Joel A. Lerman

Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors.

A cohort of 93 patients with developmental dysplasia of the hip (DDH) treated with a Pavlik harness were evaluated to determine predictors of treatment failure. Failure was defined as failure to achieve or maintain hip reduction in the Pavlik harness. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US &agr; angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction.

Reliability of radiographic parameters in neuromuscular scoliosis.

Study Design. Retrospective review of radiographic data. Objectives. This study sought to define interoberserver and intraobserver variability to further delineate reliable means by which radiographs of patients with neuromuscular scoliosis can be examined. Summary of Background Data. Previous studies analyzed the use of Cobb angles in the measurement of idiopathic and congenital scoliosis, but no study until now describes a critical analysis of measurement in evaluating neuromuscular scoliosis. Methods. Forty-eight patients with neuromuscular scoliosis radiographs were reviewed. These were evaluated for Cobb angle, end vertebrae selection, Ferguson angle, apex of the curve, C7 balance, pelvic obliquity, Risser sign, status of the triradiate cartilage, kyphosis Cobb angle, endplate selection for kyphosis, and kyphotic index. Interclass and intraclass variability was examined with statistical analysis. Results. Cobb angle had an intraobserver variability was 5.7° and the interobserver variability was 14.8°. The intraobserver and interobserver variability for Ferguson angle was 6.8° and 20.6°, respectively. The kyphotic Cobb angle intraobserver variability was found to be 17.4°, and the interobserver variability was 24.01°. Conclusions. Neuromuscular scoliosis radiographs can be reliably analyzed with the use of Cobb angle. Other forms of analysis, such as Ferguson angle, are not as reliable. Pelvic obliquity should be measured from the horizontal, as other methods are not as reliable. Kyphosis is best evaluated with the use of the kyphotic Cobb angle. Finally, it is felt that a separate anteroposterior pelvis radiograph should be used to assess skeletal maturity, as scoliosis films often truncate the vital anatomy necessary to determine skeletal maturity.

The Pediatric Outcomes Data Collection Instrument (PODCI) and functional assessment of patients with unilateral upper extremity deficiencies.

The Pediatric Outcomes Data Collection Instrument (PODCI) questionnaire was used to quantify functional abilities of a group of unilateral upper extremity deficiency (U-UED) patients and compare them with “normal” control children. Sixty-four consecutive patients with U-UED were assessed. Parents and adolescent (ages 11-21) patients responded. Underlying diagnosis, amputation level, and type of prosthesis were recorded. Scores were compared for congenital versus traumatic etiologies for patients with various amputation levels, and for patients using prostheses versus those not using prostheses. In both parent and patient responses, PODCI scores were significantly lower than “normal” for upper extremity function and sports. Scores were similar for congenital and acquired amputees. Responses from adolescent patients showed progressively decreasing scores for upper extremity, transfers, sports, and global function with progressively proximal amputation levels. Patients using prostheses with different terminal devices did not significantly differ. Parent responses for prosthesis wearers showed lower comfort/pain scores (ie, increased pain) than non-prosthesis wearers, but no significant differences in function, including upper extremity function.

Assessment of children with brachial plexus birth palsy using the Pediatric Outcomes Data Collection Instrument.

The purpose of this study was to determine whether the Pediatric Outcomes Data Collection Instrument (PODCI) measures differences in function between children with brachial plexus birth palsy (BPBP) who are candidates for shoulder tendon surgery and age-matched controls. The PODCI was administered prospectively to 23 children with BPBP who were candidates for shoulder tendon surgery. Their results were compared with published PODCI data for control subjects, and factors associated with function within the BPBP cohort were determined. Children in the BPBP cohort had significantly lower PODCI scores in upper extremity function, sports, and global function than control subjects. Limited active shoulder external rotation was significantly associated with lower functional scores. The PODCI measures diminished upper extremity function in children with BPBP who are candidates for shoulder tendon surgery, thereby showing promise as a tool for measuring baseline function and postoperative functional gains for children with BPBP.

Spinal arthrodesis for scoliosis in Down syndrome.

The results of operative treatment of scoliosis in Down syndrome at one institution are reviewed. Seven patients with progressive scoliosis who had undergone arthrodesis of the thoracolumbar spine were identified. Clinical and radiographic results were noted, as were any complications. Mean patient follow up was 9 years (range 2–25). All patients eventually showed radiographic evidence of solid fusion with no curve progression. One patient had undergone a revision procedure for pseudoarthrosis and failure of Dwyer instrumentation. Other complications included a lateral subluxation under the fusion area, pneumonia, and one asymptomatic hook dislodgment. Progressive deformities of the thoracolumbar spine in Down syndrome patients can be treated with fusion and instrumentation with cessation of progression. As is the case for upper cervical fusion in these patients, the complication rate is notable.

A biomechanical comparison of Gardner-Wells tongs and halo device used for cervical spine traction.

Summary of Background Data Unstable cervical spine fractures and dislocations are often reduced by the application of axial traction using a halo or Gardner-Wells tongs. Failure of tong or halo attachment can cause substantial morbidity and usually occurs at the pin-bone interface. Institutions commonly clean and reuse tongs. The effect of tong wear on pullout strength and the strength of the halo used as a traction device have not been documented. Methods A skull model biomechanically similar to human calvarium was used to compare the axial pullout strengths of four sets of new tongs, three sets of rarely used tongs, and one set of heavily used tongs, as well as a standard four-pin halo. Results The pullout strength of tongs tightened to the manufacturers recommended level appeared to decrease with increased use. Measurement of the pin force generated by each set of tongs and of the spring constant of each spring, as well as inspection of the tongs after testing, suggested that the decrease in pullout strength may be partly attributable to spring and/or pin wear. The pullout strength of the halo or of the new or slightly used tongs but not the heavily used tongs exceeded the maximum weight used clinically in cervical spine traction. Conclusion The data suggest that consideration be given to replacement or recalibration of heavily used tongs.

Free vascularized fibular transfer with langenskiold procedure for the treatment of congenital pseudarthrosis of the forearm.

Congenital pseudarthrosis of the radius or ulna is a rare entity. It is associated with neurofibromatosis, but occurs much less commonly than congenital pseudarthrosis of the tibia. Pseudarthrosis of the forearm can lead to pain, deformity, and limited forearm rotation. Nonsurgical management leads to poor results, as do surgical treatments such as open reduction internal fixation and conventional bone grafting. The transfer of a free vascularized fibula to the forearm pseudarthrosis has been more successful, and it is our preferred method of treatment for children with this condition. Because the transfer is often performed in young children, there is the potential for valgus deformity at the ankle after the fibula is removed. We describe here our technique for the transfer, including the technique for distal tibiofibular fusion (Langenskiöld procedure) after removal of the fibular graft. In addition, we present the results of 5 patients who have undergone this combination of procedures for pseudarthrosis of the forearm at our institution.

Effects of skin grafting on successful prosthetic use in children with lower extremity amputation.

The use of skin grafts after lower extremity amputation in pediatric patients remains a controversial decision. A skin graft may help to preserve residual limb length and knee joint function; however, the literature suggests that it may make the patient more susceptible to complications. Directly contrasting children with and without skin grafts on their residual limbs will provide important data for the clinician making this decision. This study compares amputation characteristics, complications, and functional outcomes of these two populations. A retrospective chart analysis was performed on 45 pediatric patients who underwent lower extremity amputation between 1997 and 2006. Patients were divided into two groups: the graft group had skin grafts on their residual lower extremity limb(s) and the no graft group had no skin grafts present on the residual lower extremity limb(s). The mean time from amputation to follow-up was 4.5 years in the graft group and 7.0 years in the no graft group (P = .07). The average age at amputation for the graft group was 9.4 ± 1.4 years and 5.9 ± 1.1 years for the no graft group (P = .04). The graft group had a significantly longer hospital stay with 91 inpatient days vs 31 inpatient days in the no graft group (P = .03). There was no increased incidence of surgical revisions or reported problems with prosthetic wear in the graft group. Both groups achieved comparable levels of independence with ambulation. The presence of skin grafts on a child’s amputated limb does not adversely affect functional outcome and does not lead to greater prosthetic complications for the child.

Protection of the remaining spinal cord function with intraoperative neurophysiological monitoring during paraparetic scoliosis surgery: a case report.

ObjectiveTo demonstrate the usefulness of rectus femoris muscle MEPs monitoring in a paraparetic neuromuscular scoliosis case.MethodsMultiple monitoring modalities including SEPs, MEPs and EMG were performed for an anterior and posterior correction surgery for a neuromuscular scoliosis patient with no motor and sensory function below the knees.ResultsBilateral tibial nerve SEPs were absent, and no MEPs were recordable from anterior tibialis and abductor hallucis muscles bilaterally at baseline. Robust MEPs were recorded on abductor pollicis brevis and rectus femoris muscles bilaterally. Spinal cord monitoring mainly relied on MEPs from bilateral rectus femoris muscles (RF-MEPs). Twice RF-MEPs were absent following deformity correction and returned after removal of both rods. The patient’s remaining spinal cord function was preserved.ConclusionsIntraoperative neurophysiological monitoring should be used for neuromuscular scoliosis cases with paraparesis if proximal function, such as the rectus femoris muscle, exists.

Open Versus Closed Halo Rings : Comparison of Fixation Strengths

Study Design and Objective. A mechanical skull model was used to compare axial loads to failure for three marketed and one experimental halo ring. Summary of Background Data. Open-back halo rings have become increasingly popular; however, to the authors’ best knowledge the literature provides no comparison of the fixation strength of an open-back halo versus the traditional closed design. Methods. A model biomechanically similar to a human skull was used to compare the axial force necessary to distract each of four halo rings to failure. Three clinically used halo rings were compared: a closed titanium ring, an open titanium ring, and an open graphite ring. One additional open titanium halo ring was constructed with an angular profile; this ring was compared with the clinically used halos. Results. The mean force to failure for the closed titanium ring significantly exceeded that for the open rings (P < 0.005). No significant differences were noted among the open halo rings. Discussion. The data obtained by use of this biomechanical model show that the closed halo ring provides distraction strength greater than that of the open rings, suggesting a more rigid system with the closed device. Use of an angular halo did not improve fixation strength in the open ring device. These findings may support use of a closed halo ring in cervical spine traction and immobilization, if this greater strength is shown to be sufficiently clinically important to offset any disadvantages of a closed ring.