Chadwick F. Smith

Both-bone midshaft forearm fractures in children.

Summary: To determine whether closed treatment of both-bone midshaft forearm fractures routinely results in acceptable clinical outcome for children <16 years of age, we retrospectively studied all such patients treated at our two hospitals between 1970 and 1982. All children <10 years of age at the time of fracture had excellent results. Of 14 patients between the ages of 10 and 16 years, closed treatment failed in nine. We conclude that the incidence of poor results from closed treatment of the fractures in children >10 years of age is seriously underestimated.

Supracondylar Humeral Osteotomy for Traumatic Childhood Cubitus Varus Deformity

Between 1958 and 1983, 45 corrective supracondylar osteotomies of the humerus were performed for post-traumatic cubitus varus deformity in 43 children. The average follow-up period was two and one-half years. Excellent or good results were obtained in 33 patients. Unsatisfactory results were seen in 12. The operation, though deceptively simple, had a significant complication rate (24%), including neuropraxia, sepsis, and cosmetically unacceptable scarring. After these problems were analyzed, the important points of technique that were noted were a comprehensive preoperative plan and a simple lateral closing wedge osteotomy, leaving the medial cortex intact and ignoring rotational deformity.

Infantile Blount disease: long-term follow-up of surgically treated patients at skeletal maturity.

Seventeen patients with infantile Blount disease who were treated by surgical correction and followed up to skeletal maturity were reviewed by clinical and radiographic examination. Patients with symptomatic knees or significant ligament instability or both underwent further evaluation by magnetic resonance imaging (MRI) or arthroscopy or both. Average age at time of initial surgery was 5.5 years and at final follow-up was 20.5 years. Average length of follow-up was 15 years. Recurrence of the deformity requiring repeated osteotomy occurred more frequently in children who underwent initial osteotomy at > 4 years of age or at Langenskiöld stage > or = III or both. Patients who underwent a single osteotomy for correction of their deformity had significantly decreased pain in the affected knee at maturity. All patients who were symptomatic or had significant knee instability or both had abnormal ligamentous, meniscal, or bony changes (or more than one of these) on MRI, which were confirmed by arthroscopy. Early surgical intervention during initial stages of the disease process will result in a decreased incidence of recurrence of deformity and decreased symptoms and knee pathology at skeletal maturity.

Supracondylar femoral extension osteotomies in the treatment of fixed flexion deformity of the knee.

Thirty-two supracondylar osteotomies of the femur were performed in 20 patients for the correction of fixed flexion deformity of the knee. The patients ranged in age from two to 36 years, with an average follow-up period of 4 1/2 years. Two-thirds of the patients had underlying paralytic disease, either meningomyelocele or polio. Generally, the procedure was employed only in recalcitrant cases in which other more conservative methods had failed. Femoral shortening was the key to success. Although there was a significant complication rate, including fractures, infection, and recurrence, there were no permanent neurologic sequelae or non-unions. All patients eventually obtained satisfactory correction and function. Despite the morbidity, supracondylar extension femoral osteotomy was an effective means of treatment when more conservative methods had failed or when the deformity was particularly severe.

The biological effects of carbon dioxide laser surgery on rabbit articular cartilage.

A pulsed carbon dioxide laser made predetermined superficial and deep (subchondral) lesions through arthrotomies on the femoral condyles of adult New Zealand rabbits. Twenty rabbits, including controls, were divided into acute, 1-, 3-, 6-, and 12-month sacrifice groups. Early sacrifice groups showed some fibrous ingrowth from the deep lesions, but not the superficial lesions, and this was not seen in the 6- or 12-month groups. Cells below and adjacent to the laser lesions appeared viable when compared with controls. In each group studied, no histologic evidence of healing or fibrous covering in the superficial or deep laser lesions was found. No adverse clinical effects (synovitis, infection) were found in the laser groups, and the laser permitted excellent depth control during vaporization. However, the authors caution against irradiating articular cartilage.

Congenital Vertical Talus

This series consisted of 15 congenital vertical tali in 12 patients, 11 of which were treated surgically and the remainder conservatively. Conservative treatment (casting alone) yielded poor results in three of four feet, while the results in the surgical group were four good, six fair, and one poor at an average follow-up of 8 years. The surgical procedures included a one-stage release with transfer of the anterior tibial tendon to support the neck of the talus. A Grice arthrodesis was performed either concurrently or within 2 to 4 years. The best results were obtained with early subtalar arthrodesis (Grice) and biplanar K wire fixation. Complications included skin sloughs, avascular necrosis of the talus, and pin tract drainage. Attempts to augment push-off power with tendon transfers were unrewarding.

Arthroscopic shoulder surgeyr with three different laser systems: An evaluation of laser applications☆

Twelve cadaveric shoulder arthroscopies were performed to evaluate the use of lasers as an adjunctive tool in arthroscopic shoulder surgery. The three most common lasers historically used in orthopedic surgery were examined: Holmium:YAG, Neodymium:YAG, and the CO2. The following parameters were evaluated for each laser system: (1) ease of use of the laser system and handpiece; (2) ability to excise and trim bursae, synovium, ligament, tendon, bone, and articular cartilage; and (3) ability to contract ligaments and capsule by heat transfer. None of these lasers efficiently cut bone, whereas all three systems readily debrided the soft tissues around the shoulder. The free-beam Ho:YAG and CO2 systems heat contracted soft tissues with more control than the contact Nd:YAG. The fiberoptic delivery system of the Neodymium:YAG and Holmium:YAG laser performed well in the saline arthroscopy, and the CO2 delivery system was cumbersome. Overall, the CO2 system removed tissue better than the others, but its difficult use favored the Holmium laser as the best overall current laser system for shoulder arthroscopy.

In vitro analysis of laser meniscectomy.

Partial meniscectomies were performed on 32 fresh human meniscal autopsy specimens. The following laser systems were tested: carbon dioxide (CO2), neodymium:yttrium aluminum garnet (Nd:YAG), potassium titanyl phosphate (KTP), holmium:YAG (Ho:YAG), and excimer. Meniscectomies with these lasers were compared with scalpel, mechanical, and electrocautery meniscectomies. Lasers were applied to specimens in and out of normal saline. Routine hematoxylin and eosin and sirius red sections were prepared for each specimen, and the depths of thermal changes were analyzed. Scanning electron microscopy was used to visualize the meniscectomy interface. Among these specimens, the scalpel and mechanical meniscectomies showed the least extension of cellular changes (range, 10-15 nm). The excimer laser caused the least tissue changes of the lasers tested. Tissue changes were less extensive with the pulsed CO2 laser than with the holmium:YAG, neodymium:YAG, and KTP lasers. Scanning electron microscopy showed that use of the scalpel meniscectomy resulted in the smoothest meniscectomy edge, followed by use of the excimer, CO2, holmium:YAG, neodymium:YAG, and KTP lasers. The most surface disruption occurred with electrocautery. Meniscectomies under saline required more energy and took longer in each case, with the holmium:YAG, neodymium:YAG, and CO2 laser cutting the best. Saline meniscectomies showed less thermal change. The CO2 and KTP lasers cut best in air.

Production of a Multisource, Real-Time, Interactive Lesson in Anatomy and Surgery: Corn Demonstration

During Internet2s 2002 Fall Member Meeting in Los Angeles, the California Orthopaedic Research Network (CORN) demonstrated a unique distributed learning environment that sought to enrich medical student understanding of hand anatomy and surgery. Live, streaming video of an orthopedic surgical procedure at UCLA Medical Center was combined with related stereoscopic “virtual hand” images from Stanford, to teach participants at a third location. Medical students, anatomists, and surgeons at these remote but connected sites valued the simultaneous real-time interactions among the different venues. A number of technical issues were resolved during this exercise. This article describes the process of arranging such a demonstration and summarizes the lessons learned from our experience so that this innovative pedagogical approach can be successfully adopted on a broader scale.

Light absorption characteristics of the human meniscus: applications for laser ablation

This study analyzes the light absorption characteristics of human meniscal tissue. Increased absorption at certain wavelengths of light allows increased energy transfer and the ability to cut or ablate that tissue.