Brian M. Haus

Immature animals have higher cellular density in the healing anterior cruciate ligament than adolescent or adult animals

There has been recent interest in the biologic stimulation of anterior cruciate ligament (ACL) healing. However, the effect of age on the ability of ligaments to heal has not yet been defined. In this study, we hypothesized that skeletal maturity would significantly affect the cellular and vascular repopulation rate of an ACL wound site. Skeletally Immature (open physes), Adolescent (closing physes), and Adult (closed physes) Yucatan minipigs underwent bilateral ACL transection and suture repair using a collagen‐platelet composite. The response to repair was evaluated histologically at 1, 2, and 4 weeks. All three groups of animals had completely populated the ACL wound site with fibroblasts at 1 week. The Immature animals had a higher cellular density in the wound site than the Adult animals at weeks 2 and 4. Cells in the Immature ligament wounds were larger and more ovoid than in the Adult wounds. There were no significant differences in the vascular density in the wound site. Animal age had a significant effect on the density of cells populating the ACL wound site. Whether this observed cellular difference has an effect on the later biomechanical function of the repaired ACL requires further study.

Intra-Articular Fractures of the Distal End of the Radius in Young Adults: Reexamined as Evidence-Based and Outcomes Medicine

The article “Intra-Articular Fractures of the Distal End of the Radius in Young Adults,” by Knirk and Jupiter, published in The Journal of Bone and Joint Surgery1 in 1986, in its day, was arguably one of the most important works on the management of intra-articular fractures of the distal end of the radius. Prior to the publication of that study, the critical factors that determined successful long-term management of intra-articular distal radial fractures in young patients had not been determined. The finding with the greatest impact on treatment algorithms was that accurate articular restoration was the most critical factor in preventing long-term arthritis in young patients with intra-articular distal radial fractures. However, twenty-three years of advancements in orthopaedic surgery and technology have exposed the methodological flaws of that study. The radiographic analysis incorrectly interpreted fracture lines, and the study failed to use intraobserver and interobserver validation in its analysis. The study also was conducted before the popularization of computerized tomography and wrist arthroscopy. Despite these shortcomings, an updated critical analysis reveals that its conclusions are still germane in todays treatment of distal radial fractures in young adults. The study by Knirk and Jupiter1 has been cited in 330 research and scholarly articles. Although it is sometimes inaccurately referenced2, it ranks among the most cited manuscripts in the orthopaedic surgery literature. Today, its conclusions not only direct the treatment of distal radial fractures but they also continue to generate hypotheses for outcome studies. Given the impact of the study on the standard of care and orthopaedic research, it is appropriate to critically review its methodology to determine whether the findings remain relevant today. Intra-articular fractures of the distal end of the radius in the young adult are a distinct group of fractures that can lead to accelerated …

Back pain in the pediatric and adolescent athlete.

Clinicians taking care of athletes are likely to see many young patients complaining of back pain. The young athlete places significant repetitive stresses across the growing thoracolumbar spine, which can cause acute and overuse injuries that are unique to this age and patient population. Fortunately, by using a careful and systematic approach, with a sport-specific history, careful physical exam, and proper imaging, most problems can be properly identified. Although it is important to always remember that rare and more serious problems such as a neoplasm or infection maybe a source of pain in the athletic patient, most problems are benign and can be treated conservatively. Accurate diagnosis and management of back pain not only can prevent long-term deformity and disability, but it can also allow young athletes to return to doing what they love to do most: play sports.

Case report: nonoperative treatment of an unstable Jefferson fracture using a cervical collar.

The treatment of unstable burst fractures of the atlas (Jefferson fractures) is controversial. Unstable Jefferson fractures have been managed successfully with either immobilization, typically halo traction or halo vest, or surgery. We report a patient with an unstable Jefferson fracture treated nonoperatively with a cervical collar, frequent clinical examinations, and flexion-extension radiographs. Twelve months after treatment, the patient achieved painless union of his fracture. The successful treatment confirms prior studies reporting unstable Jefferson fractures have been treated nonoperatively. The outcome challenges the clinical relevance of treatment algorithms that rely on the “rules of Spence” to guide treatment of unstable Jefferson fractures and illustrates instability may not necessarily be present in patients with considerable lateral mass widening. Additionally, it emphasizes a more reliable way of assessing C1–C2 stability in unstable Jefferson fractures is by measuring the presence and extent of anterior subluxation on lateral flexion and extension views.

Long-term follow-up of the surgical management of neuropathic arthropathy of the spine

BACKGROUND CONTEXT No studies have discussed the long-term surgical management and outcomes of Charcot arthropathy of the spine. This case series presents nine patients treated over 30 years. The study hypothesis was that surgery would reduce instability, pain, recurrence, and the need for revision surgery in the long-term, given previous study findings of successful fusion of Charcot spine in the short-term. PURPOSE To evaluate the long-term outcomes of surgery for Charcot spine. STUDY DESIGN/SETTING Retrospective case series. Cases took place at Stanford University Medical Center and Santa Clara Valley Medical Center. METHODS All patients had either complete paraplegia or dense paraparesis with both major motor and sensory deficits. Seven patients developed Charcot spine after spinal instrumentation for trauma, one after scoliosis repair for meningomyelocele, and one after spinal instrumentation for neuromuscular scoliosis caused by birth injury resulting in C6-C7 quadraplegia. Average time between initial instrumentation and development of Charcot spine was 7.6 years. Two patients underwent posterior fusion alone, six had anterior-posterior fusion, and one was managed with thoracolumbar orthosis. RESULTS Average follow-up was 14.3 years. Revisions were necessary in 75% (6 of 8) of patients for complications including nonunion, new Charcot joints, recurrent hardware failure, and osteomyelitis. Achieving fusion often required multiple operations, and there were no deaths or neurologic complications. CONCLUSIONS Long-term follow-up showed a high rate of revision surgery. Solid fusions often resulted in late breakdown or new junctional Charcot arthropathies. Patients initially fused to the lumbar spine instead of the sacrum or pelvis had a higher rate of developing another Charcot joint. Fusion was often difficult with persistent nonunions and functional deficits because of decreased mobility. We recommend that Charcot spine well tolerated without skin, seating problems, or dysreflexia should be cautiously observed with conservative management. For surgical care, we recommend three-column stabilization with either combined anterior-posterior or all posterior approaches with anterior support to obtain and secure greater long-term stability.

Effect of anterior cruciate healing on the uninjured ligament insertion site

The effect of anterior cruciate healing on the uninjured ligament insertion site after enhanced suture repair with collagen‐platelet composites (CPC) has not yet been defined. In this study, we hypothesized that fibroblasts and osteoclasts would participate in generating histologic changes in insertion site morphology after transection and bioenhanced repair of the ACL, and that these changes would be age‐dependent. Skeletally immature, adolescent, and adult Yucatan mini‐pigs underwent ACL transection and bioenhanced suture repair. The histologic response to repair of the insertion site was evaluated at 1, 2, 4, and 15 weeks. In young and adolescent animals treated with bioenhanced suture repair with CPC, changes in the insertion site included: (1) fibroblastic proliferation with loss and return of collagen alignment in the fibrous zone; (2) osteoclastic resorption within fibrocartilage zones at 2–4 weeks; and (3) partial reappearance of fibrocartilage zones at 15 weeks. In adult animals; however, degenerative changes were noted by 15 weeks: (1) loss of parallel arrangement of collagen fibers in the fibrous zone; and (2) increasing disorganization and loss of columnation of chondrocytes in the fibrocartilage zone. These results suggest that fibroblasts and osteoclasts mediate histologic changes at the insertion site during bioenhanced suture repair of the ACL which may prevent insertion site degeneration, and that the magnitude of these changes may be a function of skeletal maturity.

Treatment of Snapping Scapula Syndrome in Children and Adolescents.

Purpose: The purpose of this study was to review 2 separate cohorts of young patients treated for snapping scapula: those treated surgically and those managed nonoperatively. Methods: A retrospective IRB-approved review was conducted on 18 pediatric aged patients (19 shoulders): 12 patients (average age 13.3) were treated nonoperatively, 6 patients (average age 15.4) (7 shoulders) were treated operatively. Demographic and clinical data were collected from medical records and 2 questionnaires for level of activity, return to sport, subjective satisfaction from treatment, and preoperative/postoperative levels of pain. The American Shoulder and Elbow Society (ASES) score was measured for both groups. Results: Mean follow-up for nonoperative patients was 43.7 months (range, 20 to 116 mo). Pretreatment subjective pain levels were 5.2 (scale 1 to 10), posttreatment were 1.5. There was a 75% return to play rate, and an overall 75% satisfaction rate. Posttreatment ASES scores were 90.0. Mean follow-up for surgical patients was 129.5 months (range, 68 to 177 mo). Pretreatment subjective pain level was 8.6, posttreatment was 0.75. There was an 83% return to play rate, and an overall 100% satisfaction rate. There were no complications. Posttreatment ASES scores were 92.6. Conclusions: Outcomes for nonoperative treatment of snapping scapula are good for young patients. Surgical management of snapping scapula is a safe and viable treatment option for patients who fail nonoperative treatment. Level of Evidence: Level IV.

Anterior centre-edge angle on sagittal CT: a comparison of normal hips to dysplastic hips

Purpose: The anterior centre-edge angle (ACEA) describes anterior acetabular coverage on false profile radiographs. Variability associated with pelvic tilt, radiographic projection, and identifying the true anterior edge, causes discrepancies in measuring an accurate ACEA. Computed tomography (CT) has the potential of improving the accuracy of ACEA. However, because the ACEA on sagittal CT has been shown to not be equivalent to ACEA on false profile radiographs, the normal range of ACEA on CT currently remains unknown and cannot reliably be used to determine over/under coverage. We therefore asked: what is the normal variation of ACEA corrected for pelvic tilt on sagittal CT and how does this compare to dysplastic hips? Material and Methods: A retrospective review was conducted on patients 10–35 who underwent CT for non-orthopedic related issues and patients with known hip dysplasia. The ACEA was measured on a sagittal slice corresponding to the centre of the femoral head on the axial slice and adjusted for pelvic tilt. A statistical comparison was then performed. Results: A total of 320 normal patients and 22 patients with hip dysplasia were reviewed. The mean ACEA for all ages was 50° ± 8°, (range: 23–81º), with a larger mean ACEA for males (51°) than females (49°). The ACEA mean for dysplastic hips was 30° ± 11° with a statistically significant difference in mean from the normal hip group (p < 0.0001). Conclusion: The ACEA can be reliably measured on sagittal CT and significantly differs from dysplastic hips. ACEA measurements above 66° or below 34° may represent anterior over and under coverage.

Spondylolisthesis: Intra-rater and Inter-rater Reliabilities of Radiographic Sagittal Spinopelvic Parameters Using Standard Picture Archiving and Communication System Measurement Tools

STUDY DESIGN Reliability analysis. OBJECTIVE To determine the intra-rater and inter-rater reliability of common sagittal spinopelvic measurements from Digital Imaging and Communications in Medicine images on a commercial Picture Archiving and Communication system for patients with developmental spondylolisthesis. SUMMARY OF BACKGROUND DATA Computer-aided analysis of digital radiographs has been used in research protocols to define anatomic and positional characteristics of developmental spondylolisthesis. Previous studies have shown poor reliability and weak correlations of manual measurements used in clinical practice with research measurements, which limit the clinical value of prior research. METHODS Five raters of varying experience measured lateral spinopelvic images of 30 patients with developmental spondylolisthesis. Measurements were repeated after 1 week. Intra-rater and inter-rater reliabilities for each measurement were determined. Measurements were compared with those obtained from a computer-based image enhancement research system. Continuous variables were assessed by analysis of variance, whereas kappa statistics were determined for categorical variables. RESULTS Excellent intraclass correlations (ICC)s were obtained for all radiographic measurements based on linear values (slip ratio and C7 balance) as well as pelvic tilt angle. Angular measurements had good to excellent ICC but were weaker when the sacral plate was involved. There was poor agreement with classification of sacral doming. Some measurements had reduced reliability in the images with evidence of doming. CONCLUSIONS Excellent ICCs were found with measurements of from Digital Imaging and Communications in Medicine images using commercial Picture Archiving and Communication System tools. Sacral doming affected the reliability. A radiographic classification of spondylolisthesis will be most reliable when based on slip ratio, C7 balance, and pelvic tilt.

Distal soft tissue procedure for the correction of mild and moderate hallux valgus deformities

The DuVries modification of the McBride distal soft tissue procedure is one of more than 100 techniques described for the correction of the adult hallux valgus deformity. This simple procedure is indicated in the setting of an incongruent metatarsophalangeal joint with a mild and, in some cases, even a moderate hallux valgus deformity. In this article, we present a reliable and reproducible method of performing the modified McBride distal soft tissue procedure. Furthermore, we describe important technical steps that enhance the corrective power and may thereby extend the indications of this procedure.