RESUMEN
Lower-limb kinematics and kinetics during preferred and fast speeds of walking were measured in persons with proximal femoral focal deficiency to compare outcomes after Syme amputation (nine subjects) with those after Van Nes rotational osteotomy (10 subjects). Subjects with a Van Nes rotational osteotomy and full tibial rotation (seven subjects) demonstrated prosthetic knee function during stance as they were able to support a flexed-knee posture at both speeds and produced greater knee-extensor moments at preferred speeds as compared with the Syme group (p < 0.05). Nonprosthetic limb compensatory mechanics were significantly exacerbated in subjects with a Syme amputation compared with the Van Nes group: (a) stance-phase vaulting, resulting in greater inappropriate ankle-power generation at both walking speeds, (b) excessive hip-extensor moments at fast speeds, (c) excessive hip-power absorption and generation at both speeds, and (d) excessive knee-joint power generation at both speeds (p < 0.05). The improved gait after Van Nes rotational osteotomy is one factor that should be considered when making clinical decisions for children with proximal femoral focal deficiency.
Asunto(s)
Amputación Quirúrgica/métodos , Cabeza Femoral/anomalías , Marcha , Luxación Congénita de la Cadera/cirugía , Osteotomía/métodos , Adolescente , Adulto , Amputación Quirúrgica/rehabilitación , Miembros Artificiales , Fenómenos Biomecánicos , Niño , Preescolar , Femenino , Fémur/anomalías , Fémur/cirugía , Cabeza Femoral/cirugía , Estudios de Seguimiento , Luxación Congénita de la Cadera/diagnóstico , Luxación Congénita de la Cadera/rehabilitación , Humanos , Cinética , Pierna , Masculino , Osteotomía/rehabilitación , Diseño de Prótesis , Rango del Movimiento Articular , Estadísticas no ParamétricasRESUMEN
Postoperative fever in the pediatric orthopaedic population remains a clinical concern even though prior studies concluded that fevers are a poor predictor of surgical complications. In this retrospective study of 177 patients, we established guidelines regarding the degree and time course of fever we should expect based on the perioperative conditions of magnitude of surgery, duration of surgery, need for intraoperative transfusion, estimated blood loss, age, and gender. To provide a more sensitive assessment of fever, we developed composite temperature curves for each patient and defined the area under these curves as the total febrile response (TFR). This allowed us to assess fever as a cumulative event, taking into account both its magnitude and duration. A multivariate model then determined that of the perioperative conditions studied, intraoperative transfusion status and estimated blood loss were most helpful in predicting a patient's TFR. The results of this study can be used as an additional tool for assessing postoperative progress and whether a fever is within the normal limits indicated by a patient's perioperative variables.
Asunto(s)
Fiebre/etiología , Procedimientos Ortopédicos/efectos adversos , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Análisis Multivariante , Periodo Posoperatorio , Valores de Referencia , Análisis de Regresión , Estudios RetrospectivosRESUMEN
We performed a retrospective review of 34 humerus shaft fractures (HSFs) in children younger than 3 years to determine the frequency of child abuse in young children with this injury. Data were obtained from hospital records (including previous and subsequent emergency, clinic, and inpatient notes), radiographs, and county childprotective services. Cases were reviewed independently by four physicians and were classified as probable abuse, probable not abuse, and indeterminate. Only 18% were classified as probable abuse. The history and findings other than the fracture itself were critical in establishing cause. Neither age nor fracture pattern is pathognomonic of abuse, but suspicion should remain high. A detailed history, complete physical examination, and appropriate radiographic investigation are required in every case either to make the diagnosis of abuse or to avoid the trauma of a false accusation.
Asunto(s)
Accidentes , Maltrato a los Niños/diagnóstico , Fracturas del Húmero/diagnóstico , Fracturas del Húmero/etiología , Fenómenos Biomecánicos , Preescolar , Diagnóstico Diferencial , Femenino , Humanos , Fracturas del Húmero/clasificación , Incidencia , Lactante , Masculino , Anamnesis , Examen Físico , Estudios RetrospectivosRESUMEN
Twenty-nine children with renal osteodystrophy (RO) and angular deformities about the knee were studied, including 19 in whom 36 corrective operations were performed. Corrective osteotomy of the distal femur was performed in 20 knees, osteotomy of the proximal tibia in 11 knees, combined femoral/tibial osteotomy in three knees, and medial physeal stapling in two knees. The indication for surgery was a deformity significant enough to interfere with gait. Complications occurred in three patients and recurrence severe enough to require repeated surgery occurred in four patients. Patients who required repeated osteotomy appeared to have had poor metabolic control during the initial surgery, as measured by an increased alkaline phosphatase. Surgery for children with RO and knee deformities is quite feasible but requires careful surgical planning and preoperative metabolic stabilization. Whether to correct the femur or tibia can be determined by evaluating full-length films of the lower extremities.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/complicaciones , Rodilla , Enfermedades Musculoesqueléticas/complicaciones , Complicaciones Posoperatorias/fisiopatología , Adolescente , Adulto , Niño , Preescolar , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Rodilla/anomalías , Rodilla/cirugía , Masculino , Enfermedades Musculoesqueléticas/diagnóstico , Osteotomía/métodos , ReoperaciónRESUMEN
The energy expended during walking by sixteen children who had proximal femoral focal deficiency was measured to compare the outcomes after Syme amputation (seven subjects) with those after Van Nes rotational osteotomy (nine subjects). Multivariate regression analysis revealed that the subjects who had had a Van Nes procedure had a mean oxygen cost (energy per unit of body mass expended per distance walked) that was 0.12 milliliter per kilogram of body mass per meter lower than that of the subjects who had had a Syme amputation (p = 0.001). The subjects who had had a Van Nes procedure tended to walk faster (p = 0.07). A significant decrease in the oxygen cost as a function of increasing age was observed for both groups (p < 0.0001, r2= 0.79). We believe that the reduced energy expenditure associated with the Van Nes rotational osteotomy is one of several factors to consider when deciding which operation should be done for children who have proximal femoral focal deficiency.
Asunto(s)
Amputación Quirúrgica , Enfermedades Óseas/fisiopatología , Osteotomía , Caminata/fisiología , Adolescente , Niño , Femenino , Marcha , Humanos , Masculino , Osteotomía/métodos , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal involvement is rare, and there are few reports with clear recommendations regarding treatment. The purpose of this study was to review a series of 25 patients with musculoskeletal coccidioidomycosis and to assess their outcomes with respect to presentation and treatment. There were 36 lesions among the 25 patients, 8 located in the spine, with the remainder distributed throughout the body. Seventeen patients had a delay in diagnosis of more than 1 month. Eight patients had an elevated white blood cell count, and 10 had an elevated sedimentation rate. Only 7 of the patients had an overt pneumonia before the musculoskeletal presentation. Twenty-four patients underwent formal irrigation and debridement and 22 patients had at least 1 course of Amphotericin B. The average followup after the initiation of treatment was 3.5 years, ranging from 2 to 10 years. Seven patients had recurrent lesions that required further surgical intervention, 4 of whom had a delay in diagnosis of more than 1 month. There were 3 deaths. All surviving patients were free of disease at final followup.
Asunto(s)
Anfotericina B/uso terapéutico , Antifúngicos/uso terapéutico , Coccidioidomicosis/terapia , Enfermedades Musculoesqueléticas/terapia , Adolescente , Adulto , Niño , Preescolar , Coccidioidomicosis/diagnóstico , Desbridamiento , Errores Diagnósticos , Resultado Fatal , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Persona de Mediana Edad , Enfermedades Musculoesqueléticas/diagnóstico , Enfermedades Musculoesqueléticas/microbiología , Irrigación Terapéutica , Resultado del TratamientoRESUMEN
Knee dislocation after high energy trauma poses a major challenge to patients and treating physicians. The case presented documents the history and treatment of an unreduced posterior knee dislocation discovered 24 weeks after injury. Delayed surgical reduction was achieved, and satisfactory results were obtained with 22 months of followup of the patient. A detailed review of the literature found no comparable examples of longstanding traumatic dislocations of the knee but shed light on the probable cause for this unusual case. Close clinical followup, even after appropriate initial treatment of knee dislocations, is needed to eliminate similar occurrences.
Asunto(s)
Luxaciones Articulares/cirugía , Traumatismos de la Rodilla/cirugía , Adolescente , Humanos , Luxaciones Articulares/diagnóstico por imagen , Traumatismos de la Rodilla/diagnóstico por imagen , Traumatismos de la Rodilla/fisiopatología , Articulación de la Rodilla/fisiología , Masculino , Radiografía , Rango del Movimiento Articular , Factores de TiempoRESUMEN
There are few large series of the long-term results of severe devascularized, open fractures to the lower extremity. Therefore, we retrospectively reviewed our experience with 35 consecutively admitted patients who sustained Gustilo Type IIIC injuries and who presented to our Reimplantation Center between 1984 and 1987. To our knowledge, this group of patients represents the largest series of this injury reported to date. The review included 21 patients who required primary amputation and 14 patients who underwent vascular, orthopedic, and delayed soft tissue reconstruction. This report details the treatment protocol used to result in our 93% success rate in the 14 patients with Type IIIC injuries who were successfully revascularized. Our initial management approach to the devascularized lower limb includes immediate revascularization with temporary shunts to minimize ischemia time, followed by revascularization with vein grafts beyond the zone of injury and external fixation. Subsequent management included liberal use of microsurgical free transplantation to overcome soft tissue defects; bone grafting as soon as infection and soft tissue coverage permitted and delayed wound closure. Our approach differs in that definitive wound closure is avoided for 4 to 6 weeks to allow resolution of myonecrosis secondary to initial ischemia and subsequent reperfusion injury. Contraindications to this aggressive revascularization approach are poor patient health before injury, completely severed limb, segmental tibial loss greater than 8 cm, ischemia time greater than 6 hours, and severance of the posterior tibial nerve.
Asunto(s)
Amputación Quirúrgica , Pierna/irrigación sanguínea , Fracturas de la Tibia/clasificación , Fracturas de la Tibia/cirugía , Humanos , Estudios RetrospectivosRESUMEN
Slip progression in patients with spondylolisthesis is most commonly identified by comparing serial lateral radiographs of the lumbosacral spine. Although the demonstration of a progression in slip in a symptomatic individual can be an indication for surgical intervention, accurate measurements remain somewhat elusive. This is because of factors that introduce error into the measurement process itself. Foremost among these is the comparison of lateral radiographs that are not "true lateral" radiographs but rather have an unknown variable obliquity to the radiologic beam. To define the relationship between the measured slip and the obliquity of the x-ray beam angle from the true lateral, an experimental model was constructed with a fixed degree of slip at the L5-S1 level. Three different fixed degrees of slip (approximately 25, 50, and 75%) were studied. The standard deviation and hence the inherent measurement error of the measured slip increased as the obliquity of the beam away from the true lateral increased. In addition to this, the standard deviation as a function of beam angle from the true lateral also appeared to increase for larger slips.
Asunto(s)
Vértebras Lumbares , Sacro , Espondilolistesis/diagnóstico por imagen , Cadáver , Humanos , Modelos Anatómicos , Radiografía , Sensibilidad y Especificidad , Tecnología RadiológicaRESUMEN
Progressive spinal deformity can be an anathma for indivudials with osteogenesis imperfecta. Scoliosis or khyphosis develop indolently, being less dramatic than long bone fractures, but once significant deformities evolve, they tend to remain progressive on into adulthood. State of the art spinal fixation systems are of little help in correcting such deformities due to poor bone stock. However, most curves can be arrested by posterior spinal fusion, performed either in situ, or by utilizing basic Harrington type instrumentation with methylmethacylate supplemtation for the hook sites, along with Drummond wires where feasible. Platybasia is yet another issue involving the spine which may be complicated by neurologic deterioration. It has been posulated as a cause of death, but can respond to shunting and brain stem decompression when recognized.
Asunto(s)
Osteogénesis Imperfecta/complicaciones , Platibasia/etiología , Platibasia/cirugía , Curvaturas de la Columna Vertebral/etiología , Curvaturas de la Columna Vertebral/cirugía , Tirantes/efectos adversos , Tirantes/normas , Descompresión Quirúrgica/normas , Descompresión Quirúrgica/tendencias , Humanos , Fijadores Internos/normas , Fijadores Internos/tendencias , Platibasia/patología , Base del Cráneo/anomalías , Base del Cráneo/patología , Base del Cráneo/cirugía , Curvaturas de la Columna Vertebral/patología , Fusión Vertebral/instrumentación , Fusión Vertebral/normas , Fusión Vertebral/tendencias , Columna Vertebral/anomalías , Columna Vertebral/patología , Columna Vertebral/cirugíaRESUMEN
Dorsal defect of the patella is a benign subchondral lesion of unknown etiology, located in the superolateral region of the patella. The lesion presents with a characteristic radiographic appearance consisting of a rounded focus of radiolucency surrounded by a sclerotic margin. Although often an incidental finding on knee radiographs, it occasionally may be symptomatic. It occurs in males and females with equal frequency, is bilateral in up to one third of individuals, and is most frequently found in adolescents. This report describes a series of eight such lesions in five patients.
Asunto(s)
Artralgia/etiología , Rótula/diagnóstico por imagen , Adolescente , Adulto , Anciano , Artralgia/diagnóstico por imagen , Artralgia/terapia , Femenino , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Radiografía , Remisión EspontáneaRESUMEN
Serum intact PTH [1-84] levels were evaluated as a potential non-invasive method for the diagnosis of renal osteodystrophy in children treated with CAPD/CCPD. Sixty-eight bone biopsy samples were obtained from 55 patients, aged 13 +/- 5 (X +/- SD) years, undergoing CAPD/CCPD for 29 +/- 13 months; osteitis fibrosa was present in 34 cases, mild lesions of secondary hyperparathyroidism in six, 15 had adynamic lesions, and 13 were classified as normal histology. Serum calcium levels were higher in patients with adynamic bone or normal bone histology than in those with secondary hyperparathyroidism, whereas serum phosphorus, alkaline phosphatase and PTH levels were greater in patients with osteitis fibrosa. The combination of a serum PTH level > 200 pg/ml and a serum calcium value < 10 mg/dl was 85% sensitive and 100% specific for identifying patients with high-turnover lesions of bone. Serum PTH values < 200 pg/ml were 100% sensitive but only 79% specific for patients with adynamic bone; specificity increased to 92%, however, using the combined criteria of a PTH level < 150 pg/ml and a serum calcium level > 10 mg/dl. Higher serum calcium levels and serum PTH values within or below the normal range characterize patients with the adynamic lesion of renal osteodystrophy. Serum PTH levels of approximately 200 pg/ml are useful for distinguishing patients with low-turnover lesions of renal osteodystrophy from those with secondary hyperparathyroidism.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/sangre , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Diálisis Peritoneal Ambulatoria Continua/efectos adversos , Adolescente , Fosfatasa Alcalina/sangre , Biomarcadores , Calcio/sangre , Niño , Femenino , Predicción , Humanos , Masculino , Hormona Paratiroidea/sangreRESUMEN
A biomechanical study was initiated to compare four fracture fixation devices: the AO dynamic compression plate, a distal fin locking nail, a solid locked intramedullary nail, and paired flexible nails for humeral fracture fixation. Eighteen pairs of fresh-frozen, intact humeri were harvested, standardized midshaft transverse osteotomies were created in each specimen, and left and right specimens were fixed with plates and nails, respectively. The bending properties of the plate-fixed humeri were significantly greater than the nailed humeri in both the anteroposterior and mediolateral planes on a paired basis. The distal fin nail and solid locked nail had comparable bending properties, and both had bending properties superior to those measured for the paired flexible nails. The torsional properties of humeri fixed with plates and solid locked nails were equivalent, except for rigidity and stiffness, which were superior for the nail. Both fixation methods resulted in torsional properties significantly greater to those measured for humeri fixed with paired flexible nails or a distal fin nail.
Asunto(s)
Fijación Intramedular de Fracturas/métodos , Fracturas del Húmero/cirugía , Fenómenos Biomecánicos , Clavos Ortopédicos , Placas Óseas , Cadáver , Humanos , Húmero/fisiologíaRESUMEN
Gait kinematics and dynamics during stance of unilateral, below-knee child amputees were analyzed for self-selected, comfortable (0.9 m s-1) and fast (1.3 m s-1) speeds with the SACH foot and the energy-storing Flex-foot prostheses. The three-dimensional movements of the lower limbs were recorded and synchronized with ground reaction forces for 12 subjects (7 girls and 5 boys, ages 6-16 yr). Each lower limb was modeled as a set of interconnected rigid links (thigh, leg, and foot) with frictionless joints (hip, knee, and ankle) to calculate moment and joint power profiles. Marked asymmetries were noted in ground reaction force, joint moment, and power profiles for the prosthetic versus the natural limb, but with the Flex foot the asymmetries were less pronounced than with the SACH foot. For the amputee wearing the Flex foot, greater moments and power were generated by the natural limb at the comfortable pace as compared to the SACH foot, but during fast walking, the SACH foot required greater output from the natural limb. With both prostheses, for the prosthetic limb the amputees used similar force, moment, and power patterns, but with significantly different amplitudes. At both speeds of walking, the Flex foot returned significantly more energy (66% at comfortable and 70% at fast walking) than the SACH foot (21% at comfortable and 19% at fast walking). Thus, the Flex foot had a greater potential for reducing the energy cost of walking at comfortable and fast speeds for the below-knee child amputee.
Asunto(s)
Amputados , Pie , Marcha/fisiología , Prótesis e Implantes , Diseño de Prótesis , Adolescente , Articulación del Tobillo/fisiología , Fenómenos Biomecánicos , Niño , Femenino , Pie/fisiología , Articulación de la Cadera/fisiología , Humanos , Rodilla , Articulación de la Rodilla/fisiología , Locomoción/fisiología , Masculino , Presión , Estrés Mecánico , Propiedades de Superficie , Caminata/fisiologíaRESUMEN
Radiation therapy has been shown to be the most effective prophylactic measure against heterotopic ossification (HO) in surgically repaired hip fractures. Current research is seeking the minimum effective dose of radiation. The authors present four case reports and a review of the literature on HO.
Asunto(s)
Fracturas de Cadera/cirugía , Osificación Heterotópica/prevención & control , Complicaciones Posoperatorias/prevención & control , Adulto , Femenino , Fracturas de Cadera/radioterapia , Humanos , Masculino , Persona de Mediana Edad , Osificación Heterotópica/radioterapia , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
Wide excision, a recommended treatment for osteoid osteoma, creates needless resection of surrounding bone and causes difficult intraoperative nidus identification. Less bone resection is required by successively burring through the reactive bone to identify the nidus, which is then removed with curettes and burrs. This burr-down technique requires precise preoperative anatomic localization by thin section (1-1.5 mm) computed tomography (CT) scans. In a consecutive series of 19 osteoid osteomas, 18 were accurately diagnosed before operation, using a combination of clinical findings, plain roentgenograms, and CT scans. The burr-down technique was successfully used in 15 cases, and four were treated with wide excision. There have been no local recurrences. The follow-up period for all 19 patients was at least six months. No bone grafts were required in the burr-down group in nonspinal locations; there have been no fractures despite early return to unrestricted activity. The burr-down technique was associated with less postoperative immobilization, a shorter duration of protected weight bearing, and an earlier return to activity. The burr-down technique is recommended for accessible osteoid osteoma lesions.
Asunto(s)
Neoplasias Óseas/cirugía , Osteoma Osteoide/cirugía , Adolescente , Neoplasias Óseas/diagnóstico , Niño , Femenino , Fémur/cirugía , Humanos , Masculino , Ortopedia/métodos , Osteoma Osteoide/diagnóstico , Estudios Retrospectivos , Tibia/cirugía , Tomografía Computarizada por Rayos XRESUMEN
Five patients each with grade IIIB or IIIC distal tibial injuries are presented. All patients were treated initially by multiple debridements and external fixation of the tibial fracture. After failure of the primary treatment, each patient underwent microsurgical free muscle transfer and bone transport of the proximal tibia to reconstruct the lower leg. Soft tissue loss ranged from 8 to 20 cm. Segmental tibial loss ranged from 8 to 18 cm. Free flaps used included rectus abdominis, latissimus dorsi, and combined latissimus dorsi-serratus anterior muscles. Bone transport was accomplished by callus distraction after corticotomy. All patients are ambulatory, fully weight bearing, and without pain (range, 17-34 mo). This treatment method has obviated the need for below-the-knee amputation in all of our patients.
Asunto(s)
Alargamiento Óseo/instrumentación , Fracturas Abiertas/cirugía , Microcirugia/instrumentación , Colgajos Quirúrgicos , Fracturas de la Tibia/cirugía , Adulto , Trasplante Óseo , Fijadores Externos , Femenino , Fijación Interna de Fracturas , Curación de Fractura/fisiología , Fracturas Abiertas/clasificación , Fracturas Abiertas/diagnóstico por imagen , Fracturas no Consolidadas/clasificación , Fracturas no Consolidadas/diagnóstico por imagen , Fracturas no Consolidadas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Osteomielitis/clasificación , Osteomielitis/diagnóstico por imagen , Osteomielitis/cirugía , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/cirugía , Radiografía , Reoperación , Fracturas de la Tibia/clasificación , Fracturas de la Tibia/diagnóstico por imagenRESUMEN
In a group of 27 children with chronic renal failure and renal osteodystrophy, we identified eight patients with significant involvement of the proximal tibial physis (15 knees). The radiographic changes observed were analogous to those observed in tibia vara (Blount's disease) but involved the lateral physis rather than the medial physis. This observation is offered as further evidence that such changes are related to eccentric weight-bearing rather than alternative etiologies such as trauma, infection, or heredity.