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This report presents a retrospective analysis of the authors' experience with occipitocervical fusions in children and adolescents during the last 2 decades. A description of an operative technique devised by the senior author (JEH), and a comparison of the results using this and other methods of fusion are given. Twenty-three patients underwent occipitocervical fusion. Fifteen of the patients were operated on using the authors' technique. To achieve stable fixation of the distal cervical vertebra a threaded Kirschner wire was passed transversely through the spinous process; occipital fixation was achieved by the traditional method of wiring corticocancellous bone graft to the skull through burr holes. The occipital wires then were wrapped around the Kirschner wire and the graft was cradled in the resulting nest. Halo immobilization was used in 10 patients for an average of 12.5 weeks (range, 6-24 weeks). Twenty-two patients achieved successful fusion at an average followup of 5.8 years (range, 1-14.33 years). Several complications, including transient quadriplegia in one patient, pseudarthrosis in two (one of which persists), hardware fixation failure in one, unintended distal extension of the fusion, pneumonia, wound infection, halo pin infection, skin breakdown under the halo vest, hydrocephalus, cerebrospinal fluid leak, and traumatic fusion fracture were encountered. Results using the technique described herein are comparable with or better than the results reported in the previous literature, and the results of the patients in this series in whom the technique was not used.

The operative treatment of congenital scoliosis secondary to hemivertebra may involve in situ spinal epiphysiodesis, in situ fusion, or hemivertebra excision. The technique described in this paper, simultaneous anterior and posterior resection of the hemivertebra and correction of deformity with posterior instrumentation, has evolved from many different surgical methods used by the senior author in the past. This series of 11 patients describes the resection technique, degree of deformity correction, and complications encountered with this approach to a very difficult clinical problem. The preoperative mean age of the patients at the time of surgery was 18 months (range, 1 month-30 months), and preoperative curves averaged 47 degrees (range, 30 degrees-80 degrees). Immediate postoperative curves averaged 13 degrees (range, 1 degree-40 degrees), and at a mean of 28 months followup the curves averaged 14 degrees (range, 1 degree-47 degrees). One patient experienced transient left leg weakness. There were no long term neurologic injuries and no other surgical complications.

The strong association between congenital heart disease and spinal deformity is well established, but data on the risks and outcome of spinal fusion surgery in patients with congenital heart disease are scarce. The purpose of this study was to identify predictors of perioperative risk and outcome in a large series of children and adolescents with congenital heart disease who underwent spinal fusion for scoliosis or kyphosis. In the authors' retrospective analysis of 74 consecutive patients with congenital heart disease undergoing spinal fusion, there were two deaths (2.7%) and 18 significant complications (24.3%) in the perioperative period. Preoperative cyanosis (arterial oxygen saturation < 90% at rest) with uncorrected or incompletely corrected congenital heart disease was associated with both deaths. Complications occurred in nine of 18 (50%) patients with cyanosis and in 11 of 56 (20%) patients without cyanosis. As judged by multivariate analysis the best predictors of perioperative outcome were the overall physical status of the patient as represented by the American Society of Anesthesiologists' preoperative score and a higher rate of intraoperative blood loss. Seventeen of 43 patients (40%) with an American Society of Anesthesiologists score of 3 or higher experienced complications including two perioperative deaths. Successful spinal fusion and correction were achieved in 97% of patients. Children and adolescents with congenital heart disease can undergo elective spinal fusion with risks that relate to overall cardiac status. Careful assessment of preoperative status by pediatric cardiologists and cardiac anesthesiologists familiar with surgical treatment of patients with congenital heart disease will assist the orthopaedic surgeon in providing the most realistic estimate of risk.

Between 1986 and 1995 10 patients who were 9 to 18 years of age underwent posterior spinal fusion and instrumentation to the pelvis for correction of spinal deformity using the modified sacral bar technique at the authors' institution. Etiologies of the spinal deformity included congenital scoliosis, cerebral palsy, myelomeningocele, neurofibromatosis, and postlaminectomy kyphosis. Indications for pelvic instrumentation were progressive scoliosis of the lower lumbar spine, pelvic obliquity greater than 15 degrees, and dysraphic posterior elements. Five of the patients had prior spinal surgery. Five patients had a prior or a planned pelvic osteotomy. Nine of the patients achieved lumbosacral fusion without an additional procedure. Major complications included loss of pelvic fixation in two patients, and a dural leak and a wound infection in another patient with myelomeningocele. Mean scoliotic curve correction was from 71.9 degrees to 34.5 degrees at final followup. Lumbar lordosis essentially was unchanged. Pelvic obliquity was corrected from a mean of 20.5 degrees preoperatively to a mean of 7.6 degrees at final followup. The modified sacral bar technique was selected for fusion to the sacrum because of planned or prior pelvic osteotomies, prior posterior spinal fusion and instrumentation, sacral dysraphism, or local anatomic anomalies. The modified sacral bar technique proved to be an effective technique in these patients.

Acetabular redirection surgery is the mainstay of treatment for the symptomatic, dysplastic hip. The authors' experience with the Salter innominate osteotomy, Wagner spherical acetabular osteotomy and the modified Bernese periacetabular osteotomy shows that major acetabular redirection surgery can reliably improve the structure of the dysplastic hip and delay or prevent secondary osteoarthrosis. The limited correction achieved by the Salter innominate osteotomy suggests this procedure generally should be reserved for younger patients with mild dysplasia. The modified Bernese periacetabular osteotomy is the authors' current preferred method of treating acetabular dysplasia, even in the presence of mild to moderate secondary osteoarthrosis.

This is a retrospective review of 12 patients treated for severe postlaminectomy and postirradiation kyphosis by one surgeon from 1977 to 1994. The average age of the patients was 15 years with a range from 2 to 35 years. The duration of followup ranged from 24 months to 156 months with an average of 65 months. All patients had undergone multilevel laminectomies or irradiation of the thoracic or lumbar spine for an intraspinal lesion or trauma. The average preoperative kyphosis was 84 degrees and this was reduced to an average of 39 degrees after surgery. There were no pseudarthroses and there was an average loss of correction of 5 degrees. There were no complaints of back pain. Moderately severe but flexible kyphoses were treated in three patients by posterior instrumentation and spinal fusion. The other nine patients had combined anterior release or decompression and fusion combined with posterior instrumentation and spinal fusion. Bracing failed to halt the progressive kyphosis in those patients for whom it had been attempted. The only major complications in this series were two wound infections in patients previously treated with irradiation.

Ten patients with Scheuermann's kyphosis were surgically treated with posterior spine fusion and Harrington heavy compression-rod instrumentation. This procedure relieved pain and deformity in all ten patients. The average follow-up period was 26.6 months. The average curve before surgery was 71.4 degrees and at follow-up examination was 39.3 degrees. The postoperative correction of kyphosis averaged 32 degrees (45%), with an average loss of correction of 7.8 degrees. Posterior fusion with Harrington heavy compression-rod instrumentation may prove to be the procedure of choice in Scheuermann's kyphosis that is severe but flexible on hyperextension with a curve greater than 65 degrees.

A case of an organic foreign body consisting of wood in bone is presented along with diagnosis and treatment. The unusual delay in noting the nature and extent of the injury was due to the radiolucence of the object and its lodging within the epiphyseal cartilage.

Acute cholecystitis following the surgical treatment of spinal deformities in the adult is reported in three cases. Although acute cholecystitis is not a rare postoperative complication, it is relatively unknown to orthopedic surgeons and has been seldom reported in the orthopedic literature. A review of the literature dealing with the pathogenesis and clinical manifestations reveals that postoperative cholecystitis is a life-endangering complication which should be promptly recognized. The occurrence of upper quadrant abdominal pain, accompanied by fever, tachycardia and signs of peritoneal irritation after any major orthopedic procedure, should alert the surgeon to the possibility of postoperative cholecystitis. Considering the high incidence of gangrene and perforation of the gallbladder, cholecystectomy is the treatment of choice.

In a study of the results of each therapeutic act in the treatment program of displaced supracondylar fractures of the humerus, 108 consecutive children were analyzed. An initial attempt at closed reduction was noted in 101 cases, with the attempt successful in 61. Of these elbows, 19 were flexed at least 120 degrees following reduction, with all 19 maintaining reduction. Twenty-two of the remaining reduced fractures were splinted in less than 120 degrees of flexion; 19 lost reduction. Traction alone, via olecranon pin or skin, was unsuccessful in achieving reduction and unreliable in maintaining reduction once achieved. Crossed Kirschner wires, placed percutaneously or under direct visualization, were uniformly successful in maintaining reduction. From these data an algorithm has been constructed to facilitate objective decision-making in the treatment of this challenging fracture.

Chondrosarcoma is rare in children. Only 12 patients with a diagnosis of chondrosarcoma were treated at Children's Hospital Medical Center in Boston during the period from 1957 to 1980. Pediatric chondrosarcoma has a relatively rapid onset, manifested by pain, a palpable mass and neurological symptoms with the lesion localized in the spinal column. The pelvis was the most frequent location. Ten patients had primary and two patients had secondary chondrosarcoma. Of the latter two, one developed chondrosarcoma in a preexisting osteochondroma and the other had irradiation for neuroblastoma. The poorest outcomes were in patients who had involvement of the pelvic girdle and spinal column. Grade 2 and 3 lesions had the worst prognoses with metastases occurring within 12 months. Eight patients died at the time of study, and the longest survival time was 80 months. If surgically feasible, the treatment is radical excision. Radiation therapy and chemotherapy should be reserved for recurrences or distant metastasis.

In 26 knees treated by semitendinosus tenodesis, there was no recurrence of dislocation, but fair and poor results totaled 38% due to persistent pain because of chondromalacia of the patella. Poor results are also more common in the patients with generalized ligamentous laxity. Postoperative complications in wound healing suggest that the medial parapatellar skin incision is less than adequate. Semitendinosus tenodesis with or without modifications is a useful procedure to prevent recurrent dislocations and subluxation during the growth period.

Seventy-three patients with complex spinal deformities undergoing combined staged anterior and posterior fusion were analyzed. The indications for the combined approach were (1) severe kyphosis with or without neural compromise; (2) major thoracolumbar or lumbar curves with trunk imbalance or marked pelvic obliquity; (3) severe congenital scoliotic curves associated with hemivertebrae or anterior unsegmented bars; (4) absent posterior elements, e.g., myelodysplasia, post laminectomy; and (5) failed anterior fusion. In 35 patients with kyphosis, the deformity was reduced on the average from 78 degrees to 48 degrees. In 20 patients with marked trunk decompensation and/or pelvic obliquity due to a major thoracolumbar or lumbar curve, the scoliotic deformity was reduced from an average 85 degrees to 33 degrees. In 18 scoliotic patients with marked vertebral body deformation (hemivertebrae, anterior bars, lateral subluxation), the scoliotic curves were reduced from an average 60 degrees to 46 degrees. Postoperative morbidity was not significantly increased because of the combined procedure. The overall complication rate was high (32/73 patients). In view of this high rate of postoperative morbidity, the combined approach should not be undertaken by the occasional spinal surgeon. In selected far advanced or complex spinal deformities, combined anterior and posterior fusion may be indicated to attain optimal correction of the deformity as well as a solid pain-free fusion.

Tardy ulnar nerve palsy in the child is an infrequent occurrence. In 5 cases all occurring after injury about the elbow, the lesion involved not only lateral but also medial structures. The latency period from elbow injury to palsy was not always long and ranged from 2 months to 29 months. Possibly because of the age of the patients and short duration of the palsy, anterior transposition promoted prompt remission of symptoms and signs.

Kyphosis in myelomeningocele is a progressive condition, which can lead to severe deterioration of function and skin ulceration over the apex of the kyphus. Since bracing is impractical, surgical correction and stabilization is the recommended method of management. Three different techniques are in current use. An anterior procedure using a plate and u-bolt shackles, an anterior approach using a bone strut, and a posterior approach excising a wedge, and the spinal cord if it is functionless. We recommend the wedge excision combined with posterior Harrington compression instrumentation and spinal fusion extending well above and below the resection. Regardless of the approach used, it is the long spinal fusion both anterior and posterior, which will maintain correction.

Although several theories have been advanced about etiology of idiopathic scoliosis, the pathogenesis still remains unknown. One study detected a decrease in the glycosaminoglycan content of the nucleus pulposus in idiopathic scoliosis, and it was theorized that this represented increased degradation. The present study was designed to investigate degradative enzyme activity in scoliotic intervertebral disks. Twenty-three disks from 5 patients with idiopathic scoliosis and 18 disks from 3 patients with scoliosis resulting from myelomeningocele were obtained at surgery (Dwyer procedure). Five disks were obtained during 2 postmortem examinations. Analyses of hydroxyproline, hexosamine and acid phosphatase were performed separately on the annulus and nucleus of each disk. Hexosamine was decreased in idiopathic scoliotic nuclei versus controls (p less than 0.001) by approximately 25%. Hydroxyproline was proportionately increased (p less than 0.05). Similar changes of a greater magnitude were seen when comparing myelomeningoceles to controls. In both types of scoliosis, acid phosphatase was elevated in nuclear and annular tissue. Acid phosphatase activity and hexosamine varied inversely in the nucleus. Finding similar biochemical patterns in idiopathic and neurovascular scoliosis raises the possibility that these changes may be secondary.

Hip instability occurs in meningomyelocele patients with lumbar level paralysis because of muscle imbalance. Transferring the hip adductor origins to the ischium can be used as the primary procedure to restore muscle balance and prevent hip instability in myelodysplasia patients if performed by the age of one year. Twelve lumbar meningomyelocele patients underwent bilateral adductor transfers. Secondary procedures, such as iliopsoas release or transfer or varus derotation osteotomy, were done in 14 hips. Ten hips needed no further surgery. Twenty of 24 hips were clinically and roentgenographically stable and showed roentgenographic evidence of improving hip development. Instability was associated with scoliosis, congenital dislocation, and age greater than one year at the time of the transfer.

A brace for the non-operative treatment of scoliosis constructed without a metal superstructure is preferred by teenage patients. Preliminary results show that a 50-60% correction can be achieved as measured on standing X-rays in the brace. Three quarters of these patients have no skin problems associated with brace wearing. In several years when these patients have reached skeletal maturity and have spent 1 year out of their braces, it will be possible to determine whether the short term results are comparable to the standard set by the Milwaukee Brace.