Finding patients after 40 years: a very long term follow-up study of the Colonna arthroplasty.

Between 1952 and 1965, surgeons at the Los Angeles Shriners Hospital managed 23 hips with the Colonna two-stage capsular arthroplasty, a procedure originally described in 1936 with very stringent indications for the treatment of childhood hip dysplasia. By using chart review, credit traces, telephone listings software, and the Internet, we found 17 (90%) of 19 patients known to be alive 40 years after surgery. Only four of 16 patients questioned have not undergone total hip arthroplasty, and these patients were no better candidates for the Colonna arthroplasty than were the 12 patients who have required hip-replacement surgery. We do not support revival of this now obscure procedure. However, we do attest that the average clinical investigator currently has access to tools that allow reliable location of patients for very long term follow-up. This technology will improve the accuracy and statistical power of outcomes research.

Comparison of crossed pins and external fixation for correction of angular deformities about the knee in children.

External fixation was compared to crossed Steinman pins and plaster for fixation after osteotomy about the knee in children. A group of 26 patients treated by external fixation was compared to a control group of 26 patients fixed with crossed Steinman pins and casting. The groups were matched for age, height, and weight. Overall there was a 100% union rate. Preoperative deformity and postoperative correction were similar in the two groups. The time to union was significantly longer, and there were significantly more complications in the external fixator group. There were 16 complications (62%) in the external fixator group and five (19%) in the control group. Complications included pin tract infections, peroneal nerve palsy, and delayed union. External fixation provides certain advantages for fixation after osteotomies about the knee in children but is associated with a variety of complications.

Spinal fusion in Duchenne muscular dystrophy.

Sixty-eight patients from a clinical population of 183 patients with Duchenne muscular dystrophy underwent posterior spinal fusion with instrumentation for progressive spinal deformity. Pulmonary complications were the most common postoperative problem, occurring in 17 per cent of the patients. A 35 per cent normal forced vital capacity was a reliable indicator of pulmonary complication risk. The patients with surgically stabilized spines were more comfortable in the later years of life and easier to care for, but deteriorating pulmonary function was not affected by the spinal fusion. The average age at death for the 29 boys who underwent spinal fusion was 18.3 years, which was similar to that of the 58 boys with scoliosis. Factors that improved the patients' quality of life included segmental instrumentation, fusion from T2 to the pelvis, correcting or balancing scoliosis, creating normal sagittal plane alignment and correcting pelvic obliquity.

Current concepts in the management of pediatric hip disease.

A wide variety of disorders affects the pediatric hip. The most common of these are developmental dysplasia of the hip, Legg-Calvé-Perthes disease, and slipped capital femoral epiphysis. Magnetic resonance imaging and ultrasound improve the imaging of these diseases, but the ultimate impact of this technology on treatment is unknown. Complications of treatment for these and other pediatric hip diseases can be devastating; so much recent research concentrates on the etiology, prevention, and effects of these complications. Finally, these diseases occur in skeletally immature individuals, and long-term follow-up is essential for accurate evaluation of results.

Leg lengthening: the historical perspective.

An overview of lengthening is presented from the scarlet cloth through skeletal traction, screw distraction, and patient mobility. Unquestionably, significant advances have been made in the technology and techniques of lengthening legs, but more are yet to be made.

Unit rod segmental spinal instrumentation in the management of patients with progressive neuromuscular spinal deformity.

Thirty-four nonambulatory patients with progressive neuromuscular spinal deformity were surgically managed using a 1/4" U-shaped double rod construct with segmental instrumentation from T2 to the pelvis accompanied by posterior spinal fusion. Diagnoses included 17 patients with cerebral palsy, six with spinal bifida, and 11 with other diseases (spinal muscular atrophy, Friedreich's ataxia, polyneuropathy, nemaline myopathy, and polio). Twenty-three patients had single uncompensated thoracolumbar curves, and 11 had a double curve pattern. The mean preoperative major curve was 66 degrees (range, 22-132 degrees), the secondary curve 58 degrees (range, 23-84 degrees). No postoperative spinal support was used. Mean curve correction was 36 degrees or 54.6%. There were four major complications, including two implant failures requiring revision and two patients sustaining excessive intraoperative blood loss necessitating completion of the procedure in a second stage. There were two neurologic complications including one case of postoperative seizures and an L4 monoradicular neuropathy in a spina bifida patient. Four patients had temporary postoperative ileus, one gastroesophageal reflex, and four had urinary tract infections. There were no significant postoperative pulmonary complications. Excluding the patients with rod failure, mean loss of correction at mean follow-up of 21.3 months was 6.5%. The stability and curve correction obtained using this system supports its continued use in patients with progressive neuromuscular scoliosis.

Leg lengthening. A review of 30 years.

Leg lengthening has been a procedure of last resort because of its high complication rate and significant morbidity with a relatively long period of disability during the process even when no complications occur. The new techniques of lengthening hold promise that orthopedists will be able to achieve more length with fewer complications. It is interesting to note, however, that, while it is the technology of these techniques that has stimulated the greatest enthusiasm, it is the biologic principles that are likely to offer the greatest ultimate benefit. The modern era of leg lengthening has therefore brought two things: new technical versatility to correct complex and coexisting deformities and new concepts of the biology of lengthening that are not device specific and can be applied with most lengthening devices.

Rotational osteotomy for proximal femoral focal deficiency.

Thirteen patients who had a proximal femoral focal deficiency and were treated with a rotational osteotomy of the tibia (Van Nes procedure) were evaluated at an average of five years after operation. Five patients needed a repeat osteotomy of the tibia: four because the limb had spontaneously derotated toward the original position and one because the limb had had insufficient rotation at the time of operation. One patient had a disarticulation at the ankle after the first stage of a planned two-stage procedure because the mother was not happy with the child's appearance. In ten limbs, the distal femoral growth plate and epiphysis were removed and in two, the femoral epiphysis and growth plate and the tibial growth plate were removed so that the joint of the prosthetic knee would be positioned at the proper height at the completion of the child's growth. Neither growth plate was removed from one limb, the shorter one in the child who had bilateral involvement. A ten-point grading scale based on use and fit of the prosthesis, gait, range of motion of the ankle, use of external support, and final height of the ankle compared with that of the contralateral knee was used to evaluate the result, which was excellent in six patients, good in four, fair in one, and poor in one. One patient, who had a disarticulation at the ankle, was excluded from the final evaluation. Rotational osteotomy provided good function and acceptable cosmetic appearance in the patients who had unilateral involvement.

Progression of scoliosis in Duchenne muscular dystrophy.

We reviewed the clinical charts and spinal radiographs of fifty-one boys who had Duchenne muscular dystrophy, had not had surgical treatment of the spine, and had been followed until death. All had scoliosis. None of the following variables was useful in predicting which curves would become severe: age when the patient initially walked, age when he ceased walking, age at onset of spinal collapse, surgical release of the iliotibial bands, or age at the time of death. Radiographs were made within eighteen months before death for thirty-three patients; in thirty-one of them, the final curve exceeded 40 degrees and in seventeen, 90 degrees. For the remaining eighteen patients, final radiographs were made more than eighteen months before death; at that time, eight of them already had a curve of more than 90 degrees. Although there was a relationship between extension of the lumbar spine and severity of scoliosis at the time of final follow-up, early maintenance of the lumbar spine in extension rarely prevented the development of a severe curve. For most of the patients who had a severe curve, sitting was difficult and was accompanied by breakdown of the skin and pain. When a patient's curve exceeded 35 degrees, the vital capacity usually was less than 40 per cent of the predicted normal value. Therefore, when walking becomes impossible for boys who have Duchenne muscular dystrophy, routine spinal arthrodesis should be considered.

Assessment and prediction in leg-length discrepancy.

Successful treatment of patients with leg-length discrepancy requires rigorous assessment of the patient, usually over a period of time. This assessment involves not only the lengths of the legs, but all the factors that contribute to the asymmetry because they are all important in the selection of a treatment goal. Good results can be obtained with any of the three methods of prediction. Selection of a particular method must be based on convenience, accuracy, and user familiarity.

Pulmonary function and scoliosis in Duchenne dystrophy.

Pulmonary function data were evaluated in 68 Duchenne muscular dystrophy patients to determine the rate of decline of the percentage of normal forced vital capacity (FVC). The percentage of normal FVC declined most rapidly during the adolescent growth spurt, which demonstrated a need for an accurate and reliable means for determining height in these patients. The age at 35% of normal FVC was 14.9 +/- 3.6 years (2 SD), and survival for the 28 patients who died was 3.2 (range 0.2-5.7) years. Pulmonary function tests were performed 10-74 months after spinal stabilization on 21 Duchenne dystrophy patients and compared with 46 nonfused scoliotic Duchenne patients. No difference was found in the rate of deterioration of the percentage of normal FVC.

Leg length discrepancy.

The proper management of LLD requires careful clinical and radiologic assessment, and repeated analysis of past growth in order to predict future growth. Treatment decisions must be re-evaluated constantly in the light of new leg length data and evolving surgical technique. Surgical treatment can be especially gratifying when anatomic, cosmetic, and functional symmetry is restored and a lifetime of shoe lifts, braces, or prostheses is avoided.

Leg-length discrepancy.

Leg-length discrepancy is a condition associated with several factors that can affect growth rate, length itself, or both. Treatment decisions depend on an accurate prediction of the discrepancy at maturity, which in turn depends on vigorous assessment of the growth pattern exhibited in the past. This article reviews all of these factors.

Primary osteomyelitis caused by coagulase-negative staphylococci.

Coagulase-negative staphylococci (CONS) are occasionally cultured from foci of osteomyelitis in otherwise healthy individuals and are usually regarded as contaminants. The present report describes two children with subacute osteomyelitis of the distal tibia in which pure cultures of CONS were obtained from bone. In one patient, the infection was multifocal, and CONS were isolated from two anatomical sites at two different times. In the other patient, the infection was unifocal, and CONS were cultured from two separate specimens obtained from the same site. In both patients, the symptoms progressed until appropriate antibiotic treatment was initiated. CONS isolated from cultures of bone should not automatically be disregarded. Appropriate antibiotic therapy may result in clinical resolution.

Subluxation of the knee as a complication of femoral lengthening by the Wagner technique.

Twenty-one patients with leg-length inequality underwent femoral lengthening using the Wagner technique. When reviewed, seven were found to have varying degrees of posterior subluxation of the knee. Critical assessment demonstrated that each of these was associated with a hypoplastic femur. It is postulated that posterior displacement of the tibia on the femur occurred as a result of the distal femoral and intraarticular bony deficiencies.