Alan L. Breed

Subacute hematogenous osteomyelitis in children: a retrospective study.

We studied 55 consecutive children with hematogenous osteomyelitis and found that 18 (33%) had a subacute course marked by mild pain, few systemic or laboratory signs, and little functional impairment. Radiographic findings frequently suggested a tumor (50%), and the correct diagnosis was delayed an average of 3 months. We therefore suggest a radiographic classification that will help provide more accurate diagnosis of this disorder.

Relationship of spine deformity and pelvic obliquity on sitting pressure distributions and decubitus ulceration.

Summary: The distribution of pressure points in 16 patients with paraplegia, nine with ulcers, and six who were ulcer free were compared with the distribution in 15 normal individuals using an instrument capable of simultaneously measuring multiple pressure points under the buttocks and thighs. The nine patients with ischial and sacral decubiti showed redistribution of their sitting pressures posteriorly, asymmetrical loading of the ischiae. and higher than normal pressures under the sacrococcy, geum. These abnormal pressures were associated with unbalanced scoliosis, pelvic obliquity, and the loss of( physiological lordosis following a spinal fusion. We defined four criteria of risk for decubitus ulceration

Interspinous process segmental spinal instrumentation.

A method for interspinous segmental spinal instrumentation (ISSI) is described and the laboratory testing and early clinical results are reported. The method utilizes a button-wire implant that is passed through the thickest and strongest part of the base of the spinous process. Tension tests show the stress-relieving qualities of the implant improve pullout strength 47% over simple wire fixation of the spinous process. Tests on the scoliosis simulator show that the interspinous instrumented spine resists high compressive loads to failure, comparing favorably with other systems tested. Early clinical experience with the implant for a wide variety of uses has been encouraging. The authors use ISSI as their procedure of choice in idiopathic and congenital scoliosis.

Hamstring tenotomies in cerebral palsy: long-term retrospective analysis.

Summary: One hundred seventeen cerebral palsy patients were followed for a mean of 3.4 years after undergoing hamstring tenotomy by proximal semimembranosus release in conjunction with distal semitendinosus and biceps femoris release. Range of motion was significantly improved 1 year after the operation and remained so for 4 years. Thirty percent of nonambulatory patients improved at least one level in activity, some at up to 12 years of age. Minor recurvatum was observed at 1 year but became nearly nonexistent after 3–5 years.

Chronologic outcome of surgical tendoachilles lengthening and natural history of gastroc-soleus contracture in cerebral palsy. A two-part study.

Medical records of 59 patients with cerebral palsy were reviewed retrospectively to evaluate results of tendoachilles lengthening. Surgical lengthening resulted in highly significant (p < 0.0001) initial average gains in dorsiflexion compared with baseline. These average improvements maintained their statistical significance for seven years postoperatively. The arc of motion was not significantly different postoperatively. The initial ambulatory level was improved in 55% of the patients and maintained in the remainder. However, 14 ankles (11.9%) in eight patients (13.6%) required repeat tendoachilles lengthening during the study period, primarily after gastrocnemius procedures. Calcaneus deformity occurred in 1.7% of the surgically treated ankles. To evaluate the potential for spontaneous improvement over time in fixed equinus deformity, the records of a group of 68 additional cerebral palsy patients were reviewed. Patients treated nonoperatively despite two examinations that demonstrated fixed lack of dorsiflexion, while not representing a true control group, showed no spontaneous improvement in equinus deformity through seven years postoperatively.

Congenital dislocation of the peroneal tendons in the calcaneovalgus foot

Congenital dislocation of the peroneal tendons is a rare and infrequently reported deformity of the foot in the neonate. Four cases of this deformity associated with a congenital calcaneovalgus deformity of the foot have been treated and followed to the resolution of both of the deformities. The calcaneovalgus foot proved more resistant to correction and required more prolonged and aggressive treatment than was usual when it was found as an isolated deformity. All four patients demonstrated other stigmata of intra-uterine malposition and oligohydramnios or both. Our anatomical studies suggested that the superior peroneal retinacular ligament was the critical stabilising structure for the peroneal tendons. A concept of the pathogenesis of this deformity is discussed and a proven regimen for its treatment presented.

Observer variability in the radiographic measurement and classification of metatarsus adductus.

The classification system of Berg was evaluated using four observers and the radiographs of 42 feet from patients with metatarsus adductus. Interobserver disagreement in diagnosis was 36%. Intraobserver inconsistency averaged 26%. The error range for the lateral and anteroposterior talocalcaneal angle measurement was 13.6 and 15.1 degrees intraobserver and 19.8 and 25.2 degrees interobserver, respectively. There was no correlation between classification and the length of time required for cast correction. The irregularity of hindfoot ossification centers makes measurements inconsistent and seriously reduces the usefulness of classification based on such measurements.

Partial wound closure after surgical correction of equinovarus foot deformity.

Full correction of severe equinovarus foot deformities is frequently lost at the end of surgical release when the surgeon closes the skin incision. We retrospectively review 31 feet in 22 patients whose medial skin incisions were left open (typically 10 mm) to heal by secondary intention. The criterion to leave a wound open was if primary closure with the foot in full correction might compromise circulation to the skin or if closing the incision would require loss of corrected position. One or two cast changes were performed under outpatient anesthesia at 7- to 14-day intervals for wound care. All wounds except one were healed by week 6 at time of outpatient clinic cast removal. The appearance of the incisions is similar to feet in which primary closure is possible. One foot required split-thickness skin grafting at 3 weeks postoperatively to achieve wound coverage. There were no infections. We conclude that primary skin closure is not essential after surgical correction of equinovarus foot deformity, and that correction need not be compromised to approximate skin.

The midlumbar myelomeningocele hip: mechanism of dislocation and treatment

We define the “bowstring” force of the iliopsoas, the force applied to the femoral head as the tendon angles across the hip joint, which we believe is an important cause of dislocation of the hip in patients with a midlumbar myelomeningocele. An operative procedure consisting of iliopsoas recession and suture of its tendon to the anterolateral hip joint capsule has been developed and used in 10 dislocated and 9 subluxated hips. The procedure was performed on patients with an average age of 6.6 months; the average follow-up was 45 months. Arthrography demonstrated the subluxation pattern of Leveuf in 17 hips. Surgical observations included: (a) flattening of the femoral head beneath the iliopsoas, (b) “bowstringing” of the iliopsoas across the hip joint, (c) posterolateral displacement of the femoral head with hip extension, (d) apparent increase in leg length after release of the iliopsoas, and (e) decrease of hip flexion contracture after iliopsoas release. Following iliopsoas recession alone, 11 hips were stable; 7 had subluxation; 1 was dislocatable. Secondary varus derotation osteotomy for valgus and anteversion was performed on five hips with subluxation; each was stable at review. A combined varus derotation osteotomy and Chiari osteotomy was performed on the one dislocatable hip that remained dislocatable. Therefore, at review 16 of 19 hips were stable, two have subluxation, and one was dislocatable. Early surgical treatment to prevent secondary adaptive changes in the hip is recommended. Additional surgery to correct retained valgus and anteversion is frequently necessary to achieve stability.

Compression-distraction instrumentation of unstable thoracolumbar fractures : anatomic results obtained with each type of injury and method of instrumentation

The quality of the reductions achieved in a consecutive series of 55 patients with unstable thoracolumbar fractures were correlated with 1) the method of instrumentation, 2) the type and level of injury, 3) the effects of laminectomy and end-plate fractures, and 4) the length of time from injury to surgery. It was found that many of these variables were associated with significant differences (<0.05) in the percent correction achieved in anterior compression, angle of deformity, and sagittal plane translation. Specifically: 1) compression combined with distraction produced the best overall anatomic results, but bilateral compression and bilateral distraction were most effective for reducing flexion-distraction and flexion-axial compression (burst) fractures, respectively; 2) two or more level laminectomies adversely affected reductions; end-plate fractures did not; 3) the best reductions were obtained in flexion-distraction injuries; and 4) the poorest reductions occurred in flexionaxial compression injuries, lumbar fractures, and fractures operated on 6 weeks or more after injury.