Joseph A. Gerardi

The safety of continuous epidural infusion for postoperative analgesia in pediatric spine surgery.

Epidural analgesia and anesthesia are standard regional techniques in orthopaedic surgery of the lower extremities. Benefits of epidural anesthetic infusions include excellent analgesia, minimal respiratory depression, no somnolence, and decreased need for blood transfusion. Adverse effects include pruritus, nausea, and urinary retention, but standard methods have evolved to counter each adverse effect. A continuous epidural infusion of opioid and bupivacaine was used as the principal postoperative analgesic for 71 young patients undergoing surgery for the correction of spinal deformity. The infusion was titrated to a point at which each patient denied having any pain and was maintained for an average of 2.9 days. Sixty-four patients experienced satisfactory analgesia with minimal adverse effects. The technique worked despite multiple laminotomies for segmental fixation and did not compromise neurologic assessment. We conclude that epidural analgesia is as safe and effective after spinal-deformity surgery as it is after other types of surgery.

Combined asymptomatic congenital anterior and posterior deficiency of the atlas

Abstract. Atlas anomalies in terms of clefts and aplasia are rare. They can sometimes simulate fractures and need further evaluation. Imaging in terms of CT and MR can help resolve diagnostic confusion and also outline associated neurological involvement. A rare anomaly of anterior and posterior atlas arch, previously unclassified, is presented.

Musculoskeletal Coccidioidomycosis: A Review of 25 Cases

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal involvement is rare, and there are few reports with clear recommendations regarding treatment. The purpose of this study was to review a series of 25 patients with musculoskeletal coccidioidomycosis and to assess their outcomes with respect to presentation and treatment. There were 36 lesions among the 25 patients, 8 located in the spine, with the remainder distributed throughout the body. Seventeen patients had a delay in diagnosis of more than 1 month. Eight patients had an elevated white blood cell count, and 10 had an elevated sedimentation rate. Only 7 of the patients had an overt pneumonia before the musculoskeletal presentation. Twenty-four patients underwent formal irrigation and debridement and 22 patients had at least 1 course of Amphotericin B. The average followup after the initiation of treatment was 3.5 years, ranging from 2 to 10 years. Seven patients had recurrent lesions that required further surgical intervention, 4 of whom had a delay in diagnosis of more than 1 month. There were 3 deaths. All surviving patients were free of disease at final followup.

Injuries when children reportedly fall from a bed or couch.

One-hundred-fifteen patients with orthopaedic injuries resulting from a reported fall from a piece of furniture at home were studied to define the relationship of suspected child abuse associated with this mechanism of injury. One hundred-thirteen patients sustained fractures or dislocations and two patients were impaled with a pencil and a needle. Each patient was evaluated by a primary care physician or an emergency room physician and by an orthopaedic surgeon. In six of 115 patients (5%), a treating physician filed a child abuse report. In 109 patients (95%) the purported mechanism of injury was considered sufficient to produce the resulting injury. Two of four children younger than 1 year (50%), four of 83 children 1 to 5 years (5%), and none of the 28 children older than 5 years were investigated for potential child abuse. Orthopaedic injuries reportedly attributable to a child falling from a bed or couch at home usually are accidental unless the child is younger than 1 year.

Prevalence of positive preoperative pregnancy testing in teenagers scheduled for orthopedic surgery.

The pregnancy status of female teenagers presenting for orthopaedic surgery is often unknown. Anesthetics may have teratogenic or abortive effects. The authors report the results of a screening program for unrecognized pregnancy in 532 female teenagers presenting for orthopaedic surgery. Five patients with a positive urine human chorionic gonadotropin test were identified, for a prevalence of 1 positive result in 106 patients tested (0.9%). Surgery was cancelled in each case.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Opinion survey regarding pediatric orthopaedic trauma call and emergency trauma management.

Background: To determine the attitudes and practices of pediatric orthopaedic surgeons regarding on-call coverage and emergency fracture management. Methods: A 32-question online survey was sent to all 597 active members of the Pediatric Orthopaedic Society of North America. There were 296 completed surveys, for a response rate of 49.6%. Results: Of the respondents, 85.1% were male. The respondents ranged in age from 30 to older than 70 years, with 54% between 36and 50 years of age, corresponding to an average of 15 years in practice. Seventy-seven percent of the respondents felt that taking trauma call is an integral aspect of being a pediatric orthopaedist. Of the respondents, 64.9% take call 1 to 9 times per month, 15.8% take 10 to 19 calls, 2.7% take 20 or more, and 16.6% take no call. The number of orthopaedists taking call per practice was fairly evenly distributed between 3 and 10. Call was shared equally in 32% of practices, and mandatory in 72%. Twenty-eight percent of the respondents were additionally compensated for taking calls, in amounts ranging from

Four cases of injury involving soda vending machines.

100 to

Preliminary Report: Pediatric Femur Fractures: Single Incision Intramedullary Stabilization Technique.

2000 per night, with 1000 dollars the most common rate. One third of operative cases are done that night; one third, the next day; and one third, later in the week. Twenty-four percent of the respondents have dedicated operative block time on the day after the call. Forty-seven percent have a dedicated fracture clinic, of which 51% receive institutional support. Conclusions: Providing emergency trauma care for children is an integral aspect of pediatric orthopaedics. This survey provides information on the attitudes and strategies of practicing pediatric orthopaedic surgeons in the face of decreasing manpower and increasing demand for such services.

Single incision pediatric flexible intramedullary tibial nailing

Injuries resulting from rocking soda vending machines are severe and potentially fatal. Four cases of significant trauma stemming from soda vending machine accidents are reported: One patient died, one is disabled, and two healed uneventfully. As a result, we recommend securing heavy soda vending machines to prevent further injuries. To our knowledge, this is the first report on a mechanism of injury resulting from soda machines.