David M. Scher

Osgood Schlatter syndrome

Purpose of review Osgood Schlatter syndrome presents in growing children (boys, 12–15 years; girls, 8–12 years) with local pain, swelling and tenderness over the tibial tuberosity. Symptoms are exacerbated with sporting activities that involve jumping (basketball, volleyball, running) and/or on direct contact (e.g. kneeling). With increased participation of adolescent children in sports, we critically looked at the current literature to provide the best diagnostic and treatment guidelines. Recent findings Osgood Schlatter syndrome is a traction apophysitis of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity. Radiographic changes include irregularity of apophysis with separation from the tibial tuberosity in early stages and fragmentation in the later stages. About 90% of patients respond well to nonoperative treatment that includes rest, icing, activity modification and rehabilitation exercises. In rare cases surgical excision of the ossicle and/or free cartilaginous material may give good results in skeletally mature patients, who remain symptomatic despite conservative measures. Summary Osgood Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases.

The predictive value of indium-III leukocyte scans in the diagnosis of infected total hip, knee, or resection arthroplasties

To evaluate the usefulness of the indium-111 scan in detecting actually or potentially infected total hip, knee, and resection arthroplasties, 153 scans were performed on 143 patients who underwent reoperation for a loose or painful total joint arthroplasty or a resection arthroplasty between 1990 and 1996. Scans were interpreted as infected, not infected, or equivocal by an experienced nuclear medicine radiologist. Patients were considered to be infected if they met any 2 of the following criteria: i) positive intraoperative cultures, ii) final permanent histologic section indicating acute inflammation, and iii) intraoperative findings of gross purulence within the joint. Twenty-six patients (17%) met the infection criteria at the time of reoperation. Indium scans were found to have a 77% sensitivity, 86% specificity, 54% and 95% positive and negative predictive values, and 84% accuracy for the prediction of infection. Of 6 equivocal scans, none were infected. The results of this study suggest limited indications for the use of the indium-111 scan in the evaluation of painful hip, knee, or resection arthroplasties. A negative indium scan may be helpful in suggesting the absence of infection in cases in which the diagnosis is not otherwise evident.

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet.

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores ≥5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of ≥5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

Use of the foot abduction orthosis following Ponseti casts: Is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant groups scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.

Operative Treatment of Tibial Fractures in Children: Are Elastic Stable Intramedullary Nails an Improvement Over External Fixation?

BACKGROUND Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other. METHODS We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared. RESULTS Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons). CONCLUSIONS When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing.

The role of intraoperative gram stain in revision total joint arthroplasty

The ability to identify intraoperatively patients with an infected prosthesis at the time of a revision procedure assists the surgeon in selecting appropriate management. The results of 413 intraoperative Gram stains were compared with the results of operative cultures, permanent histology, and the surgeons intraoperative assessment to determine the ability of Gram stains to identify periprosthetic infection. Gram staining correctly identified the presence of infection in 10 of the 68 cases that met study criteria for infection (sensitivity of 14.7%). Four false-positive Gram stains were encountered. Intraoperative Gram stains do not have adequate sensitivity to be helpful in identifying periprosthetic infection and should not be performed on a routine basis. They may be helpful, however, in cases in which gross purulence is encountered to assist in the selection of initial antibiotic therapy. The use of intraoperative Gram staining alone is inadequate for ruling out infection at the time of revision total joint arthroplasty.

Treatment of pediatric diaphyseal femur fractures.

Methods of treating pediatric diaphyseal femur fractures are dictated by patient age, fracture characteristics, and family social situation. The recent trend has been away from nonsurgical treatment and toward surgical stabilization. The clinical practice guideline on pediatric diaphyseal femur fractures was undertaken to determine the best evidence regarding a number of different options for surgical stabilization. The recommendations address treatments that include Pavlik harness, spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, submuscular plating, and pain management. The guideline authors conclude that controversy and lack of conclusive evidence remain regarding the different treatment options for pediatric femur fractures and that the quality of scientific evidence could be improved for the revised guideline.

Down syndrome: orthopedic issues.

Purpose of review The purpose of this review is to update the role of the orthopedic surgeon in the management of Down syndrome as these patients are living longer and participating in sporting activities. Recent findings Approximately 20% of all patients with Down syndrome experience orthopedic problems. Upper cervical spine instability has the most potential for morbidity and, consequently, requires close monitoring. Other conditions such as scoliosis, hip instability, patellar instability and foot problems can cause disability if left untreated. In some of these conditions, early diagnosis can prevent severe disability. Summary Surgical intervention in children with Down syndrome has a high risk of complications, particularly infection and wound healing problems. Careful anesthetic airway management is needed because of the associated risk of cervical spine instability.

In vitro and in vivo activation of polymorphonuclear leukocytes in response to particulate debris.

The host inflammatory response to particulate wear debris has been implicated as a principal cause of osteolysis and aseptic loosening following total joint arthroplasty. While it has long been assumed that this inflammatory response is mediated solely by a chronic process, there has been evidence to suggest that an acute response to particulate debris may be important in initiating the chronic response. We studied the in vitro and in vivo acute inflammatory responses mediated by polymorphonuclear leukocytes (PMNs) to both retrieved particulate from a catastrophically failed uncemented metal-backed acetabular component and to commercially pure particulate (polyethylene, cobalt-chrome, and titanium). Isolated, nonactivated human PMNs in vitro exhibited both a dose- and time-dependent degranulation response to opsonized particulate debris, as evidenced by release of both specific (increased lysozyme activity) and azurophilic (increased beta-glucuronidase activity) granule contents. In the rat subcutaneous pouch model in vivo, PMNs were recruited within 3-6 h after exposure to particulate debris and were noted to phagocytize particulate and subsequently degranulate, as evidenced by increased beta-glucuronidase and PMN-specific myeloperoxidase (azurophilic granule enzymes) activities. This response peaked within the first 6 h and gradually declined by 24 h. The results of this study demonstrate the presence of an acute inflammatory response mediated by PMNs both in vitro and in vivo to particulate debris, which may be important in the sequence of events that lead to the macrophage-dominated chronic inflammatory process culminating in osteolysis and aseptic loosening of total joint arthroplasties.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Treatment of Pediatric Diaphyseal Femur Fracture

Summary of Recommendations The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Treatment of Pediatric Diaphyseal Femur Fractures (PDFF). This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. 1. We recommend that children younger than thirty-six months with a diaphyseal femur fracture be evaluated for child abuse. 2. Treatment with a Pavlik harness or a spica cast are options for infants six months and younger with …