RESUMEN
The intervertebral discs become wedged and narrowed in a scoliosis curve, and this may be due in part to altered biomechanical environment. To study this, external rings were attached by percutaneous pins transfixing adjacent vertebrae in 5-week-old Sprague-Dawley rats and four permutations of mechanical conditions (4 groups of animals) were compared: (A) 15 degrees Angulation, (B) Angulation with 0.1 MPa Compression, (C) 0.1 MPa Compression, and (D) Reduced mobility. These altered mechanical conditions were applied for 5 weeks. After 5 weeks, disc narrowing at the intervention levels was evident in micro-CT images. Average disc space loss as a percent of the initial values over the 5 weeks was 19%, 28%, 22% and 20% four groups listed above. Increased lateral bending stiffness relative to within-animal controls was also observed at all groups. The minimum stiffness was recorded at an angle close to the in vivo value, indicating that angulated discs had adapted to the imposed deformity. In the angulated and compressed discs there was a small difference in the amount of collagen crimping in the disc annuli between concave and convex sides. All experimental interventions produced substantial changes in the intervertebral discs of these growing animals. 'Reduced mobility' was present in all interventions, and the changes in the discs with reduced mobility alone were comparable with those in loaded and angulated discs. This suggests that imposed reduced mobility is the major source of disc changes, and may be a factor in disc degeneration in scoliosis. Further studies are in progress to characterize gene expression, matrix protein synthesis and composition in these discs.
Asunto(s)
Disco Intervertebral/fisiopatología , Escoliosis/fisiopatología , Columna Vertebral/crecimiento & desarrollo , Animales , Fenómenos Biomecánicos , Modelos Animales , Ratas , Ratas Sprague-Dawley , Curvaturas de la Columna Vertebral/patología , Columna Vertebral/patologíaRESUMEN
A retrospective longitudinal radiographic study of patients with progressive scoliosis was conducted to determine the relative amount of wedging between vertebrae and discs as a function of progression of the scoliosis curve, cause of the scoliosis, and anatomic curve region. Posteroanterior radiographs of 27 patients with idiopathic scoliosis and of 17 patients with scoliosis associated with cerebral palsy were studied. The amount of wedging of vertebrae and discs at the curve apex was measured by the Cobb method and expressed as a proportion of the curve's Cobb angle. On average, the relative amount of vertebral and disc wedging did not differ significantly between initial and follow-up radiographs made after progression of the scoliosis. In both groups of patients, the mean vertebral wedging was more than the disc wedging in the thoracic region; the converse was found in curves in the lumbar and thoracolumbar regions. The patients with scoliosis associated with cerebral palsy had curves that were longer and more commonly in the thoracolumbar and lumbar regions. The relative wedging did not change significantly with curve progression and did not appear to differ by diagnosis. In the management of scoliosis, including small curves, it should be recognized that both the vertebrae and discs have a wedging deformity.
Asunto(s)
Disco Intervertebral/diagnóstico por imagen , Escoliosis/diagnóstico por imagen , Columna Vertebral/diagnóstico por imagen , Adolescente , Parálisis Cerebral/complicaciones , Niño , Progresión de la Enfermedad , Humanos , Estudios Longitudinales , Vértebras Lumbares/diagnóstico por imagen , Radiografía , Estudios Retrospectivos , Escoliosis/etiología , Vértebras Torácicas/diagnóstico por imagenAsunto(s)
Epífisis Desprendida , Cabeza Femoral , Adolescente , Moldes Quirúrgicos , Niño , Epífisis Desprendida/clasificación , Epífisis Desprendida/complicaciones , Epífisis Desprendida/epidemiología , Epífisis Desprendida/etiología , Epífisis Desprendida/terapia , Femenino , Humanos , Masculino , Procedimientos Ortopédicos , Complicaciones Posoperatorias , Factores de Riesgo , Resultado del TratamientoRESUMEN
This study tested the following hypotheses: (a) a vertebral wedge deformity created by chronic static asymmetrical loading will be corrected by reversal of the load asymmetry; (b) a vertebral wedge deformity created by chronic static asymmetrical loading will remain if the load is simply removed; and (c) vertebral longitudinal growth rates, altered by chronic static loading, will return to normal after removal of the load. An external fixator was used to impose an angular deformity (Cobb angle of 30 degrees) and an axial compression force (60% body weight) on the ninth caudal (apical) vertebra in two groups of 12 5-week-old Sprague-Dawley rats. This asymmetrical loading was applied to all rats for 4 weeks to create an initial wedge deformity in the apical vertebra. The rats from group I (load reversal) then underwent 1 week of distraction loading followed by 4 weeks of asymmetrical compressive loading with the imposed 30 degree Cobb angle reversed. The rats from group II (load removal) had the apparatus removed and were followed for 5 weeks with no external loading. Weekly radiographs were obtained and serial fluorochrome labels were administered to follow vertebral wedging. After the initial 4-week loading period, the combined average wedge deformity that developed in the apical vertebra of the animals in both groups was 10.7 +/- 4.4 degrees. The group that underwent load reversal showed significant correction of the deformity with the wedging of the apical vertebra decreasing to, on average, 0.1 +/- 1.4 degrees during the 4 weeks of load reversal. Wedging of the apical vertebra in the group that underwent load removal significantly decreased to 7.3 +/- 3.9 degrees during the first week after removal of the load, but no significant changes in wedging occurred after that week. This indicated a return to a normal growth pattern following the removal of the asymmetrically applied loading. The longitudinal growth rate of the apical vertebra also returned to normal following removal of the load. Vertebrae maintained under a load of 60% body weight grew at a rate that was 59.4 +/- 17.0% lower than that of the control vertebrae, whereas after vertebrae were unloaded their growth averaged 102.4 +/- 31.8%. These findings show that a vertebral wedge deformity can be corrected by reversing the load used to create it and that vertebral growth is not permanently affected by applied loading.
Asunto(s)
Escoliosis/terapia , Columna Vertebral/crecimiento & desarrollo , Animales , Ratas , Ratas Sprague-DawleyRESUMEN
STUDY DESIGN: An Ilizarov-type apparatus was applied to the tails of rats to assess the influence of immobilization, chronically applied compression, and sham intervention on intervertebral discs of mature rats. OBJECTIVES: To test the hypothesis that chronically applied compressive forces and immobilization cause changes in the biomechanical behavior and biochemical composition of rat tail intervertebral discs. SUMMARY OF BACKGROUND DATA: Mechanical factors are associated with degenerative disc disease and low back pain, yet there have been few controlled studies in which the effects of compressive forces on the structure and function of the disc have been isolated. METHODS: The tails of 16 Sprague-Dawley rats were instrumented with an Ilizarov-type apparatus. Animals were separated into sham, immobilization, and compression groups based on the mechanical conditions imposed. In vivo biomechanical measurements of disc thickness, angular laxity, and axial and angular compliance were made at 14-day intervals during the course of the 56-day experiment, after which discs were harvested for measurement of water, proteoglycan, and collagen contents. RESULTS: Application of pins and rings alone (sham group) resulted in relatively small changes of in vivo biomechanical behavior. Immobilization resulted in decreased disc thickness, axial compliance, and angular laxity. Chronically applied compression had effects similar to those of immobilization alone but induced those changes earlier and in larger magnitudes. Application of external compressive forces also caused an increase in proteoglycan content of the intervertebral discs. CONCLUSIONS: The well-controlled loading environment applied to the discs in this model provides a means of isolating the influence of joint-loading conditions on the response of the intervertebral disc. Results indicate that chronically applied compressive forces, in the absence of any disease process, caused changes in mechanical properties and composition of tail discs. These changes have similarities and differences in comparison with human spinal disc degeneration.
Asunto(s)
Disco Intervertebral/patología , Enfermedades de la Columna Vertebral/etiología , Cola (estructura animal) , Animales , Agua Corporal/metabolismo , Glicosaminoglicanos/metabolismo , Hidroxiprolina/metabolismo , Inmovilización , Disco Intervertebral/diagnóstico por imagen , Disco Intervertebral/metabolismo , Radiografía , Ratas , Ratas Sprague-Dawley , Enfermedades de la Columna Vertebral/diagnóstico por imagen , Enfermedades de la Columna Vertebral/metabolismo , Estrés Mecánico , Cola (estructura animal)/diagnóstico por imagenRESUMEN
The purpose of this study was to determine whether compression and distraction applied to adjacent vertebrae in the calf tail could modulate vertebral growth. Seven 6-week-old calves had two pairs of adjacent tail vertebrae instrumented with an Ilizarov external fixator with calibrated springs designed to apply a 30-50-N axial load to the vertebrae. Data were obtained from 17 vertebrae loaded in compression and 4 vertebrae loaded in distraction. Vertebrae adjacent (cranial and caudal) to the instrumented vertebrae served as controls. The length of each vertebra on the postoperative radiograph was subtracted from the length of the same vertebra on the radiograph taken 6 months after the operation to calculate vertebral growth. The vertebrae loaded in compression had a growth rate of 68 +/- 42% of that of the controls. In contrast, the vertebrae loaded in distraction had a growth rate of 123 +/- 78% of that of the controls.
Asunto(s)
Escoliosis/fisiopatología , Columna Vertebral/crecimiento & desarrollo , Cola (estructura animal) , Animales , Fenómenos Biomecánicos , Bovinos , Progresión de la Enfermedad , Diseño de Equipo , Fijadores Externos , Modelos Biológicos , Osteogénesis por Distracción , Estrés Mecánico , Soporte de PesoRESUMEN
We reviewed 32 children with 41 radiation-therapy associated slipped capital femoral epiphyses (RTASCFE). Ten were from the authors' institutions and 22 from the literature. Gender distribution was equal. The age at diagnosis of the malignancy was 4.3 +/- 3.1 years; the amount of radiation was 4,240 +/- 1,445 rads. Children with RTASCFE presented younger (10.4 +/- 3.2 years) than a routine SCFE. The average symptom duration was 5 +/- 6 months. Children with RTASCFE are usually thin (median weight, 10th percentile) in contrast to children with typical SCFE, who are usually obese (<95th percentile). The majority (82%) of the slips were mild, compared to routine SCFEs (approximately 50%); 28% were bilateral. There was a positive linear relationship between the age at presentation of the SCFE and the age at diagnosis of the malignancy; there was a negative linear relationship between the age at presentation of the SCFE and the amount of radiation therapy.
Asunto(s)
Epífisis Desprendida/etiología , Neoplasias Pélvicas/radioterapia , Traumatismos por Radiación/etiología , Adolescente , Distribución por Edad , Clavos Ortopédicos , Distribución de Chi-Cuadrado , Niño , Preescolar , Epífisis Desprendida/cirugía , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Masculino , Traumatismos por Radiación/cirugía , Radioterapia/efectos adversos , Dosificación Radioterapéutica , Estudios Retrospectivos , Estadísticas no ParamétricasRESUMEN
Ninety-eight continuous postoperative epidurals were administered to 87 children. The patients were divided into two groups: group I included 63 cases in which a 0.0625-0.25% solution of bupivacaine was continuously administered; group II included 35 cases in which a similar solution of bupivacaine mixed with 2-10 micrograms of fentanyl was administered. The dose of the epidural medication was titrated by the anesthesiologist according to the patient's age and anticipated level of postoperative pain. The average pain score for all patients for the first 48 h was 1.43. Supplemental analgesia averaging 0.132 mg intravenous morphine/kg/8 h was required in 49 cases (41 in group I and eight in group II). In group I, the average dose of supplemental analgesia was 0.144 mg intravenous morphine/kg/8 h, whereas in group II, it was only 0.056 mg intravenous morphine/kg/8 h. Continuous epidural analgesia is effective in controlling postoperative pain, and the addition of fentanyl reduces the need for systemic narcotics.
Asunto(s)
Adyuvantes Anestésicos/administración & dosificación , Analgesia Epidural/métodos , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Fentanilo/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Adolescente , Niño , Preescolar , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Femenino , Humanos , Lactante , Tiempo de Internación , Masculino , Dimensión del Dolor , Pronóstico , Resultado del TratamientoRESUMEN
Progression of scoliosis deformity during growth is thought to be caused by asymmetrical loading, resulting in asymmetrical growth with vertebral and disc wedging in a "vicious cycle." The purpose of this study was to quantify the changes in disc thickness during growth in rat tails subjected to compression or distraction loading for 6 or 9 weeks, to investigate the hypothesis that disc growth is mechanically modulated. Six-week-old Sprague-Dawley rats were studied with compression loading (13 animals) or distraction loading (15 animals) applied to their tails, and there were 8 sham animals. Loading was applied to tail segments by means of an external ring fixator. Radiographic measurements of disc thickness were made at biweekly intervals. From the initial to final radiograph, compressed discs had reduced thickness averaging (+/-SD) 0.50 +/- 0.28 mm, distraction discs had average increased thickness of 0.20 +/- 0.42 mm, and sham discs lost an average of 0.21 +/- 0.18 mm of thickness (analysis of variance p < 0.001). There was an "initial change" in disc thickness averaging 0.18 +/- 0.32 mm in nonloaded discs, which was similar in magnitude to the elastic deformation and was attributed to disc swelling under anesthesia. These results indicate that growth in disc thickness is mechanically modulated by axial loading in growing rats.
Asunto(s)
Fijadores Externos , Disco Intervertebral/crecimiento & desarrollo , Disco Intervertebral/fisiología , Escoliosis/fisiopatología , Cola (estructura animal)/fisiología , Animales , Fuerza Compresiva , Modelos Animales de Enfermedad , Disco Intervertebral/cirugía , Ratas , Ratas Sprague-Dawley , Cola (estructura animal)/crecimiento & desarrollo , Cola (estructura animal)/cirugía , Soporte de PesoRESUMEN
We prospectively gathered data on skiing injuries that had been sustained at the Sugarbush North ski area since 1972 and at the Sugarbush South ski area since 1981. The purpose of the current study was to document the overall rates of injury in children, adolescents, and adults participating in alpine skiing. We also sought to determine the ten most common injuries in each age-group. Finally, we analyzed short-term and long-term trends to determine if changes in equipment had had an effect on the frequency or pattern of injury. From the 1981-1982 to the 1993-1994 season, there were 2.79 injuries per 1000 skier days: 4.27 injuries in children, 2.93 in adolescents, and 2.69 in adults. During the last eight years of the study, the most common injuries were a contusion of the knee in children, a sprain of the ulnar collateral ligament of the thumb in adolescents, and a grade-III sprain of the anterior cruciate ligament in adults. The short-term trends revealed that, in children, the frequency of tibial fractures decreased 10 per cent while that of fractures of the upper extremity increased 8 per cent. The long-term trends showed that, in adults, the rate of tibial fractures decreased 89 per cent while that of injuries of the anterior cruciate ligament increased 280 per cent. The overall rate of injury decreased 43 per cent from the beginning of the study in 1972 to the end of the study in 1994; the decrease was 58 per cent in children, 45 per cent in adolescents, and 42 per cent in adults. Data on the types of equipment and the binding-release values were collected prospectively from injured skiers and from 2083 non-injured skiers. Of the fifty-nine skiers who sustained a spiral fracture of the tibia, forty-two (71 per cent) had binding-release values that were higher than the average for the uninjured group. We believe that the use of properly functioning modern equipment will decrease the rate of injury, particularly in children.
Asunto(s)
Esquí/lesiones , Adolescente , Adulto , Traumatismos del Tobillo/epidemiología , Traumatismos del Tobillo/etiología , Lesiones del Ligamento Cruzado Anterior , Traumatismos en Atletas/epidemiología , Niño , Contusiones/etiología , Fracturas Óseas/epidemiología , Fracturas Óseas/etiología , Humanos , Traumatismos de la Rodilla/epidemiología , Traumatismos de la Rodilla/etiología , Traumatismos de la Pierna/epidemiología , Traumatismos de la Pierna/etiología , Ligamento Colateral Medial de la Rodilla/lesiones , Prevalencia , Estudios Prospectivos , Rotura , Esguinces y Distensiones/epidemiología , Esguinces y Distensiones/etiología , Fracturas de la Tibia/epidemiología , Fracturas de la Tibia/etiología , Vermont/epidemiologíaRESUMEN
STUDY DESIGN: A rat tail model was used to test the hypothesis that angulation and asymmetric axial compressive loading would lead to vertebral wedging because of asymmetric longitudinal growth in the physes. OBJECTIVES: To study the effect of angulation and asymmetric loading on the progression of spinal curvature in a rat tail model. SUMMARY OF BACKGROUND DATA: Large idiopathic scoliotic curves in children with significant growth remaining are the curves most likely to progress. The mechanism of progression of skeletal deformities is thought to be controlled by the Hueter-Volkmann law, whereby additional axial compression decelerates growth, and reduced axial compression accelerates growth. It has been hypothesized that spinal curvature leads to asymmetric loading transversely along the vertebral growth plate, causing progressive vertebral wedging by means of a vicious cycle. METHODS: Two 32-mm diameter external ring fixators were glued to 0.7-mm pins that had been inserted percutaneously through the eighth and 10th caudal vertebra of 10 6-week-old Sprague-Dawley rats. Calibrated springs and 15 degrees wedges, mounted on stainless steel threaded rods passing through holes distributed around the rings, imposed a 30 degrees Cobb angle and axially compressed the instrumented vertebrae. Fluorochrome labels and radiographs were used to document the progression of vertebral wedging. RESULTS: The wedging initially was entirely in the intervertebral discs, but by 6 weeks the wedging of the discs and vertebrae were approximately equal. Fluorochrome labeling confirmed that the vertebral wedging resulted from asymmetric growth in the physes. CONCLUSIONS: This study shows that vertebrae, when asymmetrically loaded, become wedged. This is consistent with the concept of mechanically provoked progression of scoliotic deformities according to the Hueter-Volkmann law.
Asunto(s)
Cóccix/crecimiento & desarrollo , Disco Intervertebral/crecimiento & desarrollo , Escoliosis/etiología , Animales , Cóccix/fisiopatología , Modelos Animales de Enfermedad , Fijadores Externos , Humanos , Disco Intervertebral/fisiopatología , Masculino , Ratas , Ratas Sprague-Dawley , Estrés Mecánico , Cola (estructura animal) , Soporte de PesoRESUMEN
The pre- and postoperative radiographs of 45 patients with scoliosis were compared with the preoperative lateral bending radiographs. The purpose was to compare correction of Cobb angle and apical vertebral rotation between preoperative lateral bending and operative spinal instrumentation. Twenty-one patients had Harrington instrumentation, 12 had Drummond/Wisconsin spinous process segmental instrumentation, and 12 had Texas Scottish Rite Hospital instrumentation. From the pre- and postoperative radiographs, each vertebra was marked and digitized for computerized measurements of Cobb angle and apical vertebral rotation. Correction of Cobb angle on the lateral bending radiograph averaged 22 +/- 10 degrees, which was less than that achieved at operation (Harrington 23 +/- 7 degrees, Drummond/Wisconsin 29 +/- 10 degrees, and Texas Scottish Rite Hospital 36 +/- 6 degrees; p < 0.01, paired t test). In contrast, correction of apical vertebral rotation on the lateral bending radiograph averaged 4 +/- 8 degrees, which was not significantly different from that achieved at operation (Harrington 1 +/- 8 degrees, Drummond/Wisconsin 1 +/- 7 degrees, and Texas Scottish Rite Hospital 4 +/- 8 degrees). Spinal instrumentation markedly corrected the Cobb angle but minimally corrected apical vertebral rotation. In contrast, preoperative lateral bending produced a similar proportional correction of both.
Asunto(s)
Escoliosis/diagnóstico por imagen , Escoliosis/cirugía , Adolescente , Femenino , Humanos , Fijadores Internos , Masculino , Radiografía , Rotación , Escoliosis/fisiopatologíaRESUMEN
STUDY DESIGN: The authors developed a rat-tail model to investigate the hypothesis that vertebral wedging during growth in progressive spinal deformities results from asymmetric loading in a "vicious cycle." OBJECTIVES: To document growth curves with axial compression or distraction applied to tail vertebrae to determine whether compression load slows growth and distraction accelerates it. SUMMARY OF BACKGROUND DATA: Progression of skeletal deformity during growth is believed to be governed by the Hueter-Volkmann law, but there is conflicting evidence to support this idea. METHODS: Twenty-eight 6-week-old Sprague-Dawley rats were assigned to one of three groups: compression loading, distraction loading, or sham (apparatus applied without loading). Under general anesthesia, two 0.7-mm diameter stainless steel percutaneous pins were used to transfix each of two vertebrae. The pins were glued to 25-mm diameter external ring fixators. Springs (load rate, 35 g/mm) were installed on three stainless steel threaded rods that were passed through holes in each ring and compressed with nuts to apply compression or distraction forces between 25-75% of bodyweight. Vertebral growth rates in microns/day were measured by digitizing the length of the vertebrae images in radiographs taken 0, 1, 3, 5, 7, and 9 weeks later. RESULTS: The loaded vertebrae grew at 68% of control rate for compressed vertebrae and at 114% for distracted vertebrae. (Differences statistically significant, P < 0.01 by analysis of variance.) For the compressed vertebrae, the pinned vertebrae, which were loaded at one of their two growth cartilages, grew at a reduced rate (85%), although this effect was not apparent for the distraction animals. CONCLUSIONS: The findings confirm that vertebral growth is modulated by loading, according to the Hueter-Volkmann principle. The quantification of this relationship will permit more rational design of conservative treatment of spinal deformity during the adolescent growth spurt.
Asunto(s)
Vértebras Lumbares/crecimiento & desarrollo , Vértebras Lumbares/fisiología , Escoliosis/fisiopatología , Animales , Fijadores Internos , Vértebras Lumbares/cirugía , Ratas , Ratas Sprague-Dawley , Cola (estructura animal)/crecimiento & desarrollo , Cola (estructura animal)/fisiología , Cola (estructura animal)/cirugía , Soporte de Peso/fisiologíaRESUMEN
More premature infants are now surviving because of advances in perinatal care. Premature infants often have congenital anomalies requiring operative correction and are at increased risk for developing postoperative apnea. The purpose of this study was to review our results with spinal anesthesia in infants. Twenty-two infants (average age at operation, 11 weeks) had spinal anesthesia for surgery to the spine or lower extremities. One patient with bilateral developmental dysplasia of the hip had staged operations 1 month apart. Twelve infants (55%) were considered to be at increased risk for general anesthesia. The spinal anesthetic was 1% tetracaine made hyperbaric with 10% dextrose (tetracaine dose, 0.5 mg/kg). Spinal anesthesia was successful in all 23 cases. The average follow-up was 4 years, 1 month, and no complications were attributed to the spinal. Spinal anesthesia is a safe and effective substitute for general anesthesia in infants having spinal and lower extremity operations and is particularly beneficial for high-risk infants.
Asunto(s)
Anestesia Raquidea , Cadera/cirugía , Pierna/cirugía , Enfermedades de la Columna Vertebral/cirugía , Contraindicaciones , Cadera/diagnóstico por imagen , Humanos , Lactante , Recién Nacido , Pierna/diagnóstico por imagen , Radiografía , Factores de Tiempo , Resultado del TratamientoRESUMEN
Slipped capital femoral epiphysis, the most common hip disorder in adolescence, traditionally has been classified according to symptom duration. An acute slip is 1 in which there are symptoms for < 3 weeks; for a chronic slip, there are symptoms for > 3 weeks. An acute-on-chronic slip is characterized by a combination of both with a recent exacerbation of symptoms. This classification system is misleading because it does not consider stability. A stable slipped capital femoral epiphysis has a good prognosis, but an unstable slip has a guarded prognosis. The priorities in treating an unstable (acute) slip are (1) to avoid avascular necrosis, (2) to avoid chondrolysis, (3) to prevent further slip, and (4) to correct deformity. The last priority, correcting the deformity, is associated with a high incidence of complications including avascular necrosis and chondrolysis, so manipulative reduction under anesthesia or an acute corrective osteotomy is not recommended. To address these priorities in treatment, the authors recommend preoperative bed rest to decrease the synovitis and intraarticular effusion. Operative stabilization is done in an elective fashion once the synovitis has subsided. The technique includes careful patient positioning on the fracture table, which may cause an incidental reduction, but no attempt is made to do a manipulative reduction. The technique is dependent on radiographic control. The femoral head and neck must be well visualized on the anteroposterior and lateral intensifier images before the operation is started. The slipped capital femoral epiphysis is stabilized with a single central screw, and nonweightbearing ambulation with crutches is recommended until a satisfactory painless range of motion has returned.
Asunto(s)
Epífisis Desprendida/cirugía , Cabeza Femoral , Articulación de la Cadera/cirugía , Inestabilidad de la Articulación/cirugía , Enfermedad Aguda , Adolescente , Adulto , Enfermedades de los Cartílagos/etiología , Enfermedades de los Cartílagos/prevención & control , Niño , Epífisis Desprendida/clasificación , Epífisis Desprendida/complicaciones , Femenino , Necrosis de la Cabeza Femoral/etiología , Necrosis de la Cabeza Femoral/prevención & control , Humanos , Deformidades Adquiridas de la Articulación/complicaciones , Deformidades Adquiridas de la Articulación/cirugía , Inestabilidad de la Articulación/complicaciones , Masculino , Osteotomía/métodosRESUMEN
The purpose of this study was to determine the cause of acute hemarthrosis of the knee in a prospective pediatric patient population. Between December 1988 and August 1991, 21 consecutive children who were seen with an acute traumatic hemarthrosis of the knee had an arthroscopic evaluation. The average age of the children at the time of injury was 14 years, 3 months (range, 10 to 17 years). The mechanism of injury was a torsional strain to the knee in 12 (71%) of the 17 patients who could accurately remember the injury. The initial evaluation included a history, physical examination, and anteroposterior, lateral, sunrise, and comparison radiographs. The arthroscopic procedure was performed under general anesthesia, and the arthroscopic findings were compared with preoperative findings. During arthroscopic examination, an osteochondral fracture of the lateral femoral condyle or patella was identified in 14 (67%) of the 21 patients. Preoperative radiographs failed to identify the fracture in 5 (36%) of the 14 patients who had an osteochondral fracture. The anterior cruciate ligament was visualized and probed; an injury was found in only two cases (10%). We concluded that in children an acute traumatic hemarthrosis reflects a major injury to the knee. The children in this study had a high frequency of osteochondral fractures; ACL injuries were found in only two patients. Because of the unreliable nature of radiographic evaluation, arthroscopic evaluation is a valuable tool in differential diagnosis and treatment of acute hemarthrosis of the knee.
Asunto(s)
Hemartrosis/etiología , Traumatismos de la Rodilla/complicaciones , Articulación de la Rodilla , Enfermedad Aguda , Adolescente , Lesiones del Ligamento Cruzado Anterior , Artroscopía , Niño , Diagnóstico Diferencial , Endoscopía , Femenino , Fracturas del Fémur/complicaciones , Fracturas del Fémur/diagnóstico por imagen , Fracturas Óseas/complicaciones , Fracturas Óseas/diagnóstico por imagen , Hemartrosis/diagnóstico por imagen , Hemartrosis/cirugía , Humanos , Traumatismos de la Rodilla/diagnóstico por imagen , Traumatismos de la Rodilla/cirugía , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/cirugía , Masculino , Rótula/diagnóstico por imagen , Rótula/lesiones , Examen Físico , Estudios Prospectivos , Radiografía , Rotación , Esguinces y Distensiones/complicaciones , Esguinces y Distensiones/diagnóstico por imagenRESUMEN
OBJECTIVE: The definition and early treatment of congenital dysplasia of the hip are controversial. The purpose of this study was to discuss the reasons for changing the acronym to developmental dysplasia of the hip (DDH) and to address its early detection and treatment. DESIGN: This multicenter study was designed to provide an updated assessment of the definition, pathologic anatomy, prevalence, etiology, natural history, early detection, and treatment of DDH. RESULTS: DDH more accurately describes the condition previously termed congenital dysplasia of the hip. The disorder is not always present at birth (congenital) and an infant may have a normal neonatal hip screening examination and subsequently develop a dysplastic or dislocated hip. Developmental dysplasia encompasses the wide spectrum of hip problems seen in infants and children. Physicians should understand that a normal neonatal screening examination does not assure normal hip development. The diagnosis of developmental dysplasia is made by physical examination. The Ortolani and Barlow maneuvers were designed to detect a subluxatable, dislocatable, or dislocated hip in the neonatal period. In the older child, limited abduction becomes a more reliable sign. The examination is variable depending on the type of dysplasia and changes with growth. The ultrasound is proving to be a sensitive tool in confirming the diagnosis in newborns and infants from birth to 4 months of age. The ultrasound is also valuable in older infants in terms of documenting that the dysplasia is responding to treatment. However, the ultrasound depends on an experienced sonographer and, in some cases, may be too sensitive, resulting in overtreatment. After 3 to 4 months of age, an anteroposterior pelvis radiograph can confirm the diagnosis. CONCLUSIONS: All newborns should have a neonatal hip screening physical examination. After screening, the hips should be re-examined during health examination visits at 2 weeks, 2 months, 4 months, 6 months, 9 months, and 1 year of age. If any question arises during these visits or if there are associated risk factors, we recommend an ultrasound if the infant is < 4 months of age or an anteroposterior pelvis radiograph if > 4 months of age.
Asunto(s)
Luxación Congénita de la Cadera , Estudios de Seguimiento , Luxación Congénita de la Cadera/diagnóstico , Luxación Congénita de la Cadera/epidemiología , Luxación Congénita de la Cadera/etiología , Luxación Congénita de la Cadera/patología , Luxación Congénita de la Cadera/terapia , Articulación de la Cadera/diagnóstico por imagen , Humanos , Lactante , Recién Nacido , Dispositivos de Fijación Ortopédica , Examen Físico , Prevalencia , Radiografía , Terminología como Asunto , UltrasonografíaRESUMEN
STUDY DESIGN: The effect of spinal instrumentation in idiopathic scoliosis was studied in 21 patients who had Harrington instrumentation and 15 who had Wisconsin-Drummond instrumentation. OBJECTIVE: Radiographs were analyzed to determine if the frontal and transverse plane shape of the scoliosis curve was changed by surgery, with and without segmental fixation. SUMMARY OF BACKGROUND DATA: Previous reports were based on frontal plane measurements of the curve (Cobb angle). The study reports correction in the frontal plane (Cobb angle) and transverse plane (apical vertebral rotation), as well as the regional distribution of the correction. METHODS: Radiographs before surgery, soon after, and between 5 and 48 months after surgery were marked and digitized to measure the regional distribution of the frontal plane shape and transverse plane vertebral rotation. RESULTS: Despite improvement in the magnitude of the deformity, the scoliosis curve shape remained almost constant postoperatively. There was minimal correction of the apical vertebra axial rotation in either group. CONCLUSION: This study documents that although the Harrington and Wisconsin-Drummond instrumentation systems decrease the Cobb angle, they do not change the shape of the curve or correct apical vertebra axial rotation. Newer instrumentation designs need to look beyond the Cobb angle as the only measure of outcome.
Asunto(s)
Fijadores Internos , Vértebras Lumbares/diagnóstico por imagen , Escoliosis/cirugía , Fusión Vertebral/métodos , Vértebras Torácicas/diagnóstico por imagen , Adolescente , Clavos Ortopédicos , Hilos Ortopédicos , Femenino , Estudios de Seguimiento , Humanos , Vértebras Lumbares/cirugía , Masculino , Radiografía , Escoliosis/diagnóstico por imagen , Escoliosis/epidemiología , Vértebras Torácicas/cirugía , Factores de TiempoRESUMEN
Fourteen patients with cerebral palsy (CP), 12 with Friedreich's ataxia (FA) and 26 with adolescent idiopathic scoliosis (AIS) were studied to determine whether the shape of the scoliosis curve differs between these categories. The slope of the regression relationship between vertebral rotation and lateral deviation was greater for the CP group compared with the FA and AIS groups. The authors conclude that the scoliosis curve pattern of children with Friedreich's ataxia and adolescent idiopathic scoliosis is similar. In contrast, the scoliosis curve of children with CP was distinctly different, with more rotation of the apical vertebrae into the convexity of the scoliosis curve (transverse plane deformity) in relation to the amount of lateral deviation of the apical vertebrae from the spinal axis (coronal plane deformity).
Asunto(s)
Parálisis Cerebral/diagnóstico , Ataxia de Friedreich/diagnóstico , Escoliosis/diagnóstico , Columna Vertebral/patología , Adolescente , Antropometría , Parálisis Cerebral/diagnóstico por imagen , Parálisis Cerebral/patología , Niño , Diagnóstico Diferencial , Ataxia de Friedreich/diagnóstico por imagen , Ataxia de Friedreich/patología , Humanos , Radiografía , Escoliosis/diagnóstico por imagen , Escoliosis/patología , Columna Vertebral/diagnóstico por imagen , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/patologíaRESUMEN
Thirty patients who had had a total of fifty-one Mitchell procedures to correct adolescent hallux valgus deformities were examined clinically and radiographically an average of seven years (range, three to seventeen years) after the operation. The average age of the patients at the time of the operation was fifteen years (range, ten to nineteen years). The result was excellent in nineteen feet, good in sixteen, fair in six, and poor in ten. The fair and poor results were associated with recurrence of the deformity, stiffness (real or perceived), and unsightly scars. The cause of the fair and poor results was inadequate correction at the time of the operation in six feet and loss of fixation in two; the loss of fixation resulted in one recurrence and one malunion. The remaining eight patients who had a fair or poor result were not totally satisfied and had reservations about more than one of three categories (relief of discomfort, appearance, or range of motion). Seventeen feet had a plantar callosity beneath the second metatarsal head, suggesting increased load-bearing by the second metatarsal. Although sixteen callosities caused no symptoms at the most recent follow-up evaluation, the long-term implications of this altered pattern of weight-bearing are unknown.