Sullivan Ja

Management of femoral shaft fractures in the adolescent.

Forty-four patients (45 fractures) with open physes (age range 11–16 years) underwent treatment for femoral shaft fractures. Seven malunions occurred in the 24 fractures in the nonoperative group; none occurred in the 21 fractures treated by intramedullary nailing. Hospital stay was significantly shorter in the operatively treated patients. There was no premature growth arrest in the surgical group.

Management of septic arthritis in children.

Summary: Forty-five children underwent initial nonoperative treatment of hematogenous septic arthritis in joints other than the hip. Only joints with symptoms for <6 days and without associated osteomyelitis were included. Thirty-four of the 49 joints were successfully managed by aspiration and antibiotics, whereas the remaining joints were successfully managed by surgical drainage following a lack of response to nonoperative treatment. All children had a satisfactory result after an average followup of >3 years. Early diagnosis and treatment are more important than the method of drainage. If a lack of response is seen to initial nonoperative treatment, surgical drainage will still lead to a satisfactory outcome.

Spinal cord injury without osseous spine fracture.

Sixteen patients with spinal cord injury without osseous spine fracture and 55 patients with spinal cord injury with osseous spine fracture aged from birth through 18 years were studied. Those without osseous fracture were younger (mean age 6 years) than were those with osseous fracture (mean age 16 years). Extravasation of myelographic dye from the spinal canal was a poor prognostic sign. All three in the group with this finding without osseous fracture had complete spinal cord lesions. Those without osseous fracture should be followed for the development of late spinal deformity that may require orthotic support or surgical stabilization.

Hip stabilization in severely involved cerebral palsy patients.

Thirty-two patients (48 hips) with total body involved cerebral palsy (CP) underwent medial release and proximal femoral osteotomy for hip subluxation or dislocation. Twenty-eight hips were rated good, 15 were rated fair, and five were rated poor at follow-up. The better located the hip preoperatively and the better the reduction obtained at operation, the better the final result. The major factor that correlated with a good result was early operation, performed before significant deformity had occurred.

Lawn Mower Injuries of the Pediatric Foot and Ankle: Observations on Prevention and Management

We reviewed 32 children with lower extremity injuries caused by power lawn mowers. Functional outcome of 21 patients was evaluated. Anatomical injury patterns provide some guidelines in management and prediction of functional outcome. Consistently, the most severe injuries result from ride-on mowers and wounds to the posterior/plantar foot and ankle. Our experience with pediatric foot and ankle lawn mower injuries permits recommendations for maximum functional outcome with minimal intervention. Public awareness and mower safety devices may be required to decrease the rate of accidents in the future.

Osteomyelitis of the calcaneus in children.

Eleven cases of calcaneal osteomyelitis in children are reported. Seven were hematogenous cases, and the remaining four were related to puncture wounds. The clinical presentation was less dramatic than that seen in typical long bone osteomyelitis. Laboratory findings were also less striking. A mixture of organisms was isolated from patients in the hematogenous group. In contrast, all puncture-related cases had cultures positive for Pseudomonas aeruginosa. Plain radiographic findings were noted at the time of presentation in 63%. Those findings were characteristically different in hematogenous and puncture-related cases. Oblique lateral radiographs can be important for diagnosis in puncture-related cases. Radionuclide bone scanning was an important diagnostic test in the absence of plain radiographic changes and in the very young patient. Surgery was performed in 82% of the cases. There were no recurrences or chronic infections. Two complications occurred in one patient, including residual scar sensitivity and early fusion of the calcaneal apophysis.

Effects of neurodevelopmental treatment on movement patterns of children with cerebral palsy.

Twelve children with mild, moderate, or severe cerebral palsy were examined and videotaped before and alter an intensive course of physical therapy in a neurodevelopmental treatment course. These tapes, demonstrating various predetermined movement patterns, were then randomized and viewed by six evaluators.None of the evaluators could tell the difference between before and after films. This demonstrated that significant changes were not seen in children with cerebral palsy after 6 weeks of therapy.

Clubfoot release without wide subtalar release.

Fifty-two feet treated by clubfoot release without wide subtalar release were evaluated 4.2-10.8 years after surgery. Eleven feet (21%) had undergone additional operative procedures at the time of review, and 82% of feet had good or excellent functional ratings at that time. The mean talocalcaneal index was 49 degrees (range 12-76 degrees), indicating that correction of the subtalar joint occurred in some patients. This procedure satisfactorily corrects many feet but undercorrects some. Overcorrection was rare. Foot progression angles were also determined and are reported in an accompanying article.

A comparison of Wisconsin instrumentation and Cotrel-Dubousset instrumentation

Twenty-six patients who underwent Wisconsin instrumentation and 36 patients who underwent Cotrel-Dubousset instrumentation (CDI) for idiopathic scoliosis were studied. Inclusion in the study required at least 24-month follow-up. Variables compared included operating time, blood loss, frontal plane correction, axial and sagittal plane changes, effects on compensation, and complications. In general, operating time, blood loss, and instrumentation problems were greater with CDI. Thoracic curve correction in King II curves was better with CDI. There was no advantage to either system with respect to sagittal plane alignment or rotation. When all factors were considered, a significant advantage to use of CDI could not be demonstrated.

SEGMENTAL SPINAL INSTRUMENTATION WITH SUB-LAMINAR WIRES

Fifty-eight patients who had scoliosis or kyphosis of varying etiologies were followed for a mmimum of two years (average, forty-four months) after segmental spinal instrumentation using sublaminar wires. In eight (19 per cent) of the patients who had been operated on for scoliosis one or both rods broke. The average time that had elapsed before the breakage was discovered was twenty-three months. None of the patients in whom a rod had broken had had postoperative immobilization or a first-stage anterior fusion, and only one had had supplementary grafting with banked bone. Instrumentation to the pelvis was also associated with a greater incidence of broken rods. The use of supplementary grafting with banked bone or the use of postoperative immobilization significantly decreased the loss of postoperative correction. Preliminary anterior spinal fusion helped prevent breakage of rods but not loss of correction. It was concluded that postoperative immobilization and use of large amounts of supplementary bone graft lead to better results when using this implant system. Segmental spinal instrumentation with sublaminar wires is considered by many orthopaedic surgeons to be the method of choice for the operative treatment of spinal deformities2’6’1724. The method, as originally described by Luque, consists of fixing two 0.48-centimeter (3/16-inch) thick stainless-steel Luque rods to every instrumented level of the deformity by sublaminar wire&4-t5. Modifications have subsequently been made in the method of pelvic fixation34, and sublaminar wiring of Harrington distraction rods has been used in addition to, or in place of, the rods used by LuqueH24. The original Harrington system was one of the earliest forms of segmental fixation; it employed a compression rod to apply a force to each instrumented level. Other techniques are now available for posterior segmental instrumentation of the spine, such as wiring of the spinous processes8’9 or the Cotrel-Dubousset system7 of dual rods and multiple hooks. The major advantage of these methods of segmental * No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject ofthis article. No funds were received in support of this study. t Department of Orthopedic Surgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma 73190. t Department of Orthopedic Surgery, University of South Carolina College of Medicine, Charleston, South Carolina 2940!. fixation is the decreased risk of neurological injury as wires are not passed through the spinal canal. A disadvantage is that the fixation may not be as secure’. The reported advantages of segmental spinal fixation include improved correction, a high rate of fusion, and immediate rigid fixation which obviates the need for postoperative immobilization. The reported disadvantages indude a longer operating time, greater blood loss, and a significant incidence of neurological damage when sublammar wires are used2-’#{176}-’6-23-26-27. Our report concerns only segmental instrumentation for which sublaminar wires were used. Segmental instrumentation using sublaminar wiring of two Luque rods or of a Luque rod and a Harrington rod has been used at the Oklahoma Children’s Memorial Hospital since 1978 and at the Portsmouth Naval Hospital since 1980. During this time we have noted a significant incidence of failed implants and loss of correction with this technique. The incidence of pseudarthrosis, lost correction, and broken rods, while seemingly acceptable at the reported short-term follow-up, has not been documented in patients who have been followed for two years or more. This study was undertaken to determine the rate of success and the incidence of complications with segmental instrumentation in patients with a longer period of follow-up in the hope of identifying changes in technique that will provide greater success with the procedure in the future. Materials and Methods Sixty-three patients who were between three and twenty-one years old underwent posterior spinal fusion and segmental spinal instrumentation using two Luque rods or a Luque rod and a Harrington distraction rod with sublammar wiring. All of the operations were performed by one of three of us (W. A. H., J. A. S., or R. H. G.) between September 1978 and July 1984. Three patients could not be located for follow-up and two patients died of unrelated causes at twelve and fourteen months postoperatively. The cases of fifty-eight patients were therefore available for review, with an average length of follow-up of forty-four months (range, twenty-four to eighty-four months). During this period three other patients underwent segmental instrumentation with sublaminar wires, but they did not have a formal spinal fusion and are not included in this report. All of the patients’ charts and radiographs were reviewed. Although there were fifteen different diagnoses in