Daniel R. Cooperman

The natural history of Legg-Calve-Perthes disease

Two groups of patients who had Legg-Calvé-Perthes disease were studied. The first group of patients consisted of eighty-eight patients (ninety-nine affected hips) followed in three hospitals for an average of forty years. The second group consisted of sixty-eight patients (seventy-two affected hips), all of whose radiographs from the onset of disease to maturity were available and all of whom had been treated in one hospital. The patients in this second group were followed for an average of thirty years. Each hip in both study groups could be placed into one of five classes of deformity based on its radiographic appearance at maturity. Each class showed a characteristic pattern of involvement during the active stages of the disease and had a specific long-term clinical and radiographic course. The clinical and radiographic course of an involved hip subsequent to childhood was related to the type of congruency that existed between the femoral head and acetabulum. Three types of congruency were recognized: (1) spherical congruency (Class-I and II hips) - in hips in this category arthritis does not develop; (2) aspherical congruency (Class-III and IV hips) - mild to moderate arthritis develops in late adulthood in these hips; and (3) aspherical incongruency (Class-V hips) - severe arthritis develops before the age of fifty years in these hips.

Acetabular dysplasia in the adult.

Twenty adults (32 hips) with acetabular dysplasia were followed up for an average of 22 years to determine the natural history of the disorder. Initially, all hips had a center-edge (CE) angle of Wiberg of 20 degrees or less and an essentially intact Shentons line with no roentgenographic evidence of osteoarthritis. Average patient age initially was 43 years (range, 27-57 years) and at final follow-up examination, 65 years. Various parameters of hip integrity were measured, including the CE angle of Wiberg, acetabular angle of Sharp, percentage of the femoral head covered by the acetabulum, acetabular depth, and inclination of the lateral lip of the acetabulum. None of these indicators proved a reliable prognostic aid for predicting the rate at which the osteoarthritis process supervened in any one case.

Hip dislocation in spastic cerebral palsy: long-term consequences

We evaluated 38 noninstitutionalized patients with spastic quadriplegic cerebral palsy with 51 dislocated hips. Nine hips had been reduced. The mean follow-up was 18 years, with an average age of 26 years. At follow-up, four were ambulatory with aids. Patients who could walk had normal intelligence and a level pelvis. In patients with 18 unreduced unilateral hip dislocations, pelvic obliquity and scoliosis were present in 12. In seven patients with reduced unilateral hip dislocations, similar findings were present in only two patients. Half of the dislocated hips were painful. Based on these findings, we recommend reduction of unilateral dislocations. Bilateral dislocations may benefit from reduction if treatment is undertaken before significant adaptive deformity of the femoral head occurs.

The effect of adjunctive methylmethacrylate on failures of fixation and function in patients with intertrochanteric fractures and osteoporosis.

In a retrospective review of eighty-two intertrochanteric fractures (twenty-nine stable and fifty-three unstable) in seventy-nine elderly, debilitated patients with associated advanced osteoporosis (Grade III or less by the system of Singh et al.), fifty-six were available for follow-up: twenty-eight that had been treated at the University of Illinois with an approximately anatomical reduction and compression-screw fixation and twenty-eight (in twenty-seven patients) that had been treated at the University of Chicago with an approximately anatomical reduction, compression-screw fixation, and adjunctive methylmethacrylate bone cement in the head-neck fragment. Follow-up analysis after an average of thirty-four months for the group that had augmentation with cement and an average of twenty-six months for the uncemented group showed that for the eighteen stable fractures that could be followed the rates of complications of fixation were the same in the two groups, while for the thirty-eight unstable comminuted fractures that were followed the rate of complications of fixation was lower when adjunctive methylmethacrylate cement was used. Among the unstable fractures, one failure (in twenty-one fractures) in the cement-augmented group and ten failures (in seventeen fractures) in the uncemented group were due to failure of fixation (p less than 0.01). For reasons that are not clear, when the thirty-two patients with a healed fracture who could be evaluated for function were rated using the Iowa hip score, the nineteen who were treated with adjunctive cement had significantly lower scores than did the thirteen who were treated without cement (76 +/- 16.5 compared with 92 +/- 12.1, p less than 0.01).

Post-reduction avascular necrosis in congenital dislocation of the hip.

Twenty-five patients with thirty congenitally dislocated hips in which avascular necrosis developed after closed reduction were followed for an average of thirty-nine years from the time of reduction. Twenty-four of the thirty hips had moderate or severe osteoarthritis and twenty-two of the twenty-five patients had significant pain or loss of function, or both, by the time they were forty-two years old, The deformities produced by avascular necrosis that were related to osteoarthritis included: (1) loss of sphericity of the femoral head, (2) persistent lateral and proximal subluxation, (3) irregularity of the medial part of the femoral head, and (4) acetabular dysplasia. The study suggests that if avascular necrosis develops following closed reduction of a congenitally dislocated hip, attempts should be made to prevent lateral and proximal subluxation of the femoral head and to correct thse abnormalities, if possible, once they occur.

Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture.

Triplane fractures of the distal end of the tibia in fifteen children (average age, thirteen years) represented 6 per cent of 237 consecutive epiphyseal fractures of the ankle. Thirteen children were treated by closed methods (including manipulation) and two had open reduction of the fractures. At an average of twenty-six months after injury, three of fourteen patients showed roentgenographic evidence of premature symmetrical epiphyseal closure with less than 0.5 centimeter of shortening and no angular deformity. Of twelve children examined clinically, three had a 5 to 10-degree external rotation deformity and one patient also had an articular incongruity due to inadequate reduction. In the five cases in which tomograms were used to the medial malleolus, and the anteromedial part of the epiphysis. The lateral fragment included the remainder of the epiphysis together with a piece of posterior metaphysis with attached fibula.

Compartment syndrome in ipsilateral humerus and forearm fractures in children

Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm.

Pelvic Fractures in a Pediatric Level I Trauma Center

Objectives Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures. Setting Urban university pediatric Level I trauma center in a large metropolitan community. Patients/Participants Retrospective analysis of 57 consecutive children with 66 pelvic fractures seen between 1993 and 1999. Intervention Fifty-two patients were treated nonoperatively, and five patients required operative stabilization (four acetabular fractures and one partial sacroiliac joint disruption). Main Outcome Measure Type and cause of pelvic fracture, type of management used, incidence of associated injuries, hemorrhage requiring transfusion, and mortality. Results Hemorrhage directly related to the pelvic fracture occurred in only one patient (2%), whereas 11 other patients required transfusions associated with other body-area injuries. Three patients with pelvic fractures died (5%), but deaths were due to other body-area injuries. Conclusions Children with pediatric pelvic fractures require careful evaluation for other body-area injuries, as these are most likely to be related to hemorrhage or mortality.

Mechanical disruption of human patellar cartilage by repetitive loading in vitro

Plugs of cartilage and subchondral bone from patellae were subjected to cyclic compression consisting of rapid ramp loading for 0.3 seconds followed by a 2.7 second pause. At 1000 psi cyclic load, surface abrasion of the cartilage was noted at 250 cycles of compression. Primary fissures, which penetrated to the calcified cartilage, developed at 500 cycles. Secondary fissures, emanating from the primary fissures at 30 degrees-90 degrees angles, and penetrating to varying depths, were observed at 1000 cycles. Coalescence of fissures and undermining of cartilage fragments were noted at 8000 cycles. With greater loads, the same sequence of events occurred with fewer cycles except that primary fissures appeared before the surface was abraided. Fissure formation did not occur in specimens subjected to loads of 250 psi to 500 psi even if the superficial 100 micron of cartilage was removed and specimens were loaded for 120,860 cycles. The deeper layers of cartilage appear to be of prime importance in resisting fissure formation.

The floating knee in the pediatric patient. Nonoperative versus operative stabilization.

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weight-bearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weight-bearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.