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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.

Injection-induced injury during childhood is common. The usual clinical manifestations include (1) foot drop, (2) equinovarus, (3) buttock abscess, (4) gluteal fibrosis, and (5) quadriceps fibrosis. Injection injury is more likely in newborns and small babies where the skin and nerves are in closer proximity to each other than in older children. Many of the intramuscular injections given annually in developing countries are unnecessary yet are administered due to patient or family demand and caregiver overprescription. There is a prevalent belief in traditional settings that painful injections are more powerful and effective, even when adequate and recommended oral treatments are readily available. In many African languages, the words for “fever” and “malaria” are the same, and all fevers are treated as if they were malarial.

Although the incidence of poliomyelitis has been markedly decreased, it is still present and may never be eradicated in spite of vaccinations. In fact, the incidence of polio-like diseases has increased. Hip contractures following acute poliomyelitis are extremely common and treatment is simple. Paralysis of the gluteal muscles results in an unattractive gait pattern that is energy demanding. Treatment is often unsatisfactory. Fortunately, hip dislocation in poliomyelitis is very uncommon and not usually painful. It is, however, extraordinarily difficult to manage when it does occur. The literature concerning treatment options for hip problems in poliomyelitis is scant and outdated.

Purpose To date, polio has not been eradicated and there appears to be a resurgence of the disease. Hence, there is a need to revive decision-making skills to treat the effects of polio. Methods Here, we outline the aspects of treatment of paralysis following polio based on the literature and personal experience of the authors. The surgical treatment of the lower and upper extremities and the spine have been reviewed. The scope of bracing of the lower limb has been defined. Results The effects of polio can be mitigated by judicious correction of deformities, restoration of muscle balance, stabilising unstable joints and compensating for limb length inequality. Conclusions As polio has not been eradicated and there is a risk of resurgence of the disease, paediatric orthopaedic surgeons need to be prepared to deal with fresh cases of polio. Revival of old techniques for managing the effects of paralysis following polio is needed.

Working with limited resources in unfamiliar and/or austere environments can be some of the most challenging but also most rewarding experiences in life. The operations performed in places where patients do not have ready access to quality care and needed expertise can be life changing for these individuals. The challenges often create the need for innovation, flexibility, and the use of extra precautions to avoid complications.

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.

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.

In the developed world paralytic poliomyelitis is almost extinct. This is clearly not the case elsewhere While immunization has markedly decreased the incidence it has no effect on those who already have had the disease. These children are now mostly adults. This has a number of important orthopedic implications: 1) Adults do not heal as readily; 2) Postoperative regimens need to be extended; 3) Postoperative rehabilitation facilities will be in more demand; 3) Adults will have a more difficult time accommodating alterations in the mechanics that follows some operations. Well-intended surgery may not have the results expected; 4) What will be the worldwide impact of “Post-Polio syndrome (new functional loss that may occur many decades after the disease first occurred in childhood). By some estimates 40% of polio victims will suffer from Post-Polio syndrome as they reach their 50s and 60s. The decisions in the surgical treatment of polio are more difficult than the procedures themselves. Hurried decisions are frequently bad—if in doubt, proceed cautiously and in stages.Poliomyelitis—Prioritize treatment goals—Adult consequences of polio.

Postinjection injuries are common in developing countries and need to be distinguished from polio. Surgery must be individualized with goals to maintain or improve function.

SUMMARY Because the cross-sectional shape of the long bones of patients with osteogenesis imperfecta is often elliptical, the use of preoperative radiographs to determine intramedullary rod diameter in these patients undergoing osteotomy may be misleading. To investigate this, the authors correlated the narrowest inner bone diameter (NID) on preoperative radiographs to the rod diameter (RD) on postoperative radiographs. The authors evaluated 79 bones in 27 patients undergoing primary osteotomy with intramedullary fixation. Only 5% of the bones had an equal NID and RD, with 81% of bones having a smaller RD than the measured NID. Although a positive correlation was found between RD and NID (correlation coefficient 0.76), measurement of the NID on preoperative radiographs did not provide a good prediction of the actual RD used in this series of children with osteogenesis imperfecta.

The surgical risk and complication rates for the elective excision of benign osteochondromas and associated surgical procedures is presented. Eighty patients had excision of 285 osteochondromas and underwent 22 other related surgical procedures. There were 10 complications in the group (12.5% per patient population); the most common were peroneal neurapraxias. Other complications included an arterial laceration, a compartment syndrome, and a fibula fracture. The surgical risk for the management of osteochondromas is low and is comparable to the risk of other related, elective procedures. However, osteochondromas should not be routinely excised unless proper indications exist for their removal.

The prevalence of tuberculosis15 in the United States has been rising since 1986, with morbidity increasing 14 per cent from 1985 through 1993. In 1986, the rate of tuberculosis in the United States was 9.3 new cases per 100,000 population. In 1991, the rate in New York State12,13 had risen to 17.3 per 100,000, and the rate in central Harlem was 169 per 100,000, which is similar to rates reported in the eastern and central regions of Africa7,12. Much of this increase has been in the rate of pulmonary tuberculosis, but it has been associated with a concomitant rise in the number of adults and children who have tubercular musculoskeletal involvement. In a prospective study of a cohort of intravenous drug abusers in New York City who tested positive with the tuberculin skin test, the risk of active tuberculosis was 14 per cent (seven of forty-nine patients) a year during a two-year follow-up interval76. It is becoming increasingly likely that an orthopaedic surgeon who works in a developed region of the world (especially in a big city) will encounter a patient who has tuberculosis, a disease with which the surgeon may have little experience or training13. Factors that have contributed to the increased rate of tuberculosis are the rise in the number of people who have suppression of the immune system, the development of drug-resistant strains of Mycobacterium, an aging population, and an increase in the number of health-care workers who are exposed to the disease. The human immunodeficiency virus remains the leading known risk factor for the reactivation of latent tuberculous infection65,68,79, and patients with this virus who are exposed to Mycobacterium tuberculosum are more likely to have progression to an …

Between June 1982 and April 1983, a procedure to coapt the extensor hallucis longus (EHL) to the tibialis anterior was performed in eight post-polio patients to correct drop foot and to enable the EHL to be a more efficient dorsiflexor of ankle. Although at early follow-up, every patient was able to actively dorsiflex the ankle against gravity, at final review, (mean follow-up 7.8 years), only two patients could still do so. Three patients developed a cock-up toe deformity or dorsiflexion deformity of great toe. We have attributed the poor final results to stretching of the coaptation. Use of splints or orthosis for a longer period postoperatively and a more carefully designed physical therapy may have yielded better results. Alternatively, if the EHL is anchored to navicular bone better results may be obtained.

We reviewed 13 pairs of conjoined twins treated at Children's Hospital of Philadelphia between 1957 and 1988. Orthopedic problems were related to the ischiopagus type. These included problems related to separation and to the correction of associated deformities. The technique for separation has evolved through improved preoperative imaging and with increased experience, resulting in preservation of a longer and more functional "shared leg." Better preservation of skin to cover both infants and enough of the "shared leg" to insure a functional knee has been possible with posterior iliac osteotomies to close the pelvic ring, as well as the use of tissue expanders.

Three methods of stabilizing the IP of the big toe were compared. In group A, 10 patients underwent tenodesis of the extensor hallucis longus to the extensor digitorum brevis tendon. All of them developed a toe-drop; two patients had significant symptoms that required IP fusion. In group B, 19 patients underwent IP fusion using smooth or threaded intramedullary Kirschner wire fixation. There were nine nonunions, three requiring refusion. In group C, 32 patients underwent IP fusion using intramedullary screw fixation. There was one nonunion with screw failure that required revision. Although none of our patients considered the toe-drop after extensor hallucis longus tenodesis cosmetically unacceptable, this may not be so in other cultures. All complications following IP fusion with screw fixation were technical and are avoidable. When stabilization of IP is required, we recommend fusion of IP with screw fixation.

A proximal tibial extension medial rotation osteotomy was performed on 17 tibias in postpoliomyelitis patients to correct knee flexion contractures simultaneously with the correction of lateral rotation deformity of the tibia through the same osteotomy. Gait improved in 10 patients. Five patients developed recurrence of knee flexion contractures; five more developed greater than 20 degrees genu recurvatum. One patient developed a common peroneal nerve palsy. Because of the high incidence of complications, we recommend that this procedure be abandoned.

Tendoachilles tenodesis to the fibula was performed in postpolio patients to improve their gait. The charts of 48 patients with 52 tenodeses were reviewed. The mean follow-up was 5.5 years. Gait improved in one-third. When the hindfoot was stabilized, gait improved in 40% of the patients, but when it was not stabilized, only 22% improved their gait. Excessive equinus developed in 18 patients, all of whom were less than age 12 years when operated. We conclude that it is reasonable to use this procedure to improve the gait of postpolio children with flail lower extremity, provided the hindfoot is stabilized.

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.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.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).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.Prospective study; Level 2 clinical evidence.

This investigation was undertaken to determine the value of a routine radiological consultation on all examinations taken during the course of evaluation and treatment of children with elective orthopedic problems. Shriners Hospital in Los Angeles treats children with chronic orthopedic problems. All radiographs are ordered by an orthopedic surgeon. Currently all plain examinations are also read and reported by a pediatric radiologist. The study was a retrospective chart review. Three hundred nineteen radiographic examinations (6.7% of the total performed in calendar year 1995) were reviewed. The orthopedic surgeons documented the results of their readings in 69% of the cases, while the radiology staff documented 92% of the studies. The data do not show evidence of significant misinterpretations in the readings by the orthopedic surgeons. Therefore routine radiological consultation for all examinations is unnecessary in that specific setting. If a policy change were instituted, it would represent a major saving in health-care costs.

The resistant clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Previous reviews have concluded that this method can provide satisfactory correction and outcome. This study presents a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, treated with Ilizarov external fixation and gradual distraction by 1 of 2 surgeons. Outcome measures were graded based on function and presence of residual deformity: (a) excellent (painless, plantigrade foot, with no functional limitations); (b) good (plantigrade foot in a patient able to ambulate long distances with mild pain; (c) fair (mild residual deformity, required bracing, and/or had some functional limitations but an active life); and (d) poor (significant residual deformity, pain, and activity limitations). Radiographic measures of the talocalcaneal and talo-first metatarsal angles were compared preoperatively and postoperatively. At an average follow-up of 6.64 years (range, 2.25-10.50 years), 9.5% (2) achieved an excellent result; 4.8% (1), good; 33.3% (7), fair; and 52.4% (11), poor. All 11 of the feet graded poor required revision surgery at an average of 5.63 years postoperatively (range, 2.67-10.2 years). Only the talo-first metatarsal angle displayed a clinically and statistically significant correction. We conclude that the Ilizarov method for treatment of resistant clubfoot deformities results in poor outcome associated with residual or recurrent deformity, often requiring revision surgery.

Randomized multicenter retrospective chart review of medical referral diagnoses and corresponding referral, patient, and physician demographic data.To examine the information content of medical referral diagnoses provided to outpatient physical therapists with respect to physician and patient characteristics.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.A team of blinded raters categorized the information content of referral diagnoses (n = 2183) using a classification system adapted from a previous study.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).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.

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.

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.

The association of an ovarian tumour with Ollier's disease or the Maffucci Syndrome is rare. We report what we believe to be the first patient with Ollier's disease associated with an ovarian tumour who later developed a secondary chondrosarcoma.

Retained hardware embedded deep in soft tissues or overgrown with bone poses a challenge to the surgeon assigned to its removal. A prototype of a hand-held electromagnetic metal detector-locater was used to localize retained hardware. Stainless-steel pins, screws, plates, and staples were located in 21 consecutive hardware removal procedures in 19 pediatric patients. Time to find the hardware, length of incision, blood loss, tissue maceration, and operative time were minimized. This preliminary study suggests that a metal locater may be a valuable tool when retained hardware is not palpable or readily apparent.

After severe poliomyelitis, which is still relatively common in some developing countries, lateral rotation deformity of the tibia may occur. We have reviewed 51 patients treated by O'Donoghue's rotation osteotomy of the tibia. An average lateral rotation deformity of 57 degrees was fully corrected in all the patients, and in 38 of them the graft obtained during the osteotomy was used for a simultaneous Grice-Green subtalar arthrodesis in one or both feet. All the osteotomies united in an average of 11 weeks, some with relatively minor and unintentional posterior angulation. There was no posterior angulation when the length of the step cut osteotomy was 4.5 cm or more. O'Donoghue's osteotomy is a simple and safe operation, being particularly advantageous if a Grice-Green procedure is also required.

A rare variant of congenital cutis laxa first described by Fittke is associated with congenital dislocation of the hips. A total of 18 cases have been reported, ten of which occurred in Saudis. Tre...

Pyle's disease is a rare skeletal dysplasia in which a defect in metaphyseal remodeling leads to grossly widened metaphyses of long bones. Genu valgum, one of the few clinical findings in this disease, may warrant surgical intervention. Postoperative healing is documented only in Pyle's original patient. A case is presented in which bilateral osteotomies were performed through the proximal tibia for progressive genu valgum. The osteotomies healed within 12 weeks when treatment was performed with standard techniques. This information will allow osteotomies to be performed with confidence.

Vincristine-high-dose methotrexate-citrovorum factor (VCR-MTX-CF) was administered preoperatively at weekly intervals to eight patients, four with primary tumors and four with pulmonary metastases. These patients had not received prior VCR-MTX-CF treatment. A similar treatment program was administered to five patients with pulmonary metastases who had received prior VCR-MTX-CF. Among the eight patients who had not received prior VCR-MTX-CF, complete responses were obtained in three with primary tumors (this was followed by surgical excision) and two with pulmonary metastases. Partial responses occurred in two additional patients. Partial responses were also obtained in two patients who had received VCR-MTX-CF. Chemotherapy and surgery in one patient with an extremity lesion resulted in preservation of the limb and useful function. The major toxicity was anorexia and weight loss. Other side effects included stomatitis, myelosuppression, hepatitis and transient renal impairment. The weekly program was highly effective when compared to responses obtained with the tri-weekly schedule utilized in previous studies.