Walter B. Greene

Bone-mineral density in children and adolescents who have spastic cerebral palsy

Bone-mineral density was studied in a heterogeneous group of 139 children (mean age, nine years; range, three to fifteen years) who had spastic cerebral palsy. The evaluation included serum analyses and a nutritional assessment based on a dietary history and anthropometric measurements. The bone-mineral density of the proximal parts of the femora and the lumbar spine was measured with dual-energy x-ray absorptiometry and was normalized for age against a series of ninety-five normal children and adolescents who served as controls. Bone-mineral density varied greatly but averaged nearly one standard deviation below the age-matched normal means for both the proximal parts of the femora (-0.92 standard deviation) and the lumbar spine (-0.80 standard deviation). Ambulatory status was the factor that best correlated with bone-mineral density. Nutritional status, assessed on the basis of caloric intake, skinfolds, and body-mass index, was the second most significant variable. The pattern of involvement, durations of immobilization in a cast, and a calcium intake of less than 500 milligrams per day were additional factors of less significance. The age when the child first walked, previous fractures, use of anticonvulsants, and serum vitamin-D levels did not correlate with bone-mineral density after adjustment for covariance with the ambulatory status and the nutritional status. Serum levels of calcium, phosphate, alkaline phosphatase, and osteocalcin were not reliable indicators of low bone-mineral density.

Musculoskeletal problems in association with cloacal exstrophy.

The records of all thirteen patients for whom a diagnosis of cloacal exstrophy had been recorded in our hospitals were analyzed for evidence of musculoskeletal problems. All thirteen patients had spina bifida, four had congenital scoliosis, two had congenital kyphosis, and three had non-congenital scoliosis. All had a lipomeningocele, and eleven had paralysis of the lower extremities. Hydrocephalus and its associated problems were not found, but tethered-cord syndrome was diagnosed in eleven patients. Persistent diastasis of the symphysis pubis was found in all patients. Abduction and external rotation of the hips were more than normal. Mild dysplasia was seen in six of the twenty-six hips. Deformities of the foot were common, and twelve feet had been operated on for correction. Recurrent equinovarus deformity of the foot was associated with tethered-cord syndrome in two patients.

Antibiotic prophylaxis in experimental bone infections.

The rationale for the use of prophylactic antibiotics in clean orthopaedic surgery was explored by means of an experimental model suited to the investigation of (1) antibiotic penetration and persistence in operative hematomas in bone and (2) the effect of cephaloridine administration on standard wound infections. Cephaloridine was found to penetrate hematomas in bone readily and to persist there in bacteriocidal concentrations. When cephaloridine was given preoperatively, all wounds were converted to bacteriological sterility and did not become clinically infected. When cephaloridine was begun six hours or later after contamination, infection occurred uniformly.

Orthopaedic procedures and prognosis in hemophilic patients who are seropositive for human immunodeficiency virus.

Thirty patients who had hemophilia and were seropositive for the human immunodeficiency virus were evaluated. The preoperative CD4 lymphocyte count was decreased to an average of 336 x 10(9) per liter (range, 27 to 708 x 10(9) per liter). After twenty-six orthopaedic operations in patients who had no previous bacterial infection, a nosocomial infection (cellulitis in the forearm, at the site of an intravenous catheter) developed in only one patient, but five patients had an abnormal postoperative fever that was not accompanied by the expected increase in the white blood-cell count. The preoperative CD4 lymphocyte count was significantly reduced in the patients who had an abnormal elevation in body temperature (p less than 0.004). The functional result or outcome after operation was similar to that in hemophilic patients treated before 1982. Subsequent progression of infection with the human immunodeficiency virus, as determined by the CD4 lymphocyte count and the Walter Reed classification system, occurred in most patients. Acquired immunodeficiency syndrome was diagnosed in six patients. A more rapid progression to acquired immunodeficiency syndrome was seen in the patients who had a lower CD4 lymphocyte count preoperatively. Preoperative evaluation of the CD4 lymphocyte count and the response to intradermal skin-test antigens in patients who are at risk for infection postoperatively provides additional information concerning immunological competence. With these data, the possible risk of infection in patients who are seropositive for the human immunodeficiency virus can be estimated more accurately.

Adolescent tibia vara: Alternatives for operative treatment

We reviewed the cases of fifteen obese patients (twenty-one extremities) who had had adolescent tibia vara and had been followed for at least two years. Of the nine patients (eleven extremities) who had been initially managed with lateral tibial hemiepiphyseodesis, eight (ten extremities) were skeletally mature at the time of the review (mean duration of follow-up, five years). The mechanical alignment was judged to be excellent in three of these ten extremities, fair in three, and poor in four. Excellent mechanical alignment was defined as a value within the reported normal range of 5 degrees of varus to 2 degrees of valgus. A poor result was defined as alignment that was more than 5 degrees outside the normal range. After secondary operative procedures, three of the extremities for which the result had been poor and one for which it had been fair had excellent alignment. Five of the nine patients had bilateral involvement. Two of them were managed with bilateral tibial hemiepiphyseodesis; two, with contralateral proximal tibial osteotomy; and one had a mild deformity on the contralateral side that was not treated. Six extremities in six patients (two of whom had a contralateral hemiepiphyseodesis) were managed primarily with proximal tibial osteotomy and were evaluated an average of seven years postoperatively. Two additional patients were managed with proximal tibial osteotomy because of residual varus deformity after the hemiepiphyseodesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy

Summary: Rapid progression of hip subluxation was noted in the year after selective dorsal rhizotomy in seven hips (six patients). The hips that subluxed progressed from a lateral extrusion index averaging 25% preoperatively as compared with 50% after rhizotomy. Although preexistent hip dysplasia was a predisposing factor, hips with an intermediate degree of preoperative lateral extrusion (12–25%) had variable results. Ongoing and more frequent evaluation of hip stability is necessary after dorsal rhizotomy.

BONE DENSITY IN MYELOMENINGOCELE: THE EFFECTS OF AMBULATORY STATUS AND OTHER FACTORS

Measurements were made of distal radius, mid‐radius, tibia and metatarsal bone‐density of 80 patients with myelomeningocele (17 thoracic, six L1/L2, 13 L3, 30 L4, 14 L5/sacral). For the upper extremity the bone density primarily was low in the thoracic patients, but in the tibia and metatarsal it showed a more linear correlation with neurological levels. The effect of age was highly significant at all sites; after controlling for this, the neurological level was a significant determinant of bone density at all sites, and this effect was greater in older children. Patients with impaired ambulation had decreased bone‐density in the distal radius, tibia and metatarsal, but not in the mid‐radius. Race had no significant effect on density after accounting for differences in neurological level. Weight for height and multiple fractures did not correlate with bone density. Although ambulatory status (weight‐bearing stresses) and neurological status (muscle stresses) are both important factors in bone density, this study suggests that the latter is a more important determinant.

A Modified Isokinetic Strengthening Program for Patients with Severe Hemophilia

A modified isokinetic strengthening program for the knee flexors and extensors was evaluated in 32 patients with severe hemophilia. The program was effective in significantly strengthening the knee flexors and extensors; it did not increase the number of knee hemarthroses; and it could be done at home without special equipment. The greater increases in extensor and flexor strength among adolescents and adults were associated with less severe arthropathy, a l cm increase in thigh girth, and a greater number of days on which the exercises were done.

Evaluation of magnetic resonance imaging in legg-perthes disease: A prospective, blinded study

Summary: Twenty-two patients (24 hips) with Legg-Perthes disease received 49 magnetic resonance (MRI) scans. The scans and corresponding radiographs were independently evaluated in a blinded fashion to assess the capabilities of, and indications for, MRI in Legg-Perthes disease. Early in the disease process, MRI often more clearly delineated the extent and location of areas of involvement than did plain radiographs. In one patient, MRI failed to indicate necrosis early in the course of the disease, but it was detected on plain radiographs. MRI can also be used to give a rough estimate of sphericity, which in some phases of the disease process is better than plain radiographs. For serially following the disease process through the natural healing course, plain radiographs were as good or better than MRI and considerably less costly.

Synovectomy of the ankle for hemophilic arthropathy.

The results of five patients who had hemophilia and a history of recurrent hemarthrosis and hypertrophic synovitis and who had been managed with a synovectomy of the ankle were studied at an average age of nine years (range, four years and seven months to nineteen years). Compared with the complications encountered after synovectomy of the knee or the elbow, the rehabilitation process after synovectomy of the ankle was relatively easy, even for the three youngest children in this series. The average duration of follow-up was five years (range, one to nine years). By the latest follow-up examination, the range of motion of the ankle had increased an average of 10 degrees (range, -5 to 15 degrees). The rate of hemarthrosis episodes requiring transfusion was reduced from an average of 3.4 per month (range, 0.3 to 5.0 per month) for the six months before the synovectomy to 0.1 per month (range, zero to 0.2 per month) for the twelve months before the latest follow-up examination.