The evolution of Shriners Hospitals for Children in North America.

Shriners Hospitals for Children have been providing totally free care to children with neuromusculoskeletal disabilities since 1922. This mission expanded in 1962 to include the care of children with burn injuries and expanded in 1978 to include children with spinal cord injuries. Today, Shriners Hospitals for Children include 19 hospitals that provide pediatric orthopaedic care, four hospitals that provide acute and reconstructive burn care, and three hospitals in which spinal cord injury rehabilitation centers are located. During the past 20 years, case acuity and complexity have increased, comprehensiveness of care has been emphasized, members of the medical staff have increasingly become full-time, and sponsored intramural research has increased to a budget of $22 million annually. Annually, more than 250 orthopaedic residents receive pediatric orthopaedic training and more than 150 surgical residents are trained in pediatric burn care in Shriners Hospitals. In 1998, approximately 25,000 children were admitted for care, more than 22,000 operations were performed, and 236,000 children were treated as outpatients. In 1999, the annual operating budget for Shriners Hospitals for Children was $397 million.

Synovectomy of the knee for hemophilic arthropathy.

Synovectomy of the knee for the control of recurrent hemarthrosis was performed in thirteen patients with hemophilic arthropathy. Preoperatively, all patients had experienced an average of three bleeding episodes into the affected joint per month, and had been unresponsive to at least six months of medical management. Radiographically, all knees had either Stage-II or Stage-III hemophilic arthropathy. The average age of the patients at the time of synovectomy was sixteen years and the average length of follow-up was 7.3 years (range, two to eleven years and seven months). Although the motion of the knee remained unchanged postoperatively in two patients, ten patients had an average loss of 41 degrees. One patient eventually required an arthrodesis. Radiographically, there was slight further joint deterioration after synovectomy, and no knee progressed beyond Stage-III hemophilic arthropathy. Only one patient in our series had a recurrent spontaneous hemarthrosis of the synovectomized knee, although two others had traumatic bleeding episodes. The complications included three immediate postoperative hemarthrosis requiring surgical evacuation, isoimmune hemolytic anemia in one patient, patellofemoral adhesions in two knees, and a total fibrous ankylosis that required a knee arthrodesis in one patient. It was concluded from our study that chronic recurrent hemarthrosis and the pain associated with persistent synovitis in the hemophilic knee can be effectively eliminated for as many as twelve years after open synovectomy, although usually with significant loss of motion of the knee. This procedure also appeared to slow the progression of arthropathy, and no patient had been considered for a total knee replacement at the time of writing.

Acute psoas abscess in a newborn infant.

A 1-month-old neonate was seen for an acute toxic illness, suggestive of septicemia. No obvious focus of infection was present. During attempted femoral venipuncture, purulent material, thought to originate from the right hip joint, was encountered. Because of this aspirate, as well as suggestive local signs, septic arthritis of the right hip was diagnosed. Arthrotomy failed to confirm the diagnosis, and on further surgical exploration a purulent psoas abscess was discovered. The patient made an uneventful recovery, and at follow-up 48 months later was asymptomatic with a normal clinical examination. This case illustrates the difficulty of differentiating acute psoas abscess from septic arthritis of the hip in the neonate.

Hypotensive anesthesia and autotransfusion in spinal surgery.

Sixty-eight (68) spinal operations performed under normotensive anesthesia were compared with 77 procedures performed under controlled hypotensive anesthesia. Procedures reviewed included Harrington instrumentation and fusion, dorsal arch resection, laminectomies and other spinal fusions. Intraoperative and postoperative blood loss and blood replacement were found to be reduced by approximately 50% in the group undergoing controlled hypotensive anesthesia for each procedure reviewed. This reduction in blood loss was achieved with only a moderate reduction in blood pressure (20 mm Hg systolic). Reduction in systolic blood pressure of greater than 20 mm was not associated with greater reduction in blood loss. Deliberate hypotension was coupled with hemodilution, lowering the hematocrit to 28% to 30% in order to increase cardiac output, increase tissue perfusion and decrease venous stasis. Autotransfusion has further reduced the need for homologous transfusion such that the combined techniques of hypotension and autotransfusion can eliminate the need for homologous blood transfusion in all but the most unusual cases.

Miami TLSO in the management of scoliosis: preliminary results in 100 cases.

A custom fabricated polypropylene thoraco-lumbo-sacral orthosis (TLSO) for the treatment of scoliotic curves with an apical vertebrae of T7 or below is described, and the results in 100 patients treated over a 5 year period are reported. The average follow-up for all cases was 13 months, the longest being 59 months. Average initial correction in brace for thoracic curves was 36%, for thoraco-lumbar curves 56%, and for lumbar curves 63%. Double major curves averaged 38% initial correction for the upper curves and 37% for the lower curves. Twenty cases had completed brace treatment with an average follow-up of 8 months out of brace. Of the 30 curves in the 20 patients, 11 were improved more than 5 degrees, 19 remained unchanged (+5 degrees), and none had progressed more than 5 degrees. Twenty-three percent of the patients required a second orthosis and complications occurred in only two patients. The primary advantages of this TLSO include improved cosmesis, minimal discomfort, excellent provision for heat exchange, minimal confinement of the thoracic cage, and maximum retention of spinal mobility.

Synovectomy or total replacement of the knee in hemophilia.

Eighteen major operations on the knee joint were performed in sixteen patients with hemophilia, eight operations being synovectomy and ten being total knee replacement. Synovectomy was performed for recurrent bleeding associated with synovitis. The average age at operation for patients who underwent synovectomy was 16.4 years, and the average follow-up was thirty-one months. No patient had a recurrent hemorrhage following synovectomy. The patients who had total knee arthroplasty for disabling pain had an average age at surgery of 35.7 years and an average follow-up of twenty-three months. The pain was markedly reduced in all eight patients and all achieved full unprotected weight-bearing. Loss of some motion was observed in twelve patients, but the functional gain outweighed the loss of knee mobility. Seven major complications occurred in the sixteen patients, but none of them affected the outcome.

Functional fracture-bracing of long-bone fractures of the lower extremity in children.

Fifty-six tibial fractures in fifty-five children, sixteen years old or younger, and seventeen femoral fractures in seventeen children in the same age group, seven of them with associated tibial fractures, were treated by fracture-bracing. The tibial fractures healed in an average of 13.2 weeks with no complications that could be attributed to failure of the method. The femoral fractures healed in an average of seventeen weeks. There was an angular femoral deformity of more than 5 degrees in seven of seventeen patients, all but one in fractures of the middle third of the femoral shaft. Of nine distal fractures, only one had angulation of more than 5 degrees. Therefore, the method should be restricted to fractures in the distal third of the femoral shaft. Fracture-bracing gave more freedom to the child and was eminently satisfactory to the parents.