Volume 15-1, Spring 2006

Femoral shaft fractures and supracondylar elbow fractures are two of the most common major pediatric injuries managed by the general orthopedic surgeon. Therapeutic choices frequently are influenced by many factors, including associated injuries, fracture type, and the child’s age, social situation, and economic issues. Nonsurgical management of femoral shaft fractures has been a preferred and cost-effective treatment for most age groups, but recently the use of surgical techniques has gained popularity with the overall goal of rapid mobilization of the child. Supracondylar elbow fractures are diagnostically challenging and can result in severe acute and long-term complications. An understanding of fracture presentation, anatomic detail, and surgical applications will optimize the chances for successful outcomes.

The purpose of this study was to determine the incidence of avascular necrosis and acetabular dysplasia in the normal uninvolved contralateral hip opposite a unilateral dislocated hip. Thirty-five children with unilateral developmental dislocation of the hip underwent closed reduction. Medical records were reviewed for gender, side, age at reduction, and presence of the ossific nucleus at reduction. Avascular necrosis was reported as present if there was proximal femoral deformity on postoperative radiographs. Acetabular dysplasia was noted as present based on reported values. The mean age at reduction was 10 months. The mean age at time of follow-up radiograph was 101 months. There was no evidence of avascular necrosis in any of the uninvolved hips. Acetabular dysplasia was present in 22 (63%)uninvolved hips.

This study evaluated the efficacy of vacuum-assisted closure (VAC) for treatment of fasciotomy wounds for traumatic compartment syndrome. The authors reviewed the records of a consecutive series of 34 patients who had compartment syndrome of the leg requiring the standard two-incision release of all four compartments and received the application of VAC therapy until the time of definitive wound closure or coverage. A matched series of 34 consecutive antecedent patients with the same entry criteria, except for the use of the VAC, were also studied and served as a control group. The main parameter of interest was the time to ‘‘definitive closure’’ (delayed primary closure with sutures or skin graft coverage) of the wounds. Of the 68 wounds in 34 patients managed with VAC, the average time to definitive closure for both the lateral and the medial wounds was 6.7 days. For the 70 wounds in the 34 control patients, the average time to definitive closure was 16.1 days. This difference in time to wound closure between the VAC group and the non-VAC group was statistically significant (p < .05). Subatmospheric treatment for compartment syndrome of the leg after fasciotomy theoretically helps to speed the resolution of the swelling and tissue edema that are often components of this clinical entity. Experimental work has shown vacuum-assisted wound management to be effective in hastening the resolution of wound edema, enhancing local blood flow, promoting granulation tissue, and thwarting bacterial colonization. These factors may account for its utility in the management of fasciotomy wounds in the setting of compartment syndrome of the leg.

Anterior cervical discectomy and fusion (ACDF) is commonly performed for degenerative conditions of the cervical spine with good to excellent results. There is controversy over the use of ACDF for patients with axial neck pain alone. A retrospective review of 202 patients from two private practice orthopaedic spine surgeons following ACDF with 39-month mean follow-up was performed. Patients completed pain drawings, pre- and postoperative visual analog pain scales (VAS), Oswestry functional capacity evaluations (OSW), and a postoperative neck disability index. Forty-one patients had axial neck pain alone, and 161 had radicular pain with or without neck pain. There were significant improvements in VAS and OSW scores following surgery for the combined study population as well as the neck pain only and radicular pain groups(p < .01). ACDF can be effectively used for treatment of patients with axial neck pain without radicular symptoms.

Muscle transfer provides a viable treatment option for several difficult problems involving the shoulder. Muscle transfer is often the only alternative to a salvage procedure such as shoulder fusion, and whereas salvage procedures provide pain relief at the cost of function, muscle transfer can provide pain relief while retaining acceptable function. The five most commonly encountered shoulder problems for which muscle transfer can be utilized are subscapularis rupture, irreparable rotator cuff tear, deltoid injury and dysfunction, trapezial paralysis, and serratus anterior scapular winging. Although numerous muscle transfer procedures have been described, the following procedures have proven the most reliable and are the focus of this article: 1) transfer of the pectoralis major for subscapularis rupture, 2) transfer of the latissimus dorsi for irreparable rotator cuff tears, 3) latissimus dorsi transfer for deltoid injury or dysfunction, 4) modified Eden–Lange procedure for trapezial paralysis, and 5) modified Marmor–Bechtol pectoralis major transfer for serratus anterior scapular winging.

Type II odontoid fractures are prone to undergo nonunion. Stabilization of such fractures with anterior screw fixation provides rigid internal fixation and preserves C1–C2 motion. During a 5-year period, 17 patients with displaced type II fractures of the odontoid were treated Thirteen were male and four were female with a mean age of 38.2 years. All patients were operated on for anterior screw fixation within a mean of 10.1 days from injury. Postoperatively, the patients were evaluated clinically and radiologically at regular intervals. With a mean follow-up of 3.2 years, union was observed in 16 of 17 patients (94%). One patient developed nonunion for which he required C1–C2 fusion subsequently. Screw back-out by a few millimeters was seen in another patient resulting in mild restriction of neck movements. No approach-related complications were noted. Anterior odontoid screw fixation has relatively low complication and high fusion rates. It not only restores normal anatomy but also gives better functional results by preserving intrinsic C1–C2 motion. Thus it should be considered the treatment of choice in acute displaced type II odontoid fractures.

Adolescent idiopathic scoliosis (AIS), a structural lateral curvature of the spine of uncertain etiology, is the most common cause of spinal deformity in adolescents. In its most severe form, AIS is characterized by progressive spinal curvature that may lead to a permanent deformity. Thus, the goal of treatment is early detection and prevention of progression. This article provides a review of general spinal anatomy relevant to AIS and its etiology, describes several proposed methods of classifying curves in AIS, delineates the natural history of AIS, and discusses the nonoperative and operative treatment options.

The objective of this study was to determine the incidence of local adverse events (AEs) with repeat treatment of hylan G-F 20 for osteoarthritis (OA) knee pain relief in the authors’ practice. Prospectively collected patient data (5-year period)was retrospectively reviewed from patients who initiated multiple courses of three weekly hylan G-F 20 injections. All local AEs (knee pain and swelling) were qualitatively and quantitatively assessed. The incidence of treatment-related local AEs was 3.4% of patients (0.8% of injections) at course 1, 13.1% of patients (4.3% of injections) at course 2, and 17.3% of patients (5.4% of injections) at course 3. The majority of related local AEs were mild to moderate and persisted for < 48 hours. The number of patients who discontinued injections because of local AEs was low. While the incidence of local AEs with hylan G-F 20 tends to slightly increase with subsequent courses of therapy, physicians should educate patients regarding this possibility rather than preclude them from the benefit of continued OA pain relief with repeat hylan G-F 20 therapy.

The deltopectoral approach has long been the workhorse for exposure of the shoulder. However, this exposure involves dividing the subscapularis tendon. Despite meticulous repair, suboptimal return of subscapularis may further reduce a patient’s functional capacity with an already deficient rotator cuff. This report describes an alternative approach for shoulder hemiarthroplasty, preserving subscapularis, in a patient with a deficient rotator cuff.

“Pay It Forward” was a film in the year 2000 with Haley Joel Osment and Kevin Spacey. Its premise was very simple: when someone does something nice for a person, that person has an obligation to repay the act; however, instead of repaying the debt to the original person, the obligation was repaid by doing something nice for three other people. Those people would have the obligation to repay nine other people, who would then have to repay 27 other people, and so forth. In this manner a simple act of kindness spreads through the community/world making it a better place.