James T. Guille

Injuries to the Cervical Spine in American Football Players

A national registry has documented data on more than 1300 cervical spine injuries resulting from tackle football. Axial loading of the cervical spine is the primary injury mechanism, an observation with profound implications regarding implementation of preventative measures. Characteristic injury patterns involving the middle (third and fourth) cervical segment and the more favorable response to prompt reduction of these injuries are emphasized. The marked instability and grave prognosis of axial load teardrop fractures are attributed to the associated sagittal vertebral body and posterior arch fractures. Spear tackler’s spine is described and is classified as an absolute contraindication to participation in collision sports. Cervical cord neurapraxia, with or without transient quadriplegia, is neither associated with nor presages permanent neurologic sequelae. However, there is a considerable risk of recurrence, which can be predicted on the basis of canal diameter data. The concept of spinal cord resuscitation is proposed as a means of obtaining maximum neurologic recovery by reversing the secondary injury phenomenon that occurs in acute spinal cord trauma. Athletic trauma to the cervical spine resulting in injury to the spinal cord is an infrequent but potentially catastrophic event. Recognition of the problems presented by injury to the cervical spine and spinal cord led to a series of field, clinical, and basic research studies conducted over the past twenty-five years. As a result of these efforts, basic questions have been answered regarding the epidemiology, prevention, pathomechanics, pathophysiology, and histochemical responses of reversible and irreversible cervical cord injuries. Allen et al.1 studied 165 closed indirect fractures and dislocations of the lower cervical spine, demonstrating various “spectra of injuries,” and developed a classification based on the mechanism of injury as determined by the presumed attitude of the cervical spine at the time of failure and the initial dominant mode of failure. The common …

Developmental Dysplasia of the Hip From Birth to Six Months

&NA; The term “developmental dysplasia or dislocation of the hip” (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint. Unlike the term “congenital dysplasia or dislocation of the hip,” DDH is not restricted to congenital problems but also includes developmental problems of the hip. It is important to diagnose these conditions early to improve the results of treatment, decrease the risk of complications, and favorably alter the natural history. Careful history taking and physical examination in conjunction with advances in imaging techniques, such as ultrasonography, have increased the ability to diagnose and manage DDH. Use of the Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If stable reduction cannot be obtained after 2 weeks of treatment with the Pavlik harness, alternative treatment, such as examination of the hip under general anesthesia with possible closed reduction, is indicated. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step. Toward the end of the first year of life, the toddler’s ability to stand and bear weight on the lower extremities, as well as the progressive adaptations and softtissue contractures associated with the dislocated hip, preclude use of the Pavlik harness.

Congenital Osseous Anomalies of the Upper and Lower Cervical Spine in Children

Mutations of homeobox genes may be responsible for congenital osseous anomalies of the cervical spine. Congenital osseous anomalies of the cervical spine may herald congenital malformations of other organ systems, such as those of the kidney and heart. Most congenital anomalies of the cervical spine are innocuous and may go undetected throughout life. Translational instability of adjacent vertebral bodies in a congenitally stenotic cervical spinal canal has serious implications. No existing prognostic classification system can predict which patients with a congenital osseous anomaly of the cervical spine are at risk for future neurologic injury. Congenital osseous anomalies of the upper and lower cervical spine are rare, yet their detection and treatment are important, as these deformities often set the stage for cervical spine instability and potential neurologic injury. Many of these conditions are associated with various syndromes and are, in part, developmental conditions. The presence of a congenital osseous anomaly in any part of the cervical spine often heralds congenital malformations in other organ systems. This factor is of paramount importance to the treating physician, whose main attention may be directed toward the patient’s neck. However, the vast majority of congenital anomalies pose no problems for the patient and thus go undetected. The current review focuses on the description, radiographic examination, physical findings, and treatment of these anomalies. Homeobox, or Hox, genes are a family of genes that regulate, among other things, the differentiation processes of the axial and appendicular skeletons1,2. These genes regulate the embryonic differentiation and segmentation of the craniocaudal axis by activation and repression of DNA sequences that encode the transcription factors and proteins affecting the order and direction of development of the axial skeleton3. Mutations of the homeobox genes may be responsible for congenital anomalies of the cervical spine4 …

Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis.

The mortality and morbidity after hip and knee arthroplasty were reviewed retrospectively during a 3-year period in 14 patients who had chronic renal failure and who were receiving hemodialysis. The patients had a primary total hip or knee replacement, or a revision arthroplasty or resection arthroplasty. Four of the patients (29%) died in the hospital during the postoperative period. One of the seven patients (14%) having a primary joint replacement died, whereas three of the seven patients (86%) having a revision or resection died. Every patient had multiple medical comorbidities, and every patient had a complication. The results indicate that arthroplasty procedures, especially revisions and resections, in this patient population are associated with a high rate of complications and death, and that in-depth informed consent should be provided for all patients contemplating these procedures. Meticulous treatment of medical comorbidities is mandatory. Finally, data in the literature and in the current report question whether joint arthroplasty procedures should be done in patients with end-stage renal disease who are receiving hemodialysis.

Congenital kyphosis in myelomeningocele : results following operative and nonoperative treatment

We reviewed the cases of 16 patients with myelomeningocele and congenital kyphosis. Ten patients underwent kyphectomy with wire fixation and spinal fusion for severe-curve progression and problems with decubiti ulcers. The average curve magnitude at presentation for these 10 patients was 87 degrees (range 47-146 degrees); at an average follow-up of 5 + 8 years (range 2 + 9 to 9 + 9 years) after surgery, it was 60 degrees (range 15-80 degrees). A stable fusion was achieved in nine patients, and all 10 had improved status of their skin at their last follow-up. Six patients were managed by nonoperative means such as modified wheelchairs and orthoses. The average curve magnitude at the presentation for this group was 70 degrees (range 42 degrees - 93 degrees); at an average follow-up of 19 years (range 5 + 5 to 27 + 3 years), it was 106 degrees (range 65 degrees - 130 degrees). Two of these patients continue to have problems with skin breakdown. Kyphectomy enables patients to sit straighter and is the proper treatment for these patients. If operative treatment is prohibitive or denied for some reason, then suitable wheelchair modifications can enable these patients to function with reasonable comfort.

Bilateral Legg-Calvé-Perthes disease: presentation and outcome.

Most patients who develop Legg-Calve-Perthes disease have unilateral involvement. For those children who do develop bilateral involvement, the disease and its outcome have not been characterized. This study reviewed the records and radiographs of 83 patients (20 girls and 63 boys) with bilateral Legg-Calve-Perthes disease. The patients were then divided into 3 groups based on the Waldenstrom stage at the time of the first radiograph. In Group I (26 patients), both hips were in the same stage. In Group II (45 patients), the hips were in a different stage. In Group III (12 patients), the first hip was well into the remodeling stage by the time the second hip became affected. Twenty of the 83 patients (24%) were girls. There were significantly more lateral pillar group A hips on the second side than the first side in Groups II and III, and only 10 of the 45 patients (22%) in these groups had more severe disease in the second hip. When compared with data from a group of hips with unilateral involvement, there were significantly more hips with a Catterall group I rating in the patients with bilateral involvement. In general, the Stulberg et al. class assigned appeared to be independent of bilaterality. It appears that the development of bilateral disease is an independent event. The data in the present study do not support that onset of disease in one hip leads to disease or causes a more severe disease in the second hip.

Treatment of the collapsed femoral head by containment in legg-calve-perthes disease

One hundred ninety-seven patients with unilateral Legg-Calve-Perthes disease (LCPD) were followed-up to skeletal maturity. According to the lateral pillar classification, 142 hips were classified as group B and 55 hips as group C. Radiographs were evaluated for percent of collapse of the femoral head, Waldenstrom stage of disease at diagnosis, Mose sphericity, hinge abduction, lateral acetabular shape, and limb-length discrepancy. The hips were treated either by bedrest and traction in abduction (76), Petrie cast (21), abduction brace (74), or by pelvic or femoral osteotomy (26). One hundred twenty-five hips had less than a 2-mm difference in Mose sphericity at followup. According to the classification of Stulberg et al., 89 hips (45%) were class I, 57 (29%) were class II, 35 (18%) were class III, 12 (6%) were class IV, and 4 (2%) were class V. Analyses revealed statistically significant differences between group B versus group C with regard to the classifications of Stulberg et al. and Mose, lateral acetabular shape, age at onset, and limb-length discrepancy. There was no significant statistical difference with regard to the types of treatment. Containment treatment of a deformed femoral head from LCPD improves the sphericity of the hip and gives 63% satisfactory results according to the Mose classification and 74% satisfactory results according to the Stulberg et al. classification.

Prevalence of Charcot-Marie-Tooth disease in patients who have bilateral cavovarus feet.

Abstract: It is not uncommon to see a patient with bilateral cavovarus feet in the outpatient setting. A large percentage of these patients are subsequently diagnosed with an associated condition, such as Charcot-Marie-Tooth disease. The purpose of the present report was to determine the prevalence of Charcot-Marie-Tooth disease in children who have bilateral cavovarus feet. A chart review of children with bilateral cavovarus feet was done. Patients were excluded if they had an existing medical problem known to be associated with bilateral cavovarus feet. Charcot-Marie-Tooth disease was diagnosed after a clinical assessment by an orthopaedic surgeon and a neurologist. The diagnosis was confirmed by either standard nerve conduction velocity studies and/or the CMT DNA Duplication Detection Test (Athena Diagnostics Inc, Worchester, MA). A positive family history was noted only if the diagnosis had been confirmed by a nerve conduction velocity study and/or CMT DNA Duplication Detection Test. One hundred forty-eight patients met the study criteria. The probability of a patient with bilateral cavovarus feet being diagnosed with Charcot-Marie-Tooth disease, regardless of family history, was 78% (116 patients). A family history of Charcot-Marie-Tooth disease increased the probability to 91%. It is recommended that all patients with bilateral cavovarus feet, especially with a known family history, be investigated for Charcot-Marie-Tooth disease.

Congenital and developmental deformities of the spine in children with myelomeningocele

The treatment of spinal deformities in children with myelomeningocele poses a formidable task. Multiple medical comorbidities, such as insensate skin and chronic urinary tract infection, make care of the spine difficult. A thorough understanding of the natural history of these deformities is mandatory for appropriate treatment to be rendered. A team approach that includes physicians from multiple specialties provides the best care for these patients. The two most challenging problems are paralytic scoliosis and rigid lumbar kyphosis. The precise indications for surgical intervention are multifactorial, and the proposed benefits must be weighed against the potential risks. Newer spinal constructs now allow for fixation of the spine in areas previously difficult to instrument. Complications appear to be decreasing with improved understanding of the pathophysiology associated with myelomeningocele.

Surgical treatment of scoliosis in Marfan syndrome: guidelines for a successful outcome.

Twenty-three patients with Marfan syndrome who had a posterior spinal arthrodesis, with or without instrumentation, autogenous iliac crest bone graft, and postoperative immobilization were retrospectively reviewed to formulate guidelines for the treatment of scoliosis. Patients in group 1 (7 patients) had both the primary and secondary curves arthrodesed, whereas patients in group 2 (16 patients) underwent selective arthrodesis of the entire primary and a partial arthrodesis of the secondary curves. Thirteen patients had triple curves, nine had double curves, and one patient had a single curve. At the time of follow-up all patients in group 1 had minimal or no progression of their curves, whereas 5 patients in group 2 had minimal or no progression and 11 had marked progression of at least one curve. There were no pseudarthroses or hardware failures. The authors recommend arthrodesing both the primary and secondary curves in all patients with Marfan syndrome.