroscopy. However, these studies have not considered the increased radiation exposure associated with CT. METHODS: Thirty-six patients with spinal deformity had PSI using PF and DPMPs. Accuracy of PS placement and radiation data from 14 dosimeters placed on the patient and around the operating room was analyzed. Results were compared to published data. RESULTS: Mean fluoroscopic time was 13.4 s (range 6.0-32.4), and the mean cumulative dose was 3.1 mGy (range 0.2-16.4). Median estimated effective dose to the patient was 0.22 mSv (range 0.0-0.7). The effective dose of radiation was reduced by 80% (0.22 mSv vs. 1.11 mSv) compared to low-dose O-arm. The surgical team did not receive any detectable radiation. The seconds of PF used to assist and confirm placement of PSs was reduced to 1.2 s/level compared to previous reports of 4.49 s/level using SIs. DPMPs reduced fluoroscopy to 0.84 s/PS compared to 7.36 s/PS using SIs to assist and confirm PS placement. PSs were accurately placed in 561 of 576 (97.4%), which is comparable to O-arm and fluoroscopy with SIs. CONCLUSIONS: PS placement using PF and DPMPs to assist and confirm PS placement lowers radiation exposure to the patient and surgical team without compromising accuracy compared to O-arm and fluoroscopy with SIs. LEVEL OF EVIDENCE: Therapeutic, Level IV (Retrospective case series, historical control).

Comparison of simultaneous static standing balance data on a pressure mat and force plate in typical children and in children with cerebral palsy.

BACKGROUND: Balance testing is an important component in treatment planning and outcome assessment for children with Cerebral Palsy (CP). Objective measurement for static standing balance is typically conducted in motion labs utilizing force plates; however, a plantar pressure mat may prove to be a viable alternative for this type of balance assessment. METHODS: This study examined static standing balance simultaneously on a force plate and a plantar pressure mat in 30 typically developing (TD) and 30 children with CP to determine if valid measures of static standing balance could be obtained in children with CP using a pressure mat. RESULTS: Examination of the data provided evidence that reliable and valid measures of static standing balance can be produced with a plantar pressure mat for both groups. Five variables out of the 21 variables examined were found to be reliable and valid on both devices (pressure mat and force plate) for both subgroups (TD and CP). The variables medial/lateral (ML) average radial displacement, range moved-ML, anterior/posterior average velocity, ellipse area, and area per second were found to have high test-retest reliability (ICC > .6) and possess discriminant validity between the subgroups (TD vs. CP). Additionally, the ellipse area and area per second variables also had the ability to discriminate between GMFCS levels. A normative center of pressure (CoP) balance data set using all 21 variables was also established for typically developing children for both devices (pressure mat and force plate) within this study. SIGNIFICANCE: The ability to utilize a portable plantar pressure mat for quick and reliable standing balance measurement allows for expanded ability to capture objective data in a variety of settings thereby increasing opportunity for outcomes analysis.

Dexmedetomidine Decreases Postoperative Pain and Narcotic Use in Children Undergoing Alveolar Bone Graft Surgery.

OBJECTIVE: Dexmedetomidine is a parenteral agent that combines the benefits of cooperative sedation, anxiolysis, and analgesia without the risks of respiratory depression. Off-label use has been reported in children. We have introduced dexmedetomidine for use in patients having undergone alveolar bone graft (ABG). The objective is to demonstrate the value and safety of postoperative dexmedetomidine infusion in a non-ICU setting following ABG. DESIGN: A retrospective review was performed on patients who underwent ABG by the senior author. Patients were divided into 2 groups: those who received postoperative dexmedetomidine and those who received patient-controlled anesthesia. MAIN OUTCOME MEASURE(S): The primary study outcome measures included patient demographics, adverse events, length of stay, pain scores, and doses of narcotics during admission were collected. RESULTS: Inclusion criteria were met by 54 patients; 39 received dexmedetomidine whereas 15 did not. There were no significant differences between groups in age, gender, and length of stay. The patients who received dexmedetomidine used oral narcotics less often ( P = .01). In addition, more patients reported no pain after surgery ( P = .05) and at the time of discharge if they received dexmedetomidine ( P < .01). There were no reported adverse effects. CONCLUSIONS: Dexmedetomidine provided superior pain control after surgery and at the time of discharge, as well as a significant decrease in the use of oral narcotics. In our institution, it has since replaced the PCA as a postoperative pain control modality. Absent the risk for respiratory depression, dexmedetomidine has demonstrated a safe option for postoperative pain control in our focused group of pediatric patients.

Rectus Femoris Transfer Versus Rectus Intramuscular Lengthening for the Treatment of Stiff Knee Gait in Children With Cerebral Palsy.

BACKGROUND: Rectus femoris transfer (RFT) is used to treat stiff knee gait in spastic cerebral palsy. Recently, rectus femoris lengthening has been reported as treatment for stiff knee gait. The purpose of this study was to compare short-term outcomes of 2 surgical procedures. METHODS: A retrospective chart review of 23 patients (42 limbs) with diplegic spastic cerebral palsy who had undergone rectus femoris intramuscular lengthening for treatment of stiff knee gait with a Gross Motor Function Classification System level I, II, or III was completed. These patients were matched with a cohort of 23 patients (42 limbs) who had undergone RFTs based on age, sex, Gross Motor Function Classification System level, diagnosis, preoperative Gait Deviation Index, and any simultaneous surgeries. Preoperative and 1 year postoperative motion analysis data and physical examination were compared. RESULTS: There were no significant differences in demographics between the groups. On physical examination, a positive postoperative Duncan-Ely test was seen significantly less often in the transfer limbs (20 vs. 37). Average postoperative quad tone score was 1.56 for the transfer group compared with 2.19 for the lengthening group. No significant postoperative difference was seen between groups in stride length, walking speed, cadence, knee flexion at initial contact, peak knee flexion during loading response, mean knee flexion in stance, peak knee flexion in swing, time to peak knee flexion (% swing), time to peak knee flexion (% gait cycle), Gait Deviation Index or total knee range of motion. There was a difference in time to achieve 90 degrees passive knee flexion with the lengthening group reaching this in 8.3 days and transfer group in 15.3 days (P<0.0001). CONCLUSIONS: Motion analysis parameters showed results of RFT and rectus femoris intramuscular lengthening to be equivalent 1 year postoperatively. Since rectus femoris lengthening is technically less difficult and rehabilitation faster, rectus femoris lengthening may be preferred if long-term follow-up supports these findings. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Medial malleolar screw versus tension-band plate hemiepiphysiodesis for ankle valgus in the skeletally immature.

BACKGROUND: Ankle valgus is frequently encountered in skeletally immature patients in association with a variety of musculoskeletal disorders. Guided growth with temporary medial malleolar transphyseal screw (MMS) hemiepiphysiodesis is an established surgical treatment capable of correcting the angular deformity, but is often complicated by symptomatic screw head prominence and difficult hardware removal. Tension-band plate (TBP) hemiepiphysiodesis has recently been advocated as an alternative; however, the relative efficacy of these 2 techniques has not been directly investigated. Thus, the purpose of this study was to compare MMS and TBP in treatment of pediatric ankle valgus deformity. METHODS: Medical records and radiographs of all patients undergoing distal tibial medial hemiepiphysiodesis for ankle valgus between January 1, 2005 and November 1, 2010 at a pediatric orthopaedic specialty hospital were retrospectively reviewed. Radiographs obtained preoperatively and at 6-month intervals postoperatively were reviewed and the tibiotalar angle was measured. Patient age, sex, underlying diagnosis, concurrent surgical procedures, surgical and postoperative complications, and the presence or absence of symptomatic hardware complaints were documented. RESULTS: Sixty ankles in 42 patients met the inclusion criteria, with adequate radiographs and minimum postoperative follow-up of 12 months (mean: 34 mo). Thirty-five ankles were treated with MMS, and 25 with TBP. Good mean correction of the tibiotalar angle was achieved in both groups (MMS: pre-77.1 degrees to post-87.8 degrees over 25.2 mo; TBP: pre-81.3 to post-87.6 over 20.0 mo). The mean rate of correction was faster in ankles treated with MMS than TBP, but differences did not reach statistical significance (0.55 vs. 0.36 degrees/mo, respectively; P=0.057). Complications included 6 hardware-related surgical complications in MMS ankles (17.1%) and 1 in TBP ankles (4.0%). The incidence of symptomatic hardware complaints was low in both groups (MMS, 5.7%; TBP, 0%). CONCLUSIONS: Both MMS and TBP techniques can result in successful correction of ankle valgus in the growing child. Although the rate of deformity correction may be faster with MMS, TBP seems to be associated with fewer hardware-related complications. This information may aid the clinician in selecting the surgical option most appropriate for each individual patient. LEVEL OF EVIDENCE: Level II-retrospective study.

Correction and recurrence of ankle valgus in skeletally immature patients with multiple hereditary exostoses.

BACKGROUND: Ankle valgus is encountered in children with a variety of congenital musculoskeletal disorders, including multiple hereditary exostoses (MHE). Guided growth with temporary distal tibial medial hemiepiphysiodesis (DTMH) may correct the deformity; however, exostoses about the ankle commonly observed in MHE patients may hinder correction and increase the risk of recurrence. Thus, the purpose of this study was to review the outcomes of DTMH in treatment of ankle valgus in MHE versus other diagnosis (non-MHE). METHODS: Medical records and radiographs of patients undergoing DTMH for ankle valgus between January 1, 2005, and November 1, 2010, at a single pediatric orthopedic hospital were retrospectively analyzed. Radiographs obtained preoperatively and at 6-month intervals postoperatively were reviewed and the tibiotalar angle was measured. RESULTS: Fifty-eight ankles in 41 patients met inclusion criteria, with minimum follow-up of 12 months (mean, 34 months). Mean age was 10 years (range, 4-14 years). MHE was the most common underlying diagnosis (19 ankles, 33%). The rate of tibiotalar angle correction (mean ± standard deviation) with hardware in place was 0.37 ± 0.28 deg/mo in MHE ankles and 0.51 ± 0.42 deg/mo in non-MHE ankles (P = .161). Following hardware removal, the rate of recurrence was faster in MHE (0.29 ± 0.25 deg/mo) compared with non-MHE ankles (0.12 ± 0.19 deg/mo) (P = .059), and more total recurrent valgus deformity was observed in MHE (7.8 ± 8.2 degrees) than non-MHE ankles (3.4 ± 4.6 degrees) (P = .08) over a similar follow-up period (mean 23.4 vs 23.6 months, respectively), with differences approaching statistical significance. CONCLUSION: MHE is a common cause of ankle valgus in children. Guided growth interventions in this population can be successful but require special consideration given the potential for relatively gradual deformity correction and rapid recurrence following hardware removal in the skeletally immature. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The spectrum of preaxial polydactyly of the foot.

BACKGROUND: Polydactyly is a common congenital anomaly of the foot classified as preaxial, central, or postaxial depending on the location of the duplication. Approximately 15% of all duplications of the toes are preaxial. The purpose of this study is to report our experience in the management of preaxial polydactyly of the foot over a period of 30 years at a single institution. PATIENTS AND METHODS: This is a retrospective institutional review board-approved descriptive case series of 21 children representing 28 feet with preaxial foot polydactyly seen at our institution from 1977 to 2009. All subjects were analyzed in terms of sex, laterality, anatomic patterns of polydactyly, associated anomalies, family history, clinical features, surgical indications, details of surgical procedures, and outcomes after surgical interventions, using data collected from medical records, radiographs, and clinical photographs. Clinical outcomes were evaluated at the most recent examination, according to the format published by Phelps and Grogan. RESULTS: There were 21 patients (28 feet) including 11 male and 10 female subjects. Duplications were bilateral in 7 patients and unilateral in 14. The average age at surgery was 1.8 years (range: 0.8 to 4.6 y). The average follow-up was 81.7 months (range: 5 to 180 mo). According to the Watanabey classification, the distal phalangeal type occurred in 4 feet, the proximal phalangeal type in 10 feet, the metatarsal type in 10 feet, the tarsal type in 2 feet, a combined tarsal and metatarsal type in 1 foot, and a mirror type in 1 foot. All patients had associated anomalies in the affected feet. Congenital hallux varus was the most common associated anomaly (20 feet). A longitudinal epiphyseal bracket was observed in 4 feet. Clinical outcomes after the initial surgery were excellent in 8 feet, good in 15 feet, and poor in 5 feet. The 5 feet rated as poor were because of residual deformities and required additional surgery. Good results were subsequently obtained at final follow-up in all 5 feet. CONCLUSIONS: In our opinion, the Watanabe classification is more useful than the Venn-Watson for surgical planning. However, we have added an additional type, representing a mirror foot which we feel is within the overall spectrum of preaxial polydactyly. Good or better results were obtained in all feet at final follow-up. Early detection and adequate excision of the longitudinal bracket affecting the phalanges or metatarsal can reduce residual deformity and the need for revision surgery.

Pediatric outcomes data collection instrument scores in ambulatory children with cerebral palsy: an analysis by age groups and severity level.

BACKGROUND: The Pediatric Outcomes Data Collection Instrument (PODCI) was developed in 1994 as a patient-based tool for use across a broad age range and wide array of musculoskeletal disorders, including children with cerebral palsy (CP). The purpose of this study was to establish means and SDs of the Parent PODCI measures by age groups and Gross Motor Function Classification System (GMFCS) levels for ambulatory children with CP. METHODS: This instrument was one of several studied in a prospective, multicenter project of ambulatory patients with CP between the aged 4 and 18 years and GMFCS levels I through III. Participants included 338 boys and 221 girls at a mean age of 11.1 years, with 370 diplegic, 162 hemiplegic, and 27 quadriplegic. Both baseline and follow-up data sets of the completed Parent PODCI responses were statistically analyzed. RESULTS: Age was identified as a significant predictor of the PODCI measures of Upper Extremity Function, Transfers and Basic Mobility, Global Function, and Happiness With Physical Condition. Gross Motor Function Classification System levels was a significant predictor of Transfers and Basic Mobility, Sports and Physical Function, and Global Function. Pattern of involvement, sex, and prior orthopaedic surgery were not statistically significant predictors for any of the Parent PODCI measures. Mean and SD scores were calculated for age groups stratified by GMFCS levels. Analysis of the follow-up data set validated the findings derived from the baseline data. Linear regression equations were derived, with age as a continuous variable and GMFCS levels as a categorical variable, to be used for Parent PODCI predicted scores. CONCLUSIONS: The results of this study provide clinicians and researchers with a set of Parent PODCI values for comparison to age- and severity-matched populations of ambulatory patients with CP.

Relationships among functional outcome measures used for assessing children with ambulatory CP.

In ambulatory children with cerebral palsy (CP), practitioners often examine outcomes using measures related to functions necessary for daily life. The Gross Motor Function Measure (GMFM) Dimensions D and E, Pediatric Outcomes Data Collection Instrument (PODCI) Parent and Child versions, Gillette Functional Assessment Questionnaire (FAQ) Walking subscale, Functional Independence Measure for Children (WeeFIM), Pediatric Quality of Life Inventory (PedsQL), temporal-spatial gait parameters, and O(2) cost during ambulation were selected for study. Cross-sectional data were collected in a prospective multicenter study of 562 participants with CP (339 males, 223 females), between 4 and 18 years of age (mean age 11y 1mo). There were 240 classified as Gross Motor Function Classification System Level I, 196 as Level II, and 126 as Level III. The tools that had the best interrelationships and underlying constructs predominately measured changes in physical function. These included portions of the FAQ, Parent PODCI, WeeFIM, and GMFM. GMFM Dimensions D and E exhibited a very strong relationship. Temporal-spatial gait parameters and O2 cost measures represented a different construct of physical function. The Child PODCI reports and both the Parent and Child PedsQL reports did not relate well to other measures, suggesting a pattern of answers not related to question content. The Parent PODCI, the FAQ Walking subscale, and GMFM Dimension E were found to be an appropriate minimum set of instruments for assessment of functional outcomes in patients with ambulatory CP.

A facility-based assessment of the pharmacy departments in government health institutions in St. Ann

Equity in health care is a basic concept in primary health care. To be equitable it must be available, accessible, acceptable and affordable. This includes that provision of essential drugs. This study was undertaken to exmaine the level of pharmaceutical care available to the people of St. Ann through the Government public health system and the attitude of the people to the service. To do this, direct observation of the facilities, a self administered questionnaire for pharmacists and exit interviews of 75 persons, were conducted in three of the five facilities which was required, by their classification, to offer pharmaceutical services in the parish. Results indicate that the patients have a generally fair attitude towards the service with the main agent of discontent being the long waitig time for the service and the unavailability of essential drugs. The distance travelled, more than ten miles, by a significant number of persons was greater than that desired by primary care advocates. The lack of adequate facilities and tools with which to work, were noted by the pharmacists as a hindrance to the performance of their duties. A study of the level of patient drug compliance/non-compliance and the level of admission to hospital due to drug misadventure would be useful, to determine the effect of the level of service on other aspects of health care.(Au)

A facility-based assessment of the pharmacy departments in government health institutions in St. Ann

Equity in health care is basic concept in primary health care. To be equitable it must be available, accessible, acceptable and affordable. This include the provision of essential drugs. This study was undertaken to examine the level of pharmaceutical care available to the people of St. Ann through the government public health system and the attitude of the people to the service. To do this, direct observation of the facilities, a self administered questionnaire for pharmacists and exit interviews of 75 persons, were conducted in three of the five facilities which are required, by their classification, to offer pharmaceutical services in the parish. Results indicate that the patients have a generally fair attitude towards the service with the main agent of discontent being the long waiting time for the service and the unavailability of essential drugs. The distance travelled, more than ten miles, by a significant number of persons was greater than that desired by primary care advocates. The lack of adequate facilities and tools with which to work, were noted by the pharmacists as a hindrance to the performance of their duties. A study of the level of patient drug compliance/non-compliance and the level of admission to hospital due to drug misadventure would be useful, to determine the effect of the level of service on other aspects of health care.(AU)