Steven M. Scott

The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee.

Posteroanterior weight-bearing radiographs, made with the knee in 45 degrees of flexion, were compared with conventional radiographs for fifty-five patients who had surgical treatment for a lesion causing pain in one knee. Narrowing of the cartilage space of two millimeters or more was defined as indicative of major degeneration (grade III or IV). Comparison of the intraoperatively observed degeneration with the narrowing that was seen on the radiographs revealed that the posteroanterior weight-bearing radiographs that were made with the knee in 45 degrees of flexion were more accurate (p less than 0.01), more specific (no false-positives) (p less than 0.01), and more sensitive (fewer false-negatives) than the conventional extension weight-bearing anteroposterior radiographs.

Arthroscopic meniscal repair evaluated with repeat arthroscopy

Arthroscopic meniscal repair is a technically feasible approach to the treatment of meniscal tears in young active individuals. To evaluate this premise, we repaired 29 minisci in 27 patients and then arthroscoped their knees 3 months later. Repairs were limited to displaceable longitudinal tears. In 16 patients ligaments were intact. Eleven patients were anterior cruciate ligament deficient, six of whom underwent concomitant ACL reconstructions. In two patients, bicompartmental tears were encountered. Under arthroscopic control, using curved cannulae, horizontal mattress sutures of absorbable monofilament were placed across the tear, out through the capsule, and tied over the fascia, deep to the skin. No arthrotomies were performed, and all portions of the menisci could be reached with this method. Twenty-four of 29 repairs healed completely; 5 healed partially (30 to 50% healing). Four of the five failed repairs occurred in unstable anterior cruciate ligament deficient knees.

Autogenic bone marrow injections as a treatment for simple bone cyst.

Simple bone cyst (SBC) is a benign fluid-filled cavity found primarily at the proximal ends of long bones in children. Treatments proposed for SBC range from observation to intralesional curettage and bone grafting, which are all associated with uncertainty and complications. Because of these factors, a relatively noninvasive protocol with osteoinductive autogenic bone marrow was instituted. Twelve patients were identified with SBCs. Bone marrow was aspirated from the patients iliac crests and injected into the cyst cavity. Follow-up ranged from 9 to 57 months. Eight (67%) patients demonstrated substantial healing, two (17%) showed partial healing, and two (17%) did not respond to bone marrow therapy. The advantages suggested by bone marrow injection over the currently practiced methods include a higher success rate with a single injection and earlier healing.

Grice subtalar arthrodesis followed to skeletal maturity

A retrospective review of 45 patients (62 feet) who had undergone a Grice subtalar arthrodesis and who had reached skeletal maturity was undertaken. Preoperative deformities were due to flaccid and spastic paralysis, as well as congenital abnormalities. There were failures in 32% and poor results in 61%. Unrecognized ankle valgus, overcorrection of the hindfoot into varus, uncorrected calcaneus deformity, and anterior graft orientation largely contributed to the poor results. Weight-bearing radiographs of the feet and ankles are necessary to distinguish ankle valgus from hindfoot valgus. A subtalar arthrodesis cannot be used to compensate for ankle valgus, nor can it be used to correct the calcaneus component of a deformity without appropriate muscle-balancing procedures or osteotomies.

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.

Intramedullary nailing of femoral fractures in adolescents.

Fifty femoral shaft fractures were treated with reamed, interlocking, intramedullary nails utilizing a greater trochanteric starting point from 1991 through 1998. The 17 girls and 31 boys ranged in age from 10 to 16 years (mean, 13.2 years) at the time of injury. Average follow-up after fracture was 16 months. All fractures united, and the average leg-length discrepancy was 1 mm (range, -10 mm to +11 mm). No patient had angular or rotational deformities. No patients developed osseous necrosis of the femoral head. Despite intramedullary nailing through the greater trochanteric apophysis, articulotrochanteric distance measurements increased only 4.5 mm at the time of last follow-up. No patient developed significant proximal femoral deformity with some follow-up as far as 60 months from the time of surgery. Intramedullary nailing through a trochanteric starting point is a safe, effective method for treating femur fractures in this adolescent age group.

Closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children: description of a new closed reduction technique for fractures with brachialis muscle entrapment.

Summary: A retrospective review of 43 displaced extension-type supracondylar humerus fractures in children was performed. Thirty-four fractures were completely displaced (type III). Ninety-one percent (39 of 43) of the fractures were managed by immediate closed reduction and percutaneous pinning. Ten type III fractures exhibited clinical or radiographic evidence of brachialis muscle penetration. A closed reduction maneuver designed to “milk” the entrapped brachialis muscle off of the proximal fracture spike was developed and was successful in all eight cases in which it was attempted. At mean follow-up of 35 months, 97% (38 of 39 patients) achieved a good or excellent result based on the Flynn grading scale.

Compartment syndrome in the forearm following fractures of the radial head or neck in children

A volar compartment syndrome of the forearm was identified following a minimally displaced or angulated fracture of the radial head or neck in three children. The fractures were due to a fall from a bed or from a standing height on an outstretched hand. All three patients had symptoms and signs that were consistent with elevated intracompartmental pressure in the forearm when they were first examined, twelve to twenty-four hours after the injury, and all were managed with an emergency fasciotomy of the forearm. The radial fracture was treated without reduction in the first patient, with manipulative closed reduction in the second patient, and with open reduction and stabilization with Kirschner wires in the third patient. All three patients had a full functional recovery.

Evidence by Spectral Karyotyping that 8q11.2 Is Nonrandomly Involved in Lipoblastoma

We report two cases of lipoblastoma with chromosome 8-related aberrations, ie, a 92,XXYY,t(7;8Xp22;q11.2)x2 [8]/46,XY[16] in Case 1 and a 46,XY,-8,-13,add(16) (q22),+mar, +r [cp13]/46,XY[7] in Case 2. Using spectral karyotyping and fluorescence in situ hybridization techniques, the karyotype of Case 2 was redesignated as 46,XY, r(8), del(13)(q12), der(16)ins(16;8)(q22; q24q11.2)[cp13]/46,XY[7]. This report delineates a new chromosome rearrangement, ie, der(16)ins(16;8)(q22; q24q11.2) in lipoblastoma, and also confirms the t(7; 8)(p22;q11.2), reported only once previously, as a recurrent translocation involved in such a tumor. These findings provide valuable information for clinical molecular cytogenetic diagnosis of lipoblastoma. Furthermore, this report highlights the value of cytogenetic and molecular cytogenetic analysis in differential diagnosis of childhood adipose tissue tumors and adds to the number of lipoblastomas reported with chromosomal abnormalities at 8q11.2.

The predictive value of the development of the acetabular teardrop figure in developmental dysplasia of the hip.

We reviewed the radiographs of 72 hips, 47 with developmental dysplasia of the hip (DDH), and 25 normal hips, to determine the timing of the normal appearance of the acetabular teardrop figure and the value of teardrop development after reduction of the hip in predicting outcome. In normal hips, all children had a teardrop figure by age 18 months. In the 47 hips with DDH, no teardrop figure appeared until the hip was reduced. The DDH hips were divided into two groups based on the success of the initial reduction. By using statistical analysis, we found that the appearance of the acetabular teardrop within 6 months after reduction of the hip is strongly associated with a favorable long-term outcome. We believe that the appearance of the teardrop is the earliest radiographic sign that a stable, concentric reduction of the hip has been achieved.