Dennis P. Grogan

Results of the Scoliosis Research Society instrument for evaluation of surgical outcome in adolescent idiopathic scoliosis. A multicenter study of 244 patients.

STUDY DESIGN An outcome questionnaire was constructed to evaluate patient satisfaction and performance and to discriminate among patients with adolescent idiopathic scoliosis. OBJECTIVES To determine reliability and validity in a new quality-of-life instrument for measuring progress among scoliosis patients. SUMMARY OF BACKGROUND DATA Meta-analysis of the surgical treatment of adolescent idiopathic scoliosis determined that a uniform assessment of outcome did not exist. In addition, patient measures of well-being as opposed to process measures (e.g., radiographs) were not consistently reported. This established the need for a standardized questionnaire to assess patient measures in conjunction with process measures. METHODS The instrument consists of 24 questions divided into seven equally weighted domains as determined by factor analysis: pain, general self-image, postoperative self-image, general function, overall level of activity, postoperative function, and satisfaction. The questionnaire takes approximately 5 minutes to complete and is taken at predetermined time intervals. A total of 244 of patients from three different sites responded to the questionnaire. RESULTS The reliability based on internal consistency was confirmed with a Cronbachs alpha coefficient greater than 0.6 for each domain. In addition, acceptable correlation coefficient values greater than 0.68 were obtained for each domain by the test-retest method on normal controls. Similarly; to establish validity of the questionnaire, responses of normal high school students were compared with that of the patients. Consistent differences were noted in the domains between the two groups with P < 0.003. The largest differences were in pain (control, 29.96 +/- 0.20; patient, 13.23 +/- 5.55) and general level of activity (control, 14.96 +/- 0.20; patient, 12.16 +/- 3.23). Examination of the relationship between the domains and patient satisfaction showed that pain correlates with satisfaction to the greatest degree (Pearsons correlation co-efficient, r = -0.511; P < 0.001), followed by self-image (r = 0.412; P < 0.001). CONCLUSIONS This questionnaire addresses patient measures for evaluation of outcome in adolescent idiopathic scoliosis surgery by examining several domains. It also allows for dynamic monitoring of scoliosis patients as they become adults. This is a validated instrument with good reliability measures.

Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding

Summary: Five skeletally immature patients developed premature closure of the greater trochanteric physis consequent to placement of an intramedullary rod for primary treatment of a femoral diaphyseal fracture. Each patient developed increased femoral neck valgus as compared with the contralateral hip. To date, however, none of these patients has had any functional disability, although one has developed mild radiographic subluxation. In addition, anatomic specimens demonstrated the likely hood of traversing a portion of the greater trochanteric physis. Other methods of fracture treatment, either operative or nonoperative, should be considered in skeletally immature patients who have not entered the final phase of skeletal maturation characterized by subchondral “sclerosis” along the greater trochanteric physis.

Avulsion fractures of the patella.

Forty-seven skeletally immature patients with marginal fractures of the patella were evaluated. We showed that avulsion fractures may affect the superior, inferior, and medial margins of the patella, separating through the subchondral bone along the biomechanically susceptible margin of progressive chondroosseous transformation and expansion of the ossification center. In children, the small size of the osseous fragment may belie the actual size of the more peripheral, radiolucent cartilaginous component. Treatment may be either conservative or operative, depending on the extent of separation of the fragments and the functional capacity of the patellar/quadriceps mechanism.

The Painful Accessory Navicular: A Clinical and Histopathological Study

Twenty-two skeletally immature patients with 39 accessory tarsal navicular bones were seen over a 4-yr period. Twenty-five of the feet with accessory naviculars were symptomatic and, after failure of conservative treatment, were treated by excision of the accessory bone, the synchondrosis, and the prominent portion of the main navicular ossification process. No attempt was made to reroute the posterior tibial tendon. All 25 operative feet were completely relieved of the preoperative pain. The external oblique view was found to be the best radiographic view to demonstrate the accessory navicular. Histological findings in the surgical specimens included areas of microfracture through the cartilaginous synchondrosis, acute and chronic inflammation, and cellular proliferation indicative of attempted repair. These changes are consistent with the theory that chronic chondro-osseous tensile failure can occur in this condition and is responsible for the clinical findings.

Polydactyly of the foot.

Summary: One hundred twenty-five patients with 194 supernumerary toes were analyzed. Postaxial polydactyly accounted for 79%. Duplication at the proximal phalanx with either a block metatarsal or a wide metatarsal head was the most common anatomical pattern. Sixty-one patients with 97 duplications evaluated at an average follow-up of 15.1 years postoperatively had 94% excellent or good results. Poor results were often associated with preaxial duplications and persistent hallux varus. Patients with central duplications often had a persistently wide forefoot. Surgical treatment is usually straightforward, but must be individualized. Preoperative radiologic assessment is mandatory. Certain technical considerations are related to better results

Anatomy of the os trigonum.

Summary Three anatomic specimens of os trigonum from skeletally immature patients demonstrated anatomic continuity of the cartilage containing the ossicle with the body of the talus, with a synchondrosis being present between the two ossifying regions. The os trigonum may be considered a developmental analogue of a secondary ossification center similar to the posterior Calcaneal apophysis (although there are obvious histologic differences). The chondro-osseous border of the synchondrosis may be injured either as a chronic stress fracture or, less frequently, as an acute fracture, comparable to the injury patterns involving the accessory navicular.

Operative treatment of congenital pseudarthrosis of the clavicle.

Eight children were treated operatively with resection of fibrous pseudarthrosis and sclerotic bone ends, careful dissection and preservation of the periosteal sleeve to maintain continuity, and approximation of bone ends. None had additional bone grafts or internal fixation. All had bridging ossification 6–8 weeks postoperatively, and all were solidly healed by 14 weeks after surgery. Follow-up has ranged from 2 to 14 years, with no evidence of recurrence. Remodeling of the prominence occurred slowly in 2–5 years, with the distal clavicle variably underdeveloped in all patients. Early resection of fibrous pseudarthrosis probably does not require the extensive grafting and internal fixation that has been recommended for older children.

Radiographic abnormalities and clinical symptoms associated with patella alta in ambulatory children with cerebral palsy.

One hundred seventeen randomly selected, skeletally immature, ambulatory children with spastic cerebral palsy were evaluated with clinical examination and lateral radiographs of the knee. Radiographic abnormalities within either the patella or the proximal tibia were present in 21% (41 knees) of the 193 affected knees. The most common radiographic findings were elevation of the tibial tubercle in 34 knees and fragmentation of one pole of the patella in seven knees. Clinical symptoms including pain, swelling, and tenderness were present in 32% of those children with radiographic findings (13 of 41 knees). Patella alta was seen in nearly all children in the study. The radiographic findings appeared to be chronic, were usually asymptomatic, and have required no treatment to date.

Distal ulnar physeal injury.

We reviewed 18 patients and two traumatic amputation specimens with injuries involving the distal ulnar physis. Type 1 growth mechanism injuries were the most common fracture pattern with premature physeal closure and ulnar shortening occurring in 55% of the patients. Other consequences included radial bowing, ulnar angulation of the distal radius, and ulnar translocation of the carpus. Most of the patients, however, were asymptomatic. Initial radiographic diagnosis of this physeal injury may be difficult because of the relatively late ossification of the distal ulnar physis. Concomitant ulnar physeal injuries must be suspected in any injury to the distal radius, especially when an ulnar metaphyseal or styloid fracture is not readily evident.

The role of proximal femoral valgus osteotomy in Legg-Calvé-Perthes disease

Proximal femoral valgus osteotomy for Legg-Calvé-Perthes disease was evaluated at an average 5 years postoperatively in 31 consecutive patients. The indications for osteotomy were hinge abduction and pain. The Iowa hip scores at follow-up for 21 patients averaged 93 points. Combined clinical and radiographic review for these patients yielded 6 (29%) excellent, 7 (33%) good, 5 (24%) fair, and 3 (14%) poor results. The 10 remaining patients had good pain relief and were satisfied but were unable to return for hip scale evaluation.