Hamlet A. Peterson

The relative incidence of tarsal coalition

The overall incidence of tarsal coalition in the general population is unknown, but it is far less than 1%. Calcaneonavicular coalition was found to be the most common type (53%), followed by talocalcaneal coalition (37%). The other types appear infrequently. Most calcaneonavicular and talocalcaneal coalitions present as a painful foot of some type. Peroneal spastic flatfoot is a rare finding and occurred in only two of 22 talocalcaneal coalitions in the present study. Talonavicular coalitions were always associated with other congenital foot anomalies and were typically asymptomatic. Age at presentation, sex, and time to diagnosis were not statistically different among patients with coalitions at different locations. It is thought that clinical presentation corresponds to ossification of the coalition, which occurs an average of three to four years later.

Multiple Hereditary Osteochondromata

Multiple hereditary osteochondromata is a disorder consisting of multiple projections of bone (exostoses) capped by cartilage. The lesions are most numerous in the metaphyses of long bones but may appear on diaphyses of long bones and on flat bones and vertebrae. The transmission is autosomal dominant. Sarcomatous transformation is uncommon and probably occurs in fewer than 1% of patients. The more common indications for surgical excision of lesions are pain, growth disturbance, compromised joint motion, cosmesis, and secondary impingement of tendon, nerve, or vessel. Excision of the lesions is effective in relieving pain, improving cosmesis and joint motion, and removing secondary impingement of tendon, nerve, or vessel, and may retard or prevent progressive disturbance of osseous growth. Wrist and ankle deformities are often associated with relative shortening and bowing of the ulna and fibula, respectively; tilt and tapering of the distal radial and tibial epiphyses; and distal radioulnar and tibio-fibular diastasis. These deformities can be effectively treated by ulnar and fibular lengthening combined with hemiphyseal stapling of the distal radius and tibia. Progressive genu valgum is well corrected by placement of staples over the medial side of the physis of the distal femur or proximal tibia or both.

Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: difference between children and adults.

The pathogenesis of postlaminectomy spinal deformity and instability in children was evaluated by reviewing appropriate roentgenographic findings. First, we reviewed spine roentgenograms of patients below 40 years of age who underwent spinal fusion for deformity and instability of the spine developing after a multiple level laminectomy. Two types of deformity were recognized on the roentgenograms: increased mobility between the vertebral bodies and wedging deformity of the ventral aspect of the vertebral bodies. Second, we did a follow-up study of another group of patients who had undergone laminectomy. We found the same two types of deformity in children, but not in adult patients. The incidence of deformity was higher after laminectomies of the cervical or cervicothoracic region than after lumbar laminectomies. Our data suggest that postlaminectomy spinal deformity can develop in children without irradiation or facet injury. The deformity is due to a wedging change in the cartilaginous portion of the vertebral body and to the viscoelasticity of ligaments in children. When treatment of this complication becomes necessary, anterior fusion may be effective in arresting progression. Prophylactic measures against the development of deformity are discussed. Our hypothesis concerning the mechanism of development of this complication supports the rationale of osteoplastic laminar resection and reconstruction instead of laminectomy, particularly in the management of children.

Failure of inactivation of Duchenne dystrophy X chromosome in one of female identical twins

Duchenne muscular dystrophy manifested in one of girl twins. The twins were monozygous on the basis of red cell and HL antigens and skin graft compatibility. Karyotyping, including banding techniques, showed a normal number of chromosomes and a normal conflguration of the X-chromosome in both twins. The twins were identical in appearance until symptoms of Duchenne dystrophy developed in one at age-4.years. The maternal uncle had classic Duchenne dystrophy; the mother and the nonmanifesting twin showed evidence of being heterozygous for Duchenne dystrophy. The phenotypic difference in monozygous twins is readily explained by lyonization of the X-chromosome after twinning has occurred. The findings substantiate the existence of Duchenne dystrophy manifesting in females with normal karyotypes.

Surgical treatment of Scheuermann's disease with segmental compression instrumentation

Twenty-one patients with Scheuermann’s kyphosis had surgery for progressive kyphotic deformity of 50° or greater. There were six adolescents, with a mean age of 15.6 years (range, 13–17 years) and 15 young adults, with a mean age of 25.4 years (range, 18–40 years). All patients had posterior spine arthrodesis with segmental compression instrumentation. Seven patients with rigid kyphosis had combined anterior and posterior spine arthrodesis. One patient died of superior mesenteric artery syndrome. In the group of 13 patients with posterior arthrodesis only, followup was 4.5 years. The mean preoperative thoracic kyphotic curve of 68.5° improved to 40° at latest review, with an average loss of correction of 5.75° . Junctional kyphosis occurred in two patients with a short arthrodesis: one at the cephalad end and one at the caudal end of the fused kyphotic curve. In the second group of seven patients with combined anterior and posterior arthrodesis, followup was 6 years. The mean preoperative thoracic kyphotic curve of 86.3° improved to 46.4° at latest review, with an average loss of correction of 4.4°. Overall, there was no postoperative neurologic deficit and no pseudarthrosis. Thus, posterior arthrodesis and segmental compression instrumentation seems to be effective for correcting and stabilizing kyphotic deformity in Scheuermann’s disease. Despite a long operating time, this technique provided significant correction, avoiding the development of any secondary deformity in most patients. Combined anterior and posterior spine arthrodesis is recommended for rigid, more severe kyphotic deformities.

Human muscle fiber fine structure Morphometric data on controls

Muscle fiber fine structure was quantitatively analyzed in 70 longitudinally and 65 transversely sectioned fibers from 10 control subjects without weakness. The average mitochondrial fraction of the fiber volume is close to 4 percent and the mean size of a mitochondrion is about 0.1 μm2. The sarcotubular surface area per unit fiber volume is close to 1.5 μm2/μm3 in transverse sections and 0.65 times this value in longitudinal sections. Only one-third of all fibers contain lipid droplets in the sectioned plane, and for all fibers the droplets account for approximately 0.12 percent of the fiber volume. Variations with the age and sex of the subjects and with different muscles were analyzed and the feasibility of typing human muscle fibers at the ultrastructural level was evaluated.

Opening-wedge osteotomy for angular deformities of long bones in children.

Mild angular deformities associated with a mild limb-length discrepancy of long bones in children can be treated effectively with opening-wedge osteotomy with insertion of a specially prepared autogenous tricortical iliac-crest bone graft and with minimum or no internal fixation. Thirty-one osteotomies in twenty-six children satisfactorily corrected the deformities so that the angulation and length of the bone were comparable with the values on the normal, contralateral side. Physeal arrest or ipsilateral excision of a physeal bar was performed either concomitantly or at a separate operation in twenty-one of the twenty-six patients, to aid in the treatment of the limb-length discrepancy. Opening-wedge osteotomy is applicable for correction when the angular deformity is 25 degrees or less and the limb-length discrepancy is, or will be, twenty-five millimeters or less at maturity.

Incidence of slipped capital femoral epiphysis: a population-based study.

The incidence of slipped capital femoral epiphysis (SCFE) remains controversial. A population-based database was used to identify all residents of a Midwestern American county treated for a new diagnosis of SCFE. Between 1965 and 2005, 49 patients (aged 9–16 years) underwent treatment of SCFE. This represents an annual incidence of 8.3 unilateral cases and 0.5 bilateral cases per 100 000 children. In patients with unilateral disease, mild slips developed in nine contralateral hips (19%) at a mean of 166 days (range: 6–432 days). As all contralateral slips were mild, we recommend careful follow-up rather than prophylactic pinning of the contralateral hip.

Fishtail deformity following fracture of the distal humerus in children: historical review, case presentations, discussion of etiology, and thoughts on treatment.

&NA; Fishtail deformity is an uncommon complication of distal humeral fractures in children. This article reports four cases accompanied by premature closure of a portion of the distal humeral physis with resultant deformity, length retardation, decreased elbow motion, and functional impairment. The ages of the patients at time of injury ranged from 4 years 2 months to 6 years 1 month (average 5 years 4 months). The average length of follow‐up was 9 years 9 months (range, 3 years 5 months to 18 years 10 months). The cause of the arrest is multifactorial and may be due to a gap in reduction of an intracondylar fracture, avascular necrosis of the epiphysis, or central premature physeal arrest (bar formation) without a fracture gap or avascular necrosis. If identified in a young child, surgical closure of the medial and lateral portion of the physis may prevent the deformity from progressing and would not cause significant additional humeral length discrepancy.

Metatarsal lengthening: case report and review of literature.

Shortening of one or more metatarsals may be a cause of metatarsalgia and painful toe deformity. Usually, symptoms are limited and may be successfully addressed with nonoperative treatment. Rarely, operation is indicated. This report reviews the surgical techniques, results, and complications. These operations include osteotomy and one-stage distraction with bone grafting, osteotomy and one-stage distraction without bone grafting, osteotomy with gradual distraction and bone grafting, and osteotomy with gradual distraction without bone grafting.