Editorial: Cerebral Palsy: Past, Present, and Future*--L. Andrew Koman, MD

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I first became aware of the existence of cerebral palsy Winston-Salem, NC more than 20 years ago, while I was a resident. Although things have changed considerably over the past 20 years, our approach to cerebral palsy is still based on the experience of those who have gone before us. The future will depend on our current experience. Although our knowledge base has expanded exponentially, the answers to most of the conundrums regarding optimal management of children with cerebral palsy remain unanswered. This presentation will define the historical eras of the management of cerebral palsy.

Chronic Osteomgelitis Associated with-Cat-Scratch Disease--Brad G. Prybis, MD, John L. Eady, MD, George S. Kotchmar, Jr., MD

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Cat-scratch disease (CSD) is usually a self-limited illness, though atypical presentations of infection with Bartonella henselae can occur, including osteomyelitis, oculoglandular syndrome, and granulomatous hepatitis. We describe a 6- year-old boy who had atypical CSD osteomyelitis of the left proximal femoral metaphysis due to a cat scratch. This is the second paper to report serial serology of B henselae, and the second paper to identify plasma cells on histologic examination, compatible with chronic osteomyelitis. The diagnosis was made by clinical, serologic, and histologic examination. Sixteen cases of atypical CSD osteomyelitis have been reported in the English literature and are reviewed in this paper.

Cost Impact of Botulinum Toxin Use in Medicaid-Enrolled Children With Cerebal Palsy*--Rajesh Balkrishnan, PhD, Fabian T. Camacho, MS, Beth P. Smith. PhD, Jeffrey S. hilt, MD, Laura K. Jacks, MD, L. Andrew Kornan, MD, Karen L. Rascati, PhD

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The use of botulinum toxin type A (BTX) in the management of spasticity in childhood cerebral palsy (CP) is increasing. This study examined annual health care service utilization and costs associated with BTX therapy for spastic CP in Medicaid-enrolled children receiving complete health care coverage (1997 to 1999). pair matching as well as recent statisti nique improvements (bootstrap method) to work with limited samples. The introduction of BTX was associated with an increase of approximately $62 per month in prescription costs for the patient. However, these costs were made up by reductions in hospitalization. When each year was examined individually, reimbursements for BTX users were not different from those for pairmatched non-BTX users. These ata suggest that BTX therapy does not significantly add to the costs of treating Medicaid-enrolled children with CP.

Determination of Bone Mineral Content in Cadaveric Test Specimens--Stefan M. Duma, PhD, Joel D. Stitzel, MS, Jeff R. Crandall, PhD, Liam P. Ryan, BS

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This study was designed to determine the best method for presenting the bone mineral content of cadaveric test specimens. A total of 59 bone samples were taken from the humeri, radii, and ulnae of 14 female cadavers. For each sample, Charlottesville, Va the bone mineral content was determined with a dual-energy x-ray absorptiometry scanner, and the ash-weight ratio was calculated manually. A linear regression analysis was performed to compare the ash-weight ratio to the 3 methods for reporting bone mineral content as measured by a -dual-energy x-ray absorptiometry scanner: by bone mineral content divided by sample length (in glcm), by projected area (in g/cm", or by sample volume (in g/cm3). The analysis revealed that the ash-weight ratio correlates best with the volumetric representation. Based on these data, a volumetric representation is suggested as the best rep- resentation of bone mineralization, due to its correlation with ash-weight ratio.

History of Orthopaedic Education*--James A. Nunley, MD

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Over the past century, the history of orthopaedic education has been intimately tied with the development of American medical education. I think it is critically important for us to understand the lessons of history because if we do not, we are doomed to repeat our mistakes. Therefore, let us look at how American medical education has evolved over the past century, see what the major factors and influences have been, and then look at where orthopaedic education is going in the future.

Pigmented Villonodular Synovitis of the Knee: Average Five-Year Follow-up of Arthroscopic Treatment--Peter B. Rauh, MD, FRCS, Jason Bernard, MD, FRCSE, David M. Craig, MD, FRCS

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We have reviewed the results of arthroscopic treatment of pigmented villonodular synovitis (PVNS) with reference to both recur- rence and to function. Between 1985 and 1995, a single surgeon treated eight patients. At an average 5-year follow-up, all patients were inter- viewed and had assessment of Hospital for Special Surgery (HSS) knee score for both the affected and unaffected knees. Also recorded were age, sex, and whether disease was recurrent, localized, or diffuse. Disease recurred in 4 patients, all with diffuse PVNS, and 3 of them required a further arthroscopic synovectomy at a mean of 16 months after the index procedure. All patients had good or excellent functional results. There was no significant difference between HSS knee scores for affected and unaffected knees. Arthroscopic synovectomy is a successful treatment in patients with localized PVNS of the knee and results in a knee that is functionally not different from its unaffected partner.

Proximal Femoral Allografting in Revision Total Hip Arthroplasty: Stabilization of the Host-Graft Junction With Tension Band Fixation--Brian E. Hakala, MA, MD, Joseph T. Moskal, MD

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Large deficiencies of the metaphysis and proximal diaphysis present a significant challenge to the orthopaedic surgeon undertaking revision of failed total hip arthroplasty. Proximal femoral allograft-prosthetic reconstruction may enable revision in such situations. Secure fixation is essential to successful integration and function of these allograft-prosthetic constructs. We report our experience in 7 revision total hip arthroplasties in 5 patients. Proximal femoral allograftprosthetic reconstruction was undertaken on all 7 hips using a technique of tension band fixation for securely fixing allograft to host bone at their interface to further minimize motion at the junc- tion site and maximize union. Radiographic evidence of union at the interface was noted in 6 of 7 hips. Mean Harris hip score increased from 18 preoperatively to 83 postoperatively, with a mean follow-up of 78 months (range, 56-116 months).

Thermal Capsulorrhaphy in the Treatment of Multidirectional Instability of the Shoulder--Robert S. Wolf, MD, Lawrence J. Lemak, MD

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The treatment of symptomatic multidirectional instability (MDI) of the shoulder has proven a challenge to orthopaedic surgeons. Patients who refuse activity modification often fail nonsurgical management, and traditional surgical approaches may trade the dysfunction of instability for that of decreased motion and possible future arthrosis. Recently, several methods of arthroscopic thermal capsulorrhaphy have gained popularity. Studies have shown that capsular shrinkage occurs due to the denaturation of type I collagen with maintenance of heat-stable intermolecular crosslinks. Thermally treated tissues undergo a predictable healing response. The primary advantages of this procedure are the decreased surgical morbidity and ease of procedure compared with open capsular shift. Additionally, it may provide improved stability and decreased pain while maintaining range of motion. When radiofrequency treatment provides inadequate visualized capsular contracture, arthroscopic rotator interval closure can improve stability without resorting to an open procedure. While ini- tial results in certain clinical series are promising, the long-term efficacy remains to be seen.

Transient Erectile Dysfunction Associated With Intramuscular Injection of Botulinum Toxin Type A--Anastasios S. Papadonikolakis, MD, Marios D. Vekris, MD, John P. Kostas, MD, Anastasios V. Korompilias, MD, Panayotis N. Soucacos, MD

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Autonomic nervous system dysfunction occurs rarely after botulinum toxin type A (BTX-A) intramuscular injections. We report a case of a 23-year-old man with spastic diplegia who had transient erectile dysfunction after intramuscular injection of BTX-A (total dosage, 300 IU, body weight 95 kg) in both hamstring muscles. Some investigators believe that the local spread of the toxin is responsible for autonomic dysfunction, while others believe that the transportation of the toxin to the spinal cord via retro- grade flow or via the blood flow after entering the circulation are possible mechanisms of neuro- logic side effects. On the basis of our case, a retrograde axoplasmic flow to the spinal cord could probably occur because the spinal cord level of hamstring muscles is close to spinal cord levels responsible for erection control.




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