Charles T. Price

Malunited forearm fractures in children

From 1971 to 1986, 80 skeletally immature patients with severe diaphyseal both-bone forearm fractures were treated at Orlando Regional Medical Center. Green-stick, Monteggia, and Galeazzi fractures were excluded. Seventy-nine fractures were managed by closed means. When anatomic reduction could not be obtained, the best position was accepted. There were 47 patients with malunions of whom 39 returned for follow-up evaluation >2 years after injury. They form the basis of this study. There were no delayed unions or nonunions in the entire group. Average follow-up in the group reported was 5 years 9 months (range 2 years to 13 years 10 months). All patients were satisfied with their functional and cosmetic results regardless of age, angulation, complete displacement, or loss of radial bow at time of union. Only nine patients had loss of motion. By our criteria, 36 patients (92%) had good or excellent results, with 32 excellent and four good results. Three patients (8%) had fair results, and there were no poor results. Age at time of injury did not correlate with recovery of motion. Distal fractures were found to have a better prognosis than proximal fractures. Based on the results of this study, closed reduction is the treatment of choice for skeletally immature patients with diaphyseal fractures of the radius and ulna.

Comparison of Bone Grafts for Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Study Design. A retrospective comparison of three different types of bone grafts for posterior spinal fusion in adolescent idiopathic scoliosis. Objective. To determine the efficacy of bone marrow and demineralized bone matrix as a bone graft substitute for spinal fusion. Summary of Background Data. Several reports have documented a high morbidity associated with harvesting autologous iliac crest bone graft (ICBG) for spinal fusion. Composite bone graft consisting of demineralized bone matrix and aspirated bone marrow may reduce the morbidity and still retain the osteoinductive properties of iliac crest autograft. Methods. Three different bone grafting techniques were used by a single surgeon in 88 consecutive patients who had posterior spinal fusion for adolescent idiopathic scoliosis. Segmental instrumentation with dual-rod fixation was used in all cases. Selection of type of graft was determined historically by the time when the operations were performed. Autologous ICBG was used in Group A, freeze-dried corticocancellous allograft in Group B, and composite graft of autologous bone marrow and demineralized bone matrix in Group C. Seventy-seven patients were reviewed, with a minimum of 2 years’ follow-up (mean, 3 years 7 months; range, 2 years–9 years 5 months). Radiographs were assessed for pseudarthrosis and loss of correction of 10° or more. Loss of 10° of correction has been previously identified as an indicator of potential pseudarthrosis or fusion instability. Both of these criteria were used to compare success of fusion. Results. Failure caused by pseudarthroses was seen in two patients (2.6%), one in Group A and one in Group B. Eleven patients lost greater than 10° of correction, but only one demonstrated pseudarthroses. The 13 patients with pseudarthroses or loss of correction constitute the failure group for purposes of graft assessment. The failure rate was 12.5% in Group A (ICBG), 28% in Group B (freeze-dried corticocancellous allograft), and 11.1% in Group C (composite graft of autologous bone marrow and demineralized bone matrix). Eliminating patients with crankshaft phenomenon did not substantially change the results. There was no morbidity associated with bone marrow aspiration. Conclusions. Fusion rates were comparable for GroupA (ICBG) and Group C (composite graft of autologous bone marrow and demineralized bone matrix). The composite graft is our preferred graft for fusions in adolescent idiopathic scoliosis.

Nighttime bracing for adolescent idiopathic scoliosis with the Charleston Bending Brace: long-term follow-up.

We report long-term experience with the Charleston Bending Brace for treatment of adolescent idiopathic scoliosis. This brace holds the patient in maximal side-bending correction and is worn at nighttime only. Patients included in this prospective multicenter study met all of the following criteria: skeletal immaturity (Risser 0, 1, or 2), curvature >25 degrees before bracing, no prior treatment, and >1-year follow-up since completion of bracing (skeletal maturity or progression to surgery). All curves were monitored and reported. There were 149 structural curves in 98 patients. Sixty-five (66%) patients showed improvement or <5 degrees change in curvature. Seventeen (17%) patients progressed to the point of requiring surgery for their scoliosis. Based on these long-term results and improvement of the natural history of adolescent idiopathic scoliosis, continued use of the Charleston Bending Brace is justified.

Nighttime bracing for adolescent idiopathic scoliosis with the Charleston bending brace : preliminary report

The authors report their preliminary experience with the Charleston bending brace for the treatment of adolescent idiopathic scoliosis. This brace holds the patient in the position of maximum side bend correction and is worn only at night. Patients in this prospective multicentered study met all the following criteria: skeletal immaturity (RisserO, 1 +, or 2+), curvature greater than 25° before bracing, no prior treatment, and greater than 1-year follow-up since initiation of treatment. There were 191 structural curves in the 139 patients. One hundred fifteen patients (83%) showed improvement or less than 5° change in curvature. Twenty-four patients (17%) demonstrated an increase in curvature greater than 5°. Based on these preliminary results, continued use of bending brace treatment at nighttime only is justified for adolescent idiopathic scoliosis. Patients with double curves should be observed closely for increase in compensatory curves.

Results of femoral varus osteotomy in children older than 9 years of age with Perthes disease.

We review the results of varus osteotomy in 17 patients older than 9 years of age with 18 hips affected by Perthes disease. Seventeen hips were judged as Catterall 3 or 4, and 14 hips had partial or complete loss of the lateral pillar. At an average follow-up of 10 years (4.2–17.8 years), 3 hips were rated Stulberg 1, 3 were Stulberg 2, 4 were Stulberg 3, and 8 were Stulberg 4 or 5. At follow-up, 7 hips were considered good or fair based on the use of Mose circles. Statistical analysis indicated better results in patients younger than 10 years of age compared with those older than 10 years of age. Varus osteotomy as a method of containment for Perthes disease provides improved results in children older than 9 years compared with natural history studies or studies of noncontainment methods. However, it seems likely that there is an upper age limit for effectiveness of containment treatment.

Traumatic hip dislocations in children and adolescents: pitfalls and complications

&NA; Traumatic hip dislocation is an uncommon injury in children. Lack of familiarity with management of the treating physician may lead to complications. Hip dislocation in young children can occur with minor trauma; in adolescents, greater force is required to produce a traumatic complete hip dislocation. Transient hip dislocation with spontaneous but incomplete reduction is a diagnostic pitfall that can occur in adolescents. Any asymmetric widening of the hip joint warrants additional investigation. Most dislocations in children can be reduced with gentle manipulation. Urgent reduction of the hip within 6 hours of injury reduces the risk of osteonecrosis. However, closed reduction in adolescents should be performed with caution because of the risk of displacement of the femoral head during manipulation. Open reduction is indicated when closed reduction fails or when there is interposition of bone or soft tissue following attempted closed reduction. Late complications include osteonecrosis, coxa magna, and osteoarthritis.

Dynamic Axial External Fixation in the Surgical Treatment of Tibia Vara

Osteotomy is the well-established treatment of Blounts disease (tibia vara), although the types of fixation used vary considerably. The use of dynamic axial external fixation to stabilize osteotomies for tibia vara until solid union occurs without the use of supplemental casting has not been reported by other authors. From 1985 until the present, we have used osteotomy with dynamic axial external fixation as treatment of 31 tibiae in 23 patients. All osteotomies healed and there was no postoperative loss of correction. There was an average correction of 20 degrees between the pre- and postoperative mechanical axis. Advantages of dynamic axial external fixation include ease of application, adjustability, early weight bearing, the ability to lengthen the extremity, and no second operation for removal of hardware. Based on our results, we believe that dynamic axial external fixation is an excellent form of osteotomy stabilization in the surgical treatment of tibia vara.

Choosing fusion levels in progressive thoracic idiopathic scoliosis

The selection of fusion levels in thoracic idiopathic scoliosis was subjected to multicenter retrospective review to test the validity of the classification system and recommendations of King et al. The 253 patients reviewed were treated by posterior fusion and Harrington instrumentation. Bending films were of little help in selecting fusion levels. Standing radiographs alone were usually adequate. King Type II curves may yield better lumbar correction if the lumbar curve is partially included in the fusion. Type IV curves may be safely fused one level proximal to the stable vertebrae.

Acute correction and distraction osteogenesis for the malaligned and shortened lower extremity

In limbs with combined shortening with angulation or malrotation, deformity may be quickly or slowly corrected before lengthening with external fixation. We examined a series of 35 patients with 40 limbs that underwent acute deformity correction and subsequent gradual lengthening. The average deformity corrected was 19 degrees, with subsequent average lengthening of 4.1 cm. Good radiographic callus formation was noted in 34 of the 40 segments studied. The magnitude of deformity correction had no effect on the quality of lengthened bone, incidence of complications, or the healing index. Skeletally mature segments had statistically significant decreased bone formation (p = 0.001), increased prevalence of callus complications (p = 0.001), and a higher healing index (p = 0.003). Based on this experience, it is our conclusion that immediate correction and lengthening is suitable in children and adolescents who have malaligned and shortened lower extremities. Because of poorer results in older patients, we believe that other techniques should be considered in adults.

Unilateral External Fixation for Corrective Osteotomies in Patients with Hypophosphatemic Rickets

Extremity deformities in patients with hypophosphatemic rickets (HPR) are often complex and multiplanar. Described methods for correcting these deformities are imprecise and require interruption of the medical management of the condition. Corrective osteotomies were performed on 29 bones in nine children with HPR. Use of the Orthofix external fixator enabled precise correction of the deformities without interruption of medical management.