Sherman S. Coleman

Rupture of the pectoralis major muscle. A report of eleven injuries and review of fifty-six.

1. Eight surgically confirmed ruptures of the pectoralis major are presented in detail. These and three other ruptures observed by our colleagues are added to the total of forty-five published cases. 2. The mechanisms of injury were direct trauma, excessive athletic stress, or attempts to prevent falls. The rupture occurs within the muscle belly, by avulsion of its tendinous insertion or separation of its musculotendinous junction. 3. The results of treatment depend on the portion of the muscle injured. Early surgical repair is recommended for the distal tendinous injuries, conservative therapy for ruptures of the muscle fibers. 4. Rupture of the pectoralis major muscle probably occurs much more frequently than reports would indicate.

Congenital pseudarthrosis of the tibia : treatment by transfer of the ipsilateral fibula with vascular pedicle

We performed five transfers of the ipsilateral fibula in the treatment of congenital pseudarthrosis of the tibia. In all cases, conventional treatment by intramedullary-rod and autogenous-iliac bone grafting had failed at least once. We hoped to avoid the use of contralateral-fibular grafting or other methods that have not yet been proven effective. The ipsilateral fibula was transferred, and its vascular pedicle left intact and secured to both fragments of the tibial pseudarthrosis by cerclage wires. All five transfers have united and hypertrophied with growth. We believe this salvage method is superior to others not only because of the successful results, but also because the intact limb is left undisturbed.

Coxa vara : Surgical outcomes of valgus osteotomies

Since the 1950s, valgus-producing femoral osteotomy has been the preferred treatment for significant coxa vara. Despite well-performed surgeries, the literature cites recurrence rates of 30-70%. The present study reviews our past 15 years of surgical experience for coxa vara; 26 children with 37 affected hips were retrospectively evaluated for outcome following valgus osteotomy. Both congenital and acquired types of coxa vara were included. Overall recurrence rate following valgus osteotomy was 50%. Age at time of surgery, type of surgery, and type of implant and etiology were found to have no bearing on recurrence. However, if Hilgenreiners epiphyseal angle was corrected to < 38 degrees, 95% of children had no recurrence of varus. In contrast, head-shaft angle was found not to be a reliable indicator of appropriate correction. Only six of 37 hips required pelvic osteotomy (five Pemberton, one Chiari) for dysplasia, and four of these had developmental dysplasia of the hip as the underlying etiology for their coxa vara. However, if the proximal femur was corrected and maintained before age 10, 83% of children had excellent acetabular depth, spherical congruency, relief from pain, and correction of Trendelenburg gait at latest follow-up.

Microvascularized free fibular grafts for reconstruction of skeletal defects after tumor resection.

A microvascularized free fibular graft was used to reconstruct a skeletal defect after tumor reconstruction in 13 consecutive patients. The patients were evaluated at an average follow-up of 53 months (range, 30-71). The status of each graft was evaluated for time to union, hypertrophy, functional evaluation, and complications. The average time to union was 6.5 months, and significant graft hypertrophy occurred in eight of 13 patients. Complications occurred in seven patients. Two of the 13 patients required removal of the microvascularized graft. Functional evaluation according the the Musculoskeletal Tumor Society yielded an average score of 90 (range, 83-97). The results were rated good or excellent in 11 of 13 patients, and two were rated failures. The microvascularized fibular graft provides an attractive option for the reconstruction of skeletal defects after tumor resection. The results of this procedure are especially good in skeletally immature patients.

The value of preliminary traction in the treatment of congenital dislocation of the hip

In forty-one children who had forty-seven congenitally dislocated hips, the results of attempted closed reduction with general anesthesia, but without preliminary traction, were studied. Twenty (43 per cent) of the hips could not be reduced closed, and an open reduction was needed. After the reduction, all of the involved hips were immobilized in the so-called human position (marked flexion and slight abduction). At a minimum follow-up of two years, osteonecrosis of the femoral head had developed in only two hips (4 per cent). Patients who were more than one year old when the hip was reduced had a higher incidence of osteonecrosis of the femoral head and were more likely to need reconstructive procedures later. Patients who were more than eighteen months old at the time of the attempted closed reduction were more likely to need an open reduction of the hip. Treatment of congenital dislocation of the hip in young children remains an extremely complex problem. It has not been clearly established that the use of preliminary traction decreases the incidence of osteonecrosis of the femoral head or improves the outcome of treatment. In our experience, uncomplicated (non-teratological, postnatal) congenital dislocation of the hip has been safely treated with either open or closed reduction without preliminary traction in patients who were younger than two years old, provided that the reduction could be obtained without excessive force.

Coxa breva: its pathogenesis and a rationale for its management.

Forty-four patients (50 hips) with symptomatic coxa breva underwent surgical treatment consisting of arrest and/or transfer of the “overgrown” greater trochanter. In a retrospective review, the authors compared the patients who underwent apophyseodesis to those treated by trochanteric transfer. The purpose was to clarify the indications for and results of each procedure. Patients ≤8 years of age benefited from apophyseodesis as a means of averting a Trendelenburg gait. Those patients presenting with an established Trendelenburg limp and those ≥9 years of age are best treated by distal and lateral transfer of the greater trochanter.

Pemberton Pericapsular Osteotomy to Treat a Dysplastic Hip in Cerebral Palsy

We reviewed the results of Pemberton pericapsular osteotomy in nineteen hips (fifteen patients) that were subluxated (fifteen hips) or dislocated (two hips) or had severe acetabular dysplasia (two hips) secondary to spastic cerebral palsy. At least one concomitant procedure was performed in fifteen hips. These procedures included an intertrochanteric osteotomy to correct excessive femoral anteversion or valgus deformity of the neck-shaft angle (thirteen hips), a soft-tissue release (nine hips), and an open reduction (three hips). Four hips had no concomitant procedure. Five of the nineteen hips were painful preoperatively. The average age of the patients at the time of the index operation was seven years and nine months (range, three years and five months to twelve years and three months). The average duration of follow-up was ten years and nine months (range, three years and one month to nineteen years and nine months). All osteotomy sites healed without complications. At the latest follow-up examination, all of the hips were pain-free and satisfactorily reduced and none of the patients had deterioration in function. The average center-edge angle was -5 degrees (range, -45 to 18 degrees) preoperatively and 38 degrees (range, 17 to 53 degrees) at the latest follow-up examination. The average migration index of Reimers was 55 per cent (range, 30 to 100 per cent) preoperatively compared with 12 per cent (range, 0 to 46 per cent) at the latest follow-up examination. Sixteen of the nineteen hips were followed until closure of the triradiate cartilage. There were no instances of posterior uncovering or osteonecrosis of the femoral head or premature closure of the triradiate physeal cartilage leading to deficient acetabular coverage. Our results suggest that good clinical and radiographic results can be achieved with the Pemberton pericapsular osteotomy, with simultaneous intertrochanteric osteotomy and soft-tissue release when indicated, as treatment for subluxation or dislocation of the hip or acetabular dysplasia in cerebral palsy.

Benign Chondroblastoma with Recurrent Soft-Tissue and Intra-Articular Lesions

The lesions knuown as hensigis chondroblastoma of bonse was given its presenit nianse by Jaffe anud Li(’htenisteins in 1942 “. Earlier, in 1923, Ewinsg described a lesion which he subsequenstly called calcifying gianst-cell tumor. In 1927, Kolodnuy deS(’l’ilIe(I Si o’artilage-cotstainsinsg gianst-cell tumor. Finsally, ins 1931, Codman (‘alled furthser attenstions tO) this nseopla.sns, giving an accurate description of its histological 5511(1 (‘hitsi(’Iil features and ensphasizinsg its predilections for, and probable origins from, the epipisyseal cartilage of lonsg bonies, especially the proximal humeral epiphysis. Iheo’ause (if its locations, its cartilaginsous composition, and its superficial resemblance tol giatst-(’ell tunsor, he called this lesions epiphyseal choisdromatous gianit-cell ttlfls( Ir. Roenstgens tlserapy after biopsy was recommended. Since that time, mansy r(-poln’ts have appeared its the literature 6,14,15,17 substantiatitsg the earlier observationus (If Ewitsg, Kolodnuy, Codman, and Jaffe and Lichtenstein and establishing further its genserally hensigns behavior. It is a rare lesions ; to the present time the number of reported cases ins the Eniglish laniguage is onsly slightly over one hundred. It is more commons in mcii, and its peak itucidensce is in the seconid decade of life. As far as can be determined from a re’t’ie\V (If the available SV(Irld literature, these lesionss are exclusively intraosseous withs widely scattered skeletal distribution. There is a predilection for the epiphyses about the knee antI shoulder, but the occurrence in flat, short, irregular bones is not unsusual. Ins these various locations, these lesions are invariably adjacent to (‘artilaginuous surfaces, ansd the shafts of long bones are spared. XI(Ist writers have expressed (‘oncern over the danger of overdiagnosis, since, to the inuexperienuced observer, the lesion histologically may appear more aggressive tisans is bornse out by its (‘lirsi(-al behavior. Copeland and Geschickter, however, stated that malignsanst expressions of this lesion exist and that they may nietastasize s515(l result in death. Documentation of their contention is lacking, however, ansd its the (‘It_sC presensted in the report of 1949 the lesion is clearly not a typical

Triple innominate osteotomy for acetabular dysplasia.

Summary: Fifty-six hips in 44 patients that underwent triple innominate osteotomy were reviewed. Average follow-up was 7 years (range 2–12 years). Patients were evaluated with regard to any postoperative pain and any improvement in function and as to whether they would recommend the procedure. Improvement in pain and function was considered good in 53 hips. Three hips were considered failures. Forty-two of 44 patients strongly recommended the procedure. Two patients would not recommend the procedure. In all, 94% of patients had improvement in both pain and function and recommended the operation.

Triple Innominate Osteotomy in Young Adults for the Treatment of Acetabular Dysplasia: A 9-Year Follow-Up Study

Fifty patients who underwent 60 triple innominate osteotomies were reviewed radiographically and clinically using a modified Harris hip score (HHS). Average patient age was 26 years (range: 13-48 years). At average 9-year follow-up (range: 5-14 years), 12 (20%) hips had been converted to total hip arthroplasty (THA) and 4 (7%) hips had incapacitating pain. Sixteen (27%) hips were considered failures. Average modified HHS at final follow-up was 67 (range: 28-91). Forty-nine (98%) of 50 patients reported they would recommend the procedure to others in the same situation. Radiographically, there was significant improvement in the center-to-edge angle of Wiberg and the acetabular angle of Sharp. There also was a statistically significant relationship between failure of the osteotomy and severity of preexisting hip arthrosis as measured by the Tonnis criteria. The results demonstrate triple innominate osteotomy was effective in eliminating pain, but the fact that 27% of hips required or will require THA indicates results may deteriorate with time.