Management of Terminal Osseous Overgrowth of the Humerus With Simple Resection and Osteocartilaginous Grafts.

BACKGROUND: Osseous overgrowth is a common complication in children after humeral transcortical amputation. Capping tibial overgrowth with the proximal fibula has been shown to be the most effective treatment. However, best treatment practices are not clear for the humerus. We compared patients treated surgically for humeral osseous overgrowth with simple resection or autologous osteocartilaginous graft to determine if this treatment were as effective in the humerus as it has been in the tibia. METHODS: A retrospective review of humeral amputees from 1987 to 2011 at a pediatric hospital was performed. Patients with 2 years follow-up who underwent surgical treatment for established humeral overgrowth were included. Patients initially managed with simple resection were compared with those managed with autologous osteocartilaginous grafts. Descriptive statistics were calculated for demographic and outcome variables. T tests and χ tests were used to compare differences between groups. RESULTS: Eighteen humeri in 16 patients met inclusion criteria. Mean age at surgery was 8.3 (2.6 to 13.6) years and mean follow-up was 6.3 (1.5 to 10.4) years. Thirteen humeri underwent simple resection, with recurrent overgrowth in 9, and revision surgery in 8 at a mean 2.6 years. Five humeri were primarily managed with autologous osteocartilaginous grafts. Two developed non-overgrowth-related complications at 1 and 42 months. Including revision procedures after simple resection, 10 humeri were managed with autologous osteocartilaginous grafts. Thirty percent (3/10) required revision surgery; however, there were no cases of recurrent overgrowth. χ comparison showed lower rates of complications (P=0.004) and reoperation (P=0.012) with capping as compared with simple resection. CONCLUSIONS: Autologous osteocartilaginous capping of the humerus has a significantly lower rate of complications and reoperation compared with simple resection. However, the capping procedure has the potential for other complications related to difficulty with graft fixation. Surgeons should be aware that the outcomes are not as consistent as when the technique is applied to osseous overgrowth of the tibia and anticipate the possibilities of hardware prominence and difficulty with fixation. LEVEL OF EVIDENCE: Level 3-therapeutic-retrospective comparative.

Osteocartilaginous transfer of the proximal part of the fibula for osseous overgrowth in children with congenital or acquired tibial amputation: surgical technique and results.

BACKGROUND: Osseous overgrowth is a common problem in children after tibial transcortical amputation. We present the results of forty-seven children (fifty tibiae) treated for tibial osseous overgrowth with an autologous osteocartilaginous cap from the proximal part of the ipsilateral fibula. METHODS: We reviewed the records of all patients who underwent amputation at a single pediatric hospital from 1990 to 2011. All patients who had been followed for a minimum of two years after undergoing osteocartilaginous capping with the proximal part of the ipsilateral fibula to treat established tibial overgrowth were included. Patients with acquired and congenital amputations were compared. RESULTS: Fifty tibiae in forty-seven patients met our inclusion criteria. There were thirty-one acquired and nineteen congenital amputations. The mean age at surgery was 7.6 years (range, 2.1 to 15.6 years), and the mean duration of follow-up was 7.2 years (range, 2.2 to 15.4 years). Five tibiae (10%) in four patients had recurrence of the overgrowth at a mean of 5.4 years (range, 2.8 to 7.6 years) after the osteocartilaginous transfer. There was no significant difference in the results between children with an acquired amputation and those with a congenital amputation. CONCLUSIONS: At a mean of 7.2 years after autologous osteocartilaginous capping with the proximal part of the fibula, 90% of the limbs had not had recurrent overgrowth. This is a safe and effective treatment of long-bone overgrowth following either congenital or acquired amputation in children.

The consequences for children of explosive remnants of war: Land mines, unexploded ordnance, improvised explosive devices, and cluster bombs.

Land mines are particularly a problem for children. The deaths and loss of body parts have been publicized, but the secondary effects - the loss or maiming of parents, the loss of physical and social space the loss of access to education, and the loss of cultivatable land with the resultant malnutrition and sickness, are less frequently considered. "Explosive Remnants of War" (ERW) is becoming the generic term to refer to land mines, unexploded ordnance, improvised explosive devices and cluster bombs. The United Nations estimates that there are currently as many as 100 million unexploded landmines with an equal number stockpiled around the world waiting to be planted. Mines are designed to be difficult to locate and their clearance is costly. Children in at least 80 countries are at risk due to ERW. The type of mine, the proximity of the child to the explosion, and location of the mine in relation to the child's body are the important determinants of the nature and severity of the injury. Children are especially susceptible to picking up explosive remnants thinking they are toys. The result is commonly loss of the hands, facial injuries, blindness and deafness. Rehabilitation for these children is extremely difficult due to remoteness and the limited resources available.

Diagnostic modalities for the evaluation of pediatric back pain: a prospective study.

UNLABELLED: The commonly taught premise that pediatric back pain frequently has an underlying diagnosis has been recently challenged. Previous studies have suggested that up to 84% of children with low back pain have associated serious diagnoses. Children with back pain, therefore, have frequently undergone exhaustive diagnostic testing. There have been few prospective studies, however, about the diagnosis rate and appropriate diagnostic methods for back pain in children. This study prospectively examines the rate of diagnosis for pediatric back pain and the value of various diagnostic studies for this problem. METHODS: All patients presenting to our institution with a chief complaint of back pain were evaluated for the study. Inclusion criteria consisted of age younger than 18 years, no previous back surgery, no previous diagnosis given, and duration of pain longer than 3 months. Seventy-three patients were enrolled in the study, and an algorithm was created for diagnostic evaluation. The algorithm incorporated commonly used diagnostic techniques including radiographs, magnetic resonance imaging, computed tomography, bone scan, and laboratory studies. The end point was considered to be either (1) a definitive diagnosis or (2) no diagnosis and no symptomatic or clinical changes during a 2-year period. RESULTS: Fifty-seven patients (78.1%) ended with no diagnosis. Of the remaining 16, 9 were diagnosed with spondylolysis with or without spondylolisthesis. Three other patients had abnormal laboratory values but no definitive diagnosis. Other diagnoses included Scheuermann disease (n = 2), osteoid osteoma (n = 1), and a herniated disk (n = 1). CONCLUSIONS: This investigation is the largest prospective study of diagnostic modalities in pediatric back pain to date. Contrary to most of the previously published data, most of our patients ended the study with no definitive diagnosis. In addition, the most of the diagnoses were made at initial physical examination or via initial plain radiographs. No diagnoses were missed using our algorithm. These results suggest that pediatric back pain frequently does not carry a definitive diagnosis and that exhaustive diagnostic protocols may not be necessary for this problem. LEVEL OF EVIDENCE: Prospective study; Level 2 clinical evidence.

The lengthening of short upper extremity amputation stumps.

BACKGROUND: Short upper extremity amputation stumps are difficult to fit with an appropriate-level prosthesis. Fitting at a more proximal level generally results in decreased function. Options in the past have included stump and prosthetic modification, both of which provide limited improvement in function. Anecdotal reports of lengthening short amputation stumps have been published. This article reviews our experience with lengthening short upper extremity amputation stumps in children. METHODS: All patients who underwent an upper extremity stump lengthening at Shriners Hospital Los Angeles with at least 1-year follow-up were included. Charts and radiographs were retrospectively reviewed and prosthetic use preoperatively and postoperatively, complications, and additional procedures were documented. Stump length was measured on radiographs as the length between the proximal flexion crease and the tip of the bone. RESULTS: Eleven patients with 14 amputation stumps underwent lengthening. Mean stump length increase was 264% (4 cm). Nine patients desired prosthetic fitting; all except 1 were able to be fit with an appropriate-level prosthesis. Two of the 9 patients reported only using the prosthesis on rare occasions. The 2 remaining patients underwent lengthening to improve function but did not desire a prosthesis preoperatively. CONCLUSIONS: Lengthening is a viable but controversial option for very short upper extremity amputation stumps and may result in better function and/or more appropriate prosthetic fitting. Complications and additional procedures are common. Soft tissue coverage seems to be the main limiting factor to lengthening.

Current status and correlates of physicians' referral diagnoses for physical therapy.

STUDY DESIGN: Randomized multicenter retrospective chart review of medical referral diagnoses and corresponding referral, patient, and physician demographic data. OBJECTIVE: To examine the information content of medical referral diagnoses provided to outpatient physical therapists with respect to physician and patient characteristics. BACKGROUND: Previous studies indicate that physicians commonly provide nonspecific referral diagnoses to physical therapists. The effects of patient and physician characteristics on information contained in referral diagnoses are not well elucidated. METHODS AND MEASURES: A team of blinded raters categorized the information content of referral diagnoses (n = 2183) using a classification system adapted from a previous study. RESULTS: One third (32%) of analyzed diagnoses were anatomically oriented and reported specific pathology. These specific diagnoses were provided significantly more commonly by specialist physicians (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.7-4.2; P < .001), male physicians (OR, 2.2; 95% CI, 1.6-3.1; P < .001), both early- and late-career physicians (P < .001), and for male patients (OR, 1.3; 95% CI, 1.1-1.6; P < .05). CONCLUSION: Nonspecific referral diagnoses are frequently provided to physical therapists by physicians. The practice of evidence-based physical therapy seems challenged by the high rate of nonspecific referral diagnoses. Physical therapists may also have the responsibility to conduct differential diagnosis of pathology more commonly than formally recognized by many state practice acts and third-party payers.

Outcomes of lengthening short lower-extremity amputation stumps with planar fixators.

Patients with short lower-extremity amputation stumps exhibit poor prosthetic fit and inefficient gait. Often they are fit at the next-higher prosthetic level, increasing energy consumption. This study aimed to characterize the risk/benefit ratio of stump lengthening with planar external fixators. All patients lengthened for functionally short amputation stumps were reviewed. Outcome measures included changes in prosthetic use, soft tissue problems, qualitative gait analysis, and surgical complications. Patients averaged 15.1 years of age at surgery, with 4.1 years of follow-up. The average lengthening index was 9.2 mm/mo. Femoral lengthenings obtained more length (8.7 vs. 6.9 cm). After treatment, prosthetic skin-related complications decreased and qualitative gait parameters improved. Most (85%) wore a standard prosthesis for their amputation level after surgery, whereas none could before. There were 1.4 complications per patient, all successfully surgically treated. Lengthening is time-consuming and associated with frequent complications but results in improved gait and energy consumption.

Autogenous tibial strut grafts used in anterior spinal fusion for severe kyphosis and kyphoscoliosis.

STUDY DESIGN: A retrospective review was performed. OBJECTIVE: To evaluate the results of autogenous tibial strut grafts for anterior fusions in children with severe kyphosis and kyphoscoliosis regarding maintenance of correction, clinical outcome, graft fractures, and donor-site morbidity. SUMMARY AND BACKGROUND DATA: Anterior strut grafts harvested from the iliac crest, rib, and fibula often are used to treat severe kyphosis and kyphoscoliosis. Several studies in the literature have observed graft failures, loss of correction, or donor-site morbidity when these grafts have been used. Autogenous tibial strut grafts provide some theoretical advantages with minimal donor-site morbidity. METHODS: This review included 15 patients with severe kyphosis/kyphoscoliosis who underwent anterior spinal fusion with autogenous tibial strut grafts. Among these patients, 13 underwent staged or simultaneous posterior fusions, and 4 underwent cord decompression for myelopathy. An average of seven levels (range, 3-13) were fused anteriorly. Preoperative, postoperative, and latest follow-up radiographs were evaluated for graft incorporation, fracture, hardware failure, and spinal alignment. Patients were examined at the latest follow-up visit, and charts were reviewed to assess neurologic status, back pain, alignment, complications, and donor-site problems. RESULTS: All the patients were available for clinical examination. The mean follow-up period was 3.9 years (range, 2-8 years). The mean kyphosis measured 89 degrees before surgery, 62 degrees after surgery, and 66 degrees at the most recent follow-up assessment. In patients with kyphoscoliosis, the mean coronal curve measured 64 degrees before surgery, 42 degrees after surgery, and 46 degrees at the latest follow-up assessment. Apparent fusion was observed in all cases with no graft fractures. One patient reported mild donor-site discomfort. CONCLUSIONS: Autogenous tibial strut grafts provide physical advantages over commonly used iliac crest, rib, and fibula grafts. The tibia provides dense cortical bone with ample length and mechanical strength, although the actual strength of each strut was not measured directly. In this study, adequate correction was maintained throughout an average follow-up period of 3.9 years, and solid fusion was obtained in all cases. The results indicate that this technique offers a reliable means of providing anterior support in the management of severe kyphosis with virtually no donor-site morbidity. Although the number of patients in this review was limited, the authors believe that anterior autogenous tibial struts are an excellent alternative for the treatment of severe kyphosis and kyphoscoliosis.