Roger F. Widmann

Osgood Schlatter syndrome

Purpose of review Osgood Schlatter syndrome presents in growing children (boys, 12–15 years; girls, 8–12 years) with local pain, swelling and tenderness over the tibial tuberosity. Symptoms are exacerbated with sporting activities that involve jumping (basketball, volleyball, running) and/or on direct contact (e.g. kneeling). With increased participation of adolescent children in sports, we critically looked at the current literature to provide the best diagnostic and treatment guidelines. Recent findings Osgood Schlatter syndrome is a traction apophysitis of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity. Radiographic changes include irregularity of apophysis with separation from the tibial tuberosity in early stages and fragmentation in the later stages. About 90% of patients respond well to nonoperative treatment that includes rest, icing, activity modification and rehabilitation exercises. In rare cases surgical excision of the ossicle and/or free cartilaginous material may give good results in skeletally mature patients, who remain symptomatic despite conservative measures. Summary Osgood Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases.

Spinal deformity, pulmonary compromise, and quality of life in osteogenesis imperfecta.

STUDY DESIGN A cross-sectional radiologic and clinical study of patients with osteogenesis imperfecta. OBJECTIVES To determine whether pulmonary compromise is more closely correlated with scoliosis, kyphosis, or chest wall deformity in the population with osteogenesis imperfecta, and to assess the impact of spinal deformity, chest wall deformity, and pulmonary function on quality of life. SUMMARY OF BACKGROUND DATA The incidence of scoliosis in osteogenesis imperfecta is between 39% and 80%. Up to 60% of patients with osteogenesis imperfecta have significant chest wall deformities. Pulmonary compromise is the leading cause of death in adults with osteogenesis imperfecta. METHODS Fifteen patients with osteogenesis imperfecta between the ages of 20 and 45 were evaluated with sitting or standing anteroposterior and lateral radiographs of the entire spine, pulmonary function testing, and a validated health self-assessment questionnaire (Short Form-36). Radiographs were evaluated for thoracic scoliosis, thoracic kyphosis, and chest wall deformity. Correlation analysis was performed. RESULTS Thoracic scoliosis was strongly correlated with decreased predicted vital capacity (r = -0.76). Significant diminution in vital capacity below 50% occurred at a curve magnitude of 60 degrees. Kyphosis and chest wall deformity were not predictive of decreased pulmonary function. Physical health (PCS) was closely correlated with predicted vital capacity (r = 0.65; P < 0.01) and with scoliosis (r = -0.52; P < 0.05). CONCLUSIONS Thoracic scoliosis of more than 60 degrees has severe adverse effects on pulmonary function in those with osteogenesis imperfecta. This finding may partly explain the increased pulmonary morbidity noted in adult patients with osteogenesis imperfecta and scoliosis compared with that in the general population.

Relationships among musculoskeletal impairments and functional health status in ambulatory cerebral palsy.

Orthopedic surgery for patients with cerebral palsy addresses motion impairments, assuming that this will improve motor function. This study evaluates the relationships among clinical impairment measures with standardized assessments of function and disability as an initial step in testing this assumption. A total of 129 ambulatory children and adolescents across six institutions participated in a prospective evaluation that consisted of passive motion and spasticity examination of the lower extremities, three-dimensional gait temporal-spatial and kinematic analysis, and administration of the Gross Motor Function Measure (GMFM) and the Pediatric Outcomes Data Collection Instrument (PODCI). The analysis found that isolated impairment measures of motion and spasticity were only weakly related to motor function in cerebral palsy and even when averaged across multiple joints yielded no more than a fair correlation with functional scores, nor did a combination of impairments emerge that could predict substantial variance in motor function. These findings suggest that caution should be exercised when anticipating functional change through the treatment of isolated impairment and that addressing multiple impairments may be needed to produce appreciable effects.

Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique.

Objectives: Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement. Design: Single cohort retrospective. Setting: Metropolitan university tertiary care center. Patients and Participants: Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%). Intervention: Patients were treated with a combination of medial and lateral pins using a mini-incision technique. Main Outcome Measurements: Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing. Results: The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period. Conclusions: The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.

Cast immobilization versus percutaneous pin fixation of displaced distal radius fractures in children: a prospective, randomized study.

Thirty-four patients were enrolled in a prospective randomized study comparing cast immobilization alone versus percutaneous pin fixation following closed reduction of distal radial metaphyseal fractures. Patients older than 10 years of age with greater than 30 degrees of dorsal angulation or with complete fracture displacement were eligible for enrollment. Average follow-up was 10.5 weeks. All fractures healed uneventfully without deformity, growth arrest, or functional limitations. Overall complication rates were similar between groups. Thirty-nine percent of patients treated with casting had subsequent loss of reduction requiring remanipulation; there were no cases of loss of reduction in patients treated with pin fixation. Thirty-eight percent of patients treated with pin fixation had pin-related complications; all resolved following pin removal without long-term sequelae. Cost analysis showed no significant difference in treatment charges between groups. Treating surgeons should be aware of the potential short-term complications of each treatment method and adjust their postoperative care appropriately.

Clinical Value of Routine Preoperative Magnetic Resonance Imaging in Adolescent Idiopathic Scoliosis: A Prospective Study of Three Hundred and Twenty-seven Patients

Background: The prevalence of intraspinal pathology associated with scoliosis has been reported to be as high as 26% in some series1, and, on the basis of this finding, preoperative magnetic resonance imaging is used in the screening of patients with adolescent idiopathic scoliosis. However, this practice continues to be highly controversial. In order to better resolve this issue, we performed what we believe to be the largest prospective study to evaluate the need for preoperative magnetic resonance imaging in patients with adolescent idiopathic scoliosis requiring arthrodesis of the spine. Methods: A total of 327 consecutive patients with adolescent idiopathic scoliosis were evaluated between December 1991 and March 1999. All patients in the study presented with an adolescent idiopathic scoliosis curve pattern and had a complete physical and neurologic examination. Magnetic resonance imaging of the brain and the spinal cord were performed as part of their preoperative work-up. Results: Seven patients had an abnormality noted on magnetic resonance imaging. These abnormalities included a spinal cord syrinx in two patients (0.6%) and an Arnold-Chiari type-I malformation in four (1.2%). One patient had an abnormal fatty infiltration of the tenth thoracic vertebral body. No patient required neurosurgical intervention or additional work-up. All patients who underwent spinal arthrodesis with segmental instrumentation tolerated the surgery without any immediate or delayed neurologic sequelae. Conclusions: The fact that magnetic resonance imaging did not detect any important pathology in the large number of patients in this study strongly suggests that magnetic resonance imaging is not indicated prior to arthrodesis of the spine in patients with an adolescent idiopathic scoliosis curve pattern and a normal physical and neurologic examination.

Resection arthroplasty of the hip for patients with cerebral palsy: an outcome study.

Thirteen patients (18 hips) with cerebral palsy and painful hip subluxation or dislocation underwent proximal femoral resection-interposition arthroplasty (PFRIA) as a salvage procedure for intractable pain or seating difficulty. Eleven patients (14 hips) had a prior failed soft-tissue or bony reconstruction. The average age at surgery was 26.6 years (range, 10.7-45.5 years), and average follow-up was 7.4 years (range, 2.2-20.8 years). All patients/caregivers noted significant improvement in subjective assessment of pain after the surgery. Upright sitting tolerance improved from an average preoperative value of 3.2-8.9 h postoperatively (p < 0.01). Four patients who were unable even to sit in a customized wheelchair before the operation could be easily seated in a custom chair after surgery. Hip range of motion including flexion, extension, and abduction was significantly improved postoperatively (p < 0.05). Single-dose radiation therapy was used postoperatively for five hips and resulted in a significantly lower grade of heterotopic ossification at final follow-up (p < 0.005). Skeletal traction in the postoperative period did not prevent proximal migration of the femur compared with skin traction. Maximal pain relief was achieved at an average of 5.6 months postoperatively (range, 0.03-14 months). Complications included transient postoperative decubitus ulceration (four patients), pneumonia (two patients), and symptomatic heterotopic bone (two patients). The significant improvements in pain management, sitting tolerance, and range of motion suggest that PFRIA is a reasonable salvage procedure for the painful, dislocated hip in cerebral palsy. Resolution of pain may not be immediate, as was noted in this series.

Measurement variance in limb length discrepancy: clinical and radiographic assessment of interobserver and intraobserver variability.

The purpose of this study was to assess interobserver and intraobserver variability in the assessment of clinical and radiographic measurement of lower limb length discrepancy. Clinical measurements included direct measurement with a tape measure from anterior superior iliac spine (ASIS) to lateral malleolus and ASIS to medial malleolus as well as block measurement. Slit scanogram radiographic measurement was also evaluated. All three clinical measurements had excellent reliability, but the relatively large mean differences and the large 95% confidence intervals for clinical measurements limit the usefulness of these techniques. Slit scanogram measurement was the most reliable measurement technique. The intraobserver variance of direct slit scanogram measurement included intraclass correlation coefficient of 0.99, mean difference of 0.1 cm, and 95% confidence interval of 0.4 cm. Results were not influenced by patient age or body mass index. Slit scanogram measurement is the preferred method for assessment of limb length discrepancy. The direct slit scanogram measurement described in the text follows the mechanical axis line of the leg in the “at ease” standing position described by Paley. Direct measurement using a measuring tape on a full-length slit scanogram is more reliable than indirect measurement using horizontal lines drawn to a radiolucent ruler that is positioned by a technician, since direct measurement avoids errors due to nonparallel positioning of the limb relative to the ruler, and direct measurement also avoids errors due to non-horizontal lines drawn from standard bony landmarks to the ruler. The ideal radiographic measurement technique would have high reliability and accuracy and would minimize or eliminate radiation.

Down syndrome: orthopedic issues.

Purpose of review The purpose of this review is to update the role of the orthopedic surgeon in the management of Down syndrome as these patients are living longer and participating in sporting activities. Recent findings Approximately 20% of all patients with Down syndrome experience orthopedic problems. Upper cervical spine instability has the most potential for morbidity and, consequently, requires close monitoring. Other conditions such as scoliosis, hip instability, patellar instability and foot problems can cause disability if left untreated. In some of these conditions, early diagnosis can prevent severe disability. Summary Surgical intervention in children with Down syndrome has a high risk of complications, particularly infection and wound healing problems. Careful anesthetic airway management is needed because of the associated risk of cervical spine instability.

Long-Term Magnetic Resonance Imaging Follow-up Demonstrates Minimal Transitional Level Lumbar Disc Degeneration After Posterior Spine Fusion for Adolescent Idiopathic Scoliosis

Study Design. Retrospective cohort study. Objective. To describe long-term clinical and imaging results focusing on the uninstrumented lumbar spine after posterior spinal fusion for adolescent idiopathic scoliosis. Summary of Background Data. Although previous studies found rates of low back pain after long fusion for adolescent idiopathic scoliosis which are comparable to rates found in the general population, many surgeons believe that the long lever arm associated with the fusion mass will result in increased stress at uninstrumented caudal intervertebral discs and accelerated degenerative changes. Methods. This is a retrospective chart and imaging review of adolescent idiopathic scoliosis patients treated with posterior fusion and segmental instrumentation. Patients completed follow-up examination, outcome questionnaires, radiographs, and magnetic resonance (MR) imaging. MR images were scored for evidence of degeneration of lumbar discs below the level of the fusion. Results. Twenty patients participated in the study, providing 90 discs below fusions for evaluation. The average follow-up was 11.8 years. The distal level of fixation was at L1 on average. The major curve averaged 55° ± 11° before surgery and was corrected to 25° ± 10° at follow-up. Follow-up MR imaging demonstrated new disc pathology in 85% of patients enrolled. Only one patient demonstrated significant degenerative disc disease at the junctional level, whereas most pathology was seen at the L5–S1 disc. The average Pfirrmann grade at uninstrumented levels deteriorated from 1.1 before surgery to 1.8 at follow-up. The greatest degree of degeneration was seen at the L5–S1 disc space where average degenerative scores increased from 1.2 before surgery to 2.3 after surgery. Three patients with severe disc disease were taking nonsteroidal anti-inflammatory drugs for pain, but no narcotics. Only mild scoliosis research society (SRS) and Oswestry changes were noted in this severe degeneration group. Conclusion. Despite demonstrating an accelerated rate of L5–S1 disc degeneration, our study group has good functional scores and maintenance of correction over 10 years postfusion. In this long-term MR imaging follow-up study, disc degeneration was found remote to the lowest instrumented vertebra.