Michael Conklin

Posterior cranial fossa volume in patients with rickets: insights into the increased occurrence of Chiari I malformation in metabolic bone disease.

OBJECTIVE:Some have proposed that the calvarial thickening seen in patients with rickets results in an increased rate of Chiari I malformation (CIM) in these patients. The present study measures the posterior fossa volume in children with rickets to verify previous case reports indicting a small posterior fossa as the cause for an increased rate of CIM in children with rickets. METHODS:Patients were chosen by use of a computer database to search for individuals diagnosed with rickets. Nineteen patients were identified with this diagnosis. Seven patients were found from this cohort to have imaging of the head. Axial computed tomographic and magnetic resonance images were analyzed by use of the Cavalieri method to define posterior fossa volumes. These data were then compared with those from age-matched control subjects. RESULTS:Mean volumes of the posterior fossa were significantly reduced in all patients compared with age-matched control subjects (P < 0.0001). CONCLUSION:We have found that the volume of the posterior fossa is significantly smaller in children with rickets versus age-matched control subjects. Furthermore, 29% of our study group had an associated CIM. We may hope that these data will aid in the further understanding of the pathophysiology of CIM in cases of metabolic bone disease.

Molecular characterization of a patient with an interstitial 1q deletion [del(1)(q24.1q25.3)] and distinctive skeletal abnormalities†

Here we report on a patient with an interstitial deletion on the long(q) arm of chromosome 1 who presents with a unique constellation of anomalies including brachydactyly type E, Müllerian agenesis, growth hormone deficiency, as well as other abnormalities. We present the clinical details of this patients presentation, the skeletal findings, and provide characterization of the deletion at the molecular level. We postulate that these skeletal anomalies are distinctive to 1q deletions involving the 1q24q25 region.

L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus

IntroductionSpondylolysis is most commonly observed in the lumbar spine, particularly L5, and is associated with spondylolisthesis, or anterior “slippage” of a vertebra in relation to an adjacent vertebra. Isthmic spondylolisthesis is the result of a pars interarticularis defect and will be the only type of spondylolisthesis addressed in this review.ConclusionsSpondylolysis and spondylolisthesis represent a relatively common cause of low back pain, especially in young athletes, and a less common cause of neurologic compromise. When discovered in a symptomatic patient with corroborating imaging findings, early intervention provides an excellent prognosis. Herein, we review the anatomy and pathology of spondylosis and spondylolisthesis of the L5 vertebra.

Presentation of distal humerus physeal separation.

Objectives: The study was undertaken to describe the presenting features of children with physeal separation of the distal humerus and review the radiographic features of the diagnosis. Methods: The charts of all children with elbow injuries aged 3 or younger were reviewed to find those with distal humerus physeal separation. Presenting complaint, initial diagnosis, and time to correct diagnosis were recorded. Results: Of 101 children aged 3 or younger with elbow fractures, 7 were noted to have distal humerus physeal separation. All patients presented with pain, swelling, or disuse. Two cases resulted from suspected or confirmed nonaccidental injury. In no case was a diagnosis of distal humerus physeal separation assigned by the emergency physician or radiologist. Delay in assignment of final diagnosis ranged from 2 to 14 days. Conclusions: Physeal separation of the distal humerus is an unusual injury but accounts for a significant number of elbow fractures in children 3 or younger. Attention to the radiographic relationship of the ulna and humerus and an appropriate index of suspicion are keys to diagnosis. Nonaccidental injury should be considered as an etiology.

The Use of Chewing Gum Postoperatively in Pediatric Scoliosis Patients Facilitates an Earlier Return to Normal Bowel Function

PURPOSE In surgical correction of scoliosis in pediatric patients, gastrointestinal complications including postoperative ileus can result in extended hospital stays, poorer pain management, slower progression with physical therapy, and overall decreased patient satisfaction. In patients undergoing gastrointestinal, gynecological, and urological surgery, gum chewing has been shown to reduce time to flatus and passage of feces. The authors hypothesized that chewing gum could also speed return to normal bowel function in pediatric patients undergoing surgical correction of scoliosis. METHODS The researchers obtained institutional review board approval for a prospective, randomized, controlled trial. Eligible patients included all adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. Exclusion criteria included previous gastrointestinal surgery or preexisting gastrointestinal disease. Patients were randomized by coin flip. The treatment group chewed sugar-free bubble gum 5 times a day for 20 to 30 minutes beginning on postoperative day 1; the control group did not chew gum. Patients were asked a series of questions regarding subjective gastrointestinal symptoms each day. Time to flatus and first passage of feces were recorded as indicators of return to normal bowel function. Normality of data was assessed using normal probability plots. RESULTS A total of 83 patients completed the study (69 females and 14 males; mean age, 14.4 years). Of the 42 patients in the chewing gum group, 8 elected to stop chewing gum regularly before discharge for to a variety of reasons. Patients who chewed gum experienced first bowel movement on average 145.9 hours after surgery, 30.9 hours before those who did not chew gum (p = .04). Gum-chewing patients first experienced flatus an average of 55.2 hours after surgery, compared with 62.3 hours for controls. This trend did not reach statistical significance (p = .12). No difference was noted in duration of hospital stay, medications administered as required, or subjective symptoms. CONCLUSION Chewing gum after posterior spinal fusion for scoliosis is safe and may speed return of normal bowel function. Chewing gum after surgical correction of scoliosis facilitates an earlier return to normal bowel function, which may improve patient satisfaction in the early postoperative period.

BMI and Magnitude of Scoliosis at Presentation to a Specialty Clinic

OBJECTIVE: To determine whether curve magnitude of scoliosis at presentation correlates with BMI. METHODS: Retrospective chart review of 180 patients presenting with scoliosis was performed. Curve pattern and magnitude, Risser status, occurrence of surgery, zip code, height and weight, race, and insurance status were recorded. Relationships were examined by Spearman rank and Pearson correlations, and logistic regression analysis was used to determine odds ratios. RESULTS: For both thoracic and lumbar curve patterns, there was a correlation between BMI and curve magnitude. Spearman rank correlation was 0.19 for thoracic (P = .03) and 0.24 for lumbar curves (P = .02). Overweight or obese patients were not more likely, however, to present with curves at higher risk of progression or more likely to have surgical intervention. With respect to potential confounding socioeconomic variables, thoracic curve magnitude was negatively correlated with median family income (Spearman rank correlation –0.17, P = .04). Curve magnitude was not correlated with race, distance, or insurance payer. CONCLUSIONS: Patients with high BMI and scoliosis are more likely to present with larger curves, but not more likely to require surgery. This is concerning because of the national trend of increasing childhood obesity and because scoliosis treatment may be more complicated in larger curves. Socioeconomic factors may also be barriers to access.

Predicting orthopedic involvement in patients with lipomyelomeningoceles

IntroductionLipomyelomeningoceles (LMM) occur in approximately 1 in every 4,000 live births in the United States. They are associated with a wide range of problems in affected patients, including skin abnormalities, sensory and motor deficits, pain, urinary bladder and anal sphincter dysfunction, and orthopedic deformities.Materials and methodsIn an effort to better understand the orthopedic complications associated with LMM, the present study examined the long-term orthopedic deformities in 50 patients after surgical correction of their LMM and observed for correlation between these deformities and the type and level of LMM.ResultsAnalysis of the collected data revealed a statistically significant relationship between of the type of LMM and the presence of orthopedic complications. However, no statistically significant relationship existed between the vertebral level of the LMM and the presence of orthopedic deformities. No correlation was identified between the level and type of LMM.ConclusionIn this study, caudal LMM were much more likely than either dorsal or transitional types to have orthopedic complications. These data may prove useful to clinicians in predicting outcome and in counseling patients and their parents.

Prospective evaluation of the use of Mitchell shoes and dynamic abduction brace for idiopathic clubfeet.

Ponseti treatment for clubfoot has been successful, but recurrence continues to be an issue. After correction, patients are typically braced full time with a static abduction bar and shoes. Patient compliance with bracing is a modifiable risk factor for recurrence. We hypothesized that the use of Mitchell shoes and a dynamic abduction brace would increase compliance and thereby reduce the rate of recurrence. A prospective, randomized trial was carried out with consecutive patients treated for idiopathic clubfeet from 2008 to 2012. After casting and tenotomy, patients were randomized into either the dynamic or static abduction bar group. Both groups used Mitchell shoes. Patient demographics, satisfaction, and compliance were measured with self-reported questionnaires throughout follow-up. Thirty patients were followed up, with 15 in each group. Average follow-up was 18.7 months (range 3–40.7 months). Eight recurrences (26.7%) were found, with four in each group. Recurrences had a statistically significant higher number of casts and a longer follow-up time. Mean income, education level, patient-reported satisfaction and compliance, and age of caregiver tended to be lower in the recurrence group but were not statistically significant. No differences were found between the two brace types. Our study showed excellent patient satisfaction and reported compliance with Mitchell shoes and either the dynamic or static abduction bar. Close attention and careful education should be directed towards patients with known risk factors or difficult casting courses to maximize brace compliance, a modifiable risk factor for recurrence. Level of evidence II: prospective comparative study.

Intradural spine surgery may not carry an increased risk of shunt revision compared with extradural spine surgery in pediatric patients with myelomeningocele

OBJECTIVE Patients with myelomeningocele are often affected by scoliosis and tethered cord syndrome, and frequently require spine surgery. Intradural spine surgeries may carry an inherently higher risk of inducing shunt malfunction due to entry into the subarachnoid space. In this study, the authors sought to compare rates of shunt malfunction after intradural and extradural spine surgeries among pediatric patients with myelomeningocele. METHODS The authors reviewed records of the National Spina Bifida Program Registry for Childrens Hospital of Alabama. The Exago reporting function was used to identify patients who had received at least one of the following procedures: shunt revision, tethered cord release (TCR), or spinal fusion for deformity. The registry records were reviewed for all identified patients to determine if a shunt revision was performed within the 1st year after TCR or spinal fusion. RESULTS Final analyses included 117 patients, of whom 39 underwent spinal fusion and 78 underwent TCR. Among patients who underwent spinal fusion, shunt revision was performed within 30 days in 2 patients (5.1%), within 60 days in 2 (5.1%), within 90 days in 4 (10.3%), and within 1 year in 5 (12.8%). Among patients who underwent TCR, shunt revision was performed within 30 days in 7 patients (9.0%), within 60 days in 10 (12.8%), within 90 days in 11 (14.1%), and within 1 year in 17 (21.8%). Using the log-rank test, there was no significant difference in Kaplan-Meier curves between intradural and extradural groups (p = 0.59). CONCLUSIONS In a review of single-institution registry data, the authors found no statistically significant difference in the risk of shunt malfunction after intradural and extradural spine surgeries.

Is retained bone debris in cannulated orthopedic instruments sterile after autoclaving

Aims: Cannulated surgical instruments may retain biologic debris after routine cleaning and sterilization. Residual debris after cleaning is assumed to be sterile; however, there is no experimental basis for this assumption. The purpose of this study was to determine the sterility of retained biodebris found within cannulated surgical instruments after autoclave sterilization. Materials and Methods: Fifteen cannulated drill bits were used to drill pig scapulae to create a plug of bone that was exposed to a mixture of Bacillus cereus, Pseudomonas aeruginosa, and methicillin‐resistant Staphylococcus aureus for 60, 120, or 180 minutes prior to sterilization. The drill bits were autoclave sterilized using standard settings. The “sterilized” bone cores were then incubated in solution and streak‐plated on blood agar. Results: All 3 positive controls were positive for the experimental bacteria. Two negative controls were positive for contaminant bacteria. A B. cereus strain was recovered from 1 of the experimental group drill bits in the 180‐minute group. Pulsed‐field gel electrophoresis confirmed that the recovered B. cereus strain was identical to the experimental inoculate. Conclusion: Retained biodebris in cannulated drills may not be sterile after standard autoclave sterilization. In addition, delay of surgical instrument reprocessing may increase the risk of resistant contamination.