Search

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.

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., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

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.

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.

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.

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.

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.

Pyle's disease is 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.

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.

This study was undertaken to assess the inter- and intraobserver variability associated with the assessment of acetabular index. Five readers (three senior orthopaedic residents and two pediatric orthopaedic attendings) read each of 24 films on three separate occasions (360 total readings). An independent observer who was blinded to the results of the study assessed whether the radiographs would result in a reproducible acetabular index. Variability was increased for the radiographs that were deemed poorly reproducible by the independent observer. Interobserver variability exceeded intraobserver variability. Variability was comparable for senior orthopaedic residents and attending pediatric orthopaedic surgeons. Even in the group with the least variability (intraobserver variability for reproducible radiographs), the 95% tolerance interval was 8.35 degrees. The results of this study cast doubt on the reliability of the acetabular index based on a single reading.

Severe knee flexion contractures in patients with arthrogryposis multiplex congenita were treated by distal femoral extension osteotomy. Thirty-two operations were followed for an average of 32 months. Contractures were corrected from 49 degrees to 6 degrees. During follow-up there was a loss of correction of 22 degrees at a rate of 0.9 degrees/ month. The angle of the distal femoral physis and the shaft of the femur was 2 degrees of flexion preoperatively, and postoperatively it measured 43 degrees of extension and at late follow-up it measured 19 degrees. Remodeling occurred at a rate of 1.0 degrees/month, which correlated with recurrence. All patients increased their ambulatory ability at least one level. There was one wound infection. Distal femoral extension osteotomy is effective and safe for the correction of knee flexion contracture. Recurrence occurs in all growing children.

Between 1979 and 1989, 105 supracondylar extension osteotomies of the femur were performed to correct knee flexion contractures. Disturbed by serious neurovascular complications, we reviewed our experience. Besides other complications, nine patients developed serious neurovascular complications; seven had permanent residua. There was no correlation between neurovascular complications and degree of preoperative contracture, patients' ages, or scarring from previous operation. We conclude that this osteotomy, although it appears to be technically simple, is potentially dangerous. We propose that the osteotomy be internally fixed and that the knee be flexed to relax the posterior neurovascular structures.

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.

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.

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.

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.

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.

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.

Resections for high-grade musculoskeletal sarcomas are feasible. For osteosarcomas, they appear to be safe if performed properly. For other sarcomas, there are insufficient data. A major issue is whether such procedures are worthwhile. For lesions of the upper extremity, resections are clearly advantageous over amputations. For lesions in the lower extremities proximal to the knee joint, resection is usually preferable, while those below the knee joint are best amputated. Lesions involving the knee are the most challenging problems.

Three cases are reported in which the split-heel technique was successfully used in the management of calcaneal osteomyelitis in children. Antibiotic therapy and debridement when necessary through medial or lateral incisions will usually eradicate the infection. Gaenslen's technique is recommended for refractory cases or patients with a draining sinus centrally located on the plantar aspect of the heel. An excellent functional result can be obtained. In general, excision of the calcaneus for chronic osteomyelitis in children is not necessary.

Osteonecrosis occurred in nine of thirty-six children following renal transplantation. The distal femoral condyle was the most common location but the femoral head was the most symptomatic and required total hip replacement in three of five patients. Total steroid dosage did not correlate with the development of osteonecrosis. There were no cases of osteonecrosis in patients under the skeletal age of ten years or in patients who did not have rejection reactions. In three children non-progressive focal lesions developed, similar to those of osteochondritis dissecans.

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.