Eliana D. Delgado

Periacetabular osteotomy for the treatment of severe acetabular dysplasia

BACKGROUND The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients. METHODS Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively. RESULTS Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees ) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees ) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees ) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures. CONCLUSIONS The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

Musculoskeletal manifestations of Hurler syndrome: long-term follow-up after bone marrow transplantation.

Bone marrow transplantation (BMT) is effective in ameliorating many of the clinical manifestations of Hurler syndrome. However, long-term data on the natural history of the musculoskeletal disorders of Hurler syndrome after BMT are limited. The authors report the orthopaedic outcomes in seven patients with Hurler syndrome who were successfully engrafted between 1990 and 1999, and have been followed for a mean of 7.6 years since transplantation. Medical records, clinical examinations, and imaging studies were reviewed to assess the development and management of hip dysplasia, genu valgum, spine abnormalities, hand abnormalities, and joint range of motion. BMT does not appear to alter the natural history of the musculoskeletal disorders in Hurler syndrome, although there may be a beneficial effect on upper extremity joint mobility.

Pulseless Arm in Association with Totally Displaced Supracondylar Fracture

Seven children (3-10 years of age) were treated for a type III supracondylar fracture of the humerus. All fractures were reduced and pinned. Closed reduction was performed in four patients; three required open reduction. Before reduction six of the seven patients did not have a distal palpable pulse in the involved forearm. After reduction of the fractures all patients had a pulseless arm and a seemingly viable hand. Doppler pulses were absent or greatly diminished compared with the normal side in all involved extremities. Six patients underwent immediate antecubital fossa exploration of the brachial artery without arteriogram; one patient, referred to us from another facility, underwent angiography followed by immediate exploration. In three patients the brachial artery was directly damaged or transected and was repaired via saphenous vein graft, with reestablishment of distal pulses in each case. In the other four patients the brachial artery was kinked or entrapped at the fracture site, necessitating microdissection to mobilize the vessel and reestablish pulses in each case. At an average follow-up of 30 months, all seven patients had normal circulatory status, including a radial pulse. All fractures had healed, and all extremities had a normal carrying angle and normal elbow motion. Immediate exploration of the antecubital fossa should be considered if an extremity remains pulseless (to palpation and Doppler) after reduction and stabilization of significantly displaced supracondylar fractures of the humerus.

Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results.

To investigate the importance of arterial integrity in tibial fracture healing, the authors retrospectively assessed prognosis as a function of arterial injury in a large series of tibial fracture patients. The records of 114 patients who were treated for an open fracture of the tibia at a San Francisco hospital between 1981 and 1991 were selected for review; in each case, the injury had been caused by a blunt trauma, and arteriography had been performed to evaluate a suspected arterial injury in the ipsilateral extremity. Sixty-two patients had had a normal arteriogram and 52 had demonstrated occlusion of one or two of the three arteries that supply the foot. The group of patients who had demonstrated arterial occlusion had a significantly greater incidence of delayed union or nonunion (24 of 52 compared with ten of 62) and notably more cases of osteomyelitis (nine of 52 compared with four of 62); when the patients with osteomyelitis are excluded, the difference between the groups is still significant. This study is the first that indicates that patients with open fractures of the tibia who demonstrate arterial occlusion in their ipsilateral extremity may be more prone to delayed union or nonunion. More vigilant follow-up evaluation may therefore be warranted in such patients to better anticipate the need for exchange rodding or bone grafting.

Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique.

BACKGROUND The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients. METHODS Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively. RESULTS Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures. CONCLUSIONS The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

Treatment of severe torsional malalignment syndrome.

Over a 7-year period (1984-1991), nine patients (aged 10-18 years) with 13 involved extremities were operatively treated for symptomatic severe torsional malalignment of the lower extremity and associated patellofemoral pathology. Physical examination and analysis of gait revealed severe rotational deformity characterized by excessive femoral anteversion and external tibial torsion. The cosmetic and functional pathologic effect of this torsional malalignment was centered about the knee joint. In all patients, conservative treatment, including therapy for muscle strengthening and nonsteroidal medication, was unsuccessful in alleviating suspected patellofemoral pain. Subsequent definitive operative treatment in all 13 extremities consisted of corrective osteotomies, internally rotating the distal part of the tibia or externally rotating the distal part of the femur or both. Osteotomies were performed as close to the knee joint as possible. No additional soft-tissue procedures were performed directly to affect patellar tracking. All osteotomies healed without complications. At an average follow-up of 2 years + 7 months (range, 18-48 months) overall, patients had an improvement in gait pattern, extremity appearance, and a marked decrease in knee pain.

Pemberton pelvic osteotomy and varus rotational osteotomy in the treatment of acetabular dysplasia in patients who have static encephalopathy

Forty-four patients (fifty-two hips) who had static encephalopathy and acetabular dysplasia were managed with a Pemberton osteotomy as part of a comprehensive operative approach. Thirty-three patients had quadriplegia and were unable to walk; the remaining eleven patients had diplegia and could walk. The age at the time of the operation ranged from four years and five months to sixteen years and five months, as an open triradiate cartilage is a prerequisite for the Pemberton procedure. Concomitant operative procedures included a varus rotational osteotomy in fifty of the involved hips, a soft-tissue release in thirty-seven hips, and an open reduction in thirteen hips. The mean center-edge angle preoperatively was -11 degrees (range, -80 to 17 degrees), which improved to a mean of 27 degrees (range, 5 to 62 degrees) at the time of the latest follow-up. The mean duration of follow-up was four years (range, two years to eight years and eight months). At the time of writing, none of the hips had redislocated but one hip had subluxated. Eight of the hips had been painful preoperatively, but none of these was painful at the time of the most recent follow-up. One patient who had not had pain in the hip preoperatively had pain at the time of the follow-up evaluation. There were no complications attributable to posterior uncovering of the hip. The age of the patient at the time of the operation had no discernible effect on the result.

Magnetic resonance arthrography in children with developmental hip dysplasia.

Conventional and gadolinium enhanced magnetic resonance arthrograms were done on 14 hips in 10 children ages 7 to 24 months. The contralateral normal hips in those with unilateral disease were studied with unenhanced magnetic resonance imaging for comparison. By conventional arthrography, there were no well visualized structures. Visualized structures seen as filling defects were the labrum, ligamentum teres, and transverse acetabular ligament. By magnetic resonance arthrography, well visualized structures were the labrum, ligamentum teres, transverse acetabular ligament, and pulvinar. By unenhanced magnetic resonance imaging, well visualized structures were the labrum, ligamentum teres, and transverse acetabular ligament. The difference in visualization by magnetic resonance arthrography versus conventional arthrography was statistically significant with respect to all five structures: labrum, ligamentum teres, transverse acetabular ligament, pulvinar, and psoas tendon. The difference in visualization by magnetic resonance arthrography versus unenhanced magnetic resonance imaging was statistically significant with respect to the labrum and pulvinar. Magnetic resonance arthrography is indicated for assessing complete concentric reduction when it does not appear to be achieved by conventional arthrography, for confirming closed reduction immediately after manipulation, and potentially for preoperative planning for an open reduction.

Cultural competence: serving Latino patients.

Culturally competent strategies are necessary as populations in many countries become increasingly diverse. In the United States, Latinos are the fastest-growing minority group. In this study, the authors interviewed Latino patients and families, collected demographics from 570 patients in pediatric orthopedic practices in California, and conducted population census and literature reviews. Based on these sources of information, the authors identified barriers to health care for Latino pediatric orthopedic patients and propose culturally competent strategies to overcome these barriers. This approach can be applied to other populations so that culturally competent care is available to patients from all ethnic, racial, and cultural backgrounds.

Unreamed Rod With Early Wound Closure for Grade IIIA and IIIB Open Tibial Fractures: Analysis of 40 Consecutive Patients

This study evaluated 40 patients with grades IIIA and IIIB open tibial fractures from July 1987 to September 1990. Aggressive debridement of all dead tissue and bone, irrigation with > 9 L of fluid, and emergent intramedullary unreamed rodding (mean time from the emergency room to the operating room: 4 hours 20 minutes) was performed in all patients. Surgical debridement was repeated every 48 to 72 hours until the wound could be successfully closed (mean time: 6.2 days). Progressive weight bearing in a short leg cast was allowed depending on the fracture configuration, with full weight bearing usually beginning at 6 weeks. Additional autogenous iliac crest bone grafting was performed at 2 to 4 months if required. There were 14 grade IIIA and 26 grade IIIB open tibial fractures. Thirty-nine of the 40 patients underwent follow-up until union was obtained both clinically and radiographically. One patient was lost to follow-up. Complications included three soft-tissue infections and two late subflap abscesses. There was no evidence of osteomyelitis in any of these cases. Aggressive debridement and early wound closure appear to be the key in the successful use of unreamed interlocking intrameduallary rods for fixation of open tibial fractures.