Biomedical subjects
D R Wenger
Publications and source records attributed to D R Wenger.
Early surgical correction of residual hip dysplasia: the San Diego Children's Hospital approach.
Studies of the etiology of premature osteoarthritis of the hip show that the most common cause is residual childhood hip dysplasia. Hip dysplasia is often asymptomatic in childhood, making detection difficult and creating complex treatment decisions (major surgery in the asymptomatic child). Symptoms do not develop typically until the teenage or early adult years, and surgical correction at this age is often incomplete and complicated. In contrast, if the dysplasia is recognized early, surgical correction can be performed using simpler osteotomies with more predictable results. Our experience with children, adolescents and adults with residual hip dysplasia has led us to adopt a philosophy of early surgical correction which seeks to normalize hip joint morphology by age 5 or 6 years. The reasoning, methods and early results of this approach are reviewed in this paper.
Scoliosis in total-body-involvement cerebral palsy. Analysis of surgical treatment and patient and caregiver satisfaction.
STUDY DESIGN: A nonrandomized descriptive case series. OBJECTIVES: To analyze the results of spinal fusion in patients with total-body-involvement cerebral palsy to determine early and late outcomes, including caregiver satisfaction. METHODS: Data from 79 to 100 patients with total-body-involvement spastic cerebral palsy who underwent posterior Luque instrumentation, or anterior spinal fusion, or both, were adequate to be included in the study. Functional status was evaluated by physical examination, and a personal interview was conducted with the patient, parents, and primary caregiver. RESULTS: Median follow-up was 4 years (range, 2-14 years). Late progression of scoliosis (> 10 degrees), pelvic obliquity (> 5 degrees), and decompensation (> 4cm ) were noted in more than 30% of the patients. More than 75% of patients with late progression were skeletally immature at the time of surgery and underwent a posterior procedure only. Twenty-one percent of the patients required a revision procedure because of disease progression. Progression was not noted in any patient who underwent anterior fusion (with or without anterior instrumentation) plus posterior instrumentation from the upper thoracic spine to the pelvis. Eighty-five percent of parents or caregivers were very satisfied with the results of surgery and noted a beneficial impact of the patient's sitting ability, physical appearance, ease of care, and comfort. CONCLUSIONS: To avoid late progression of trunk deformity in skeletally immature patients, anterior spinal release and fusion combined with posterior segmental spinal instrumentation and fusion from the upper thoracic spine to the pelvis are recommended. Skeletally mature patients with good curve flexibility can be treated with posterior instrumentation and fusion only. Skeletally mature patients with large fixed curves benefit from an anterior-posterior procedure for better correction of the scoliosis and pelvis obliquity. Despite the surgical complexity and expected complications, the overall good surgical results and high patient and caregiver satisfaction confirm that corrective spinal surgery is indicated and is beneficial for most patients with total-body-involvement cerebral palsy and scoliosis.
Anterior release and fusion in pediatric spinal deformity. A comparison of early outcome and cost of thoracoscopic and open thoracotomy approaches.
STUDY DESIGN: A consecutive series of patients undergoing thoracoscopic anterior spinal release and fusion for scoliosis or kyphosis was compared with a consecutive series of patients treated with an open thoracotomy approach. OBJECTIVES: To compare the early clinical results, costs, and charges of performing an anterior thoracic spinal release and fusion with the two approaches. SUMMARY OF BACKGROUND DATA: The thoracoscopic approach to the spine is gaining acceptance, yet there are little data comparing the technique with standard open methods for the treatment of spinal deformity. METHODS: The first 14 thoracoscopic cases performed at the authors' hospital were compared with 18 open thoracotomy cases treated during the previous 12-month period. In each case the discs were excised and bone grafted before performing a posterior fusion. The early clinical outcomes and the hospital charges/costs were analyzed. RESULTS: The percent curve correction was similar between the thoracoscopic and open methods: scoliosis 56% and 60%, respectively; kyphosis, 88% and 94%, respectively. The blood loss and complication rates were similar between the two groups; however, the chest tube output was greater in the thoracoscopic group. The length of hospital stay was not reduced, and the cost of the open procedure is 29% less than the thoracoscopic approach. The minimally invasive thoracoscopic approach avoids cutting the chest/shoulder musculature, greatly decreasing the morbidity of anterior spinal surgery. CONCLUSIONS: The thoracoscopic technique is a safe and effective alternative to open thoracotomy in the approach to the anterior thoracic spine for the treatment of pediatric and adolescent spinal deformity.
Diagnostic clarity in orthopedics due to advanced technology: thoughts on the surgeon's role and responsibilities.
Explore the source record for details and available documents.
Superior gluteal artery injury secondary to posterior iliac crest bone graft harvesting. A surgical technique to control hemorrhage.
STUDY DESIGN: This case series and cadaveric dissection illustrates a method of obtaining hemostasis of iatrogenic superior gluteal vessel injury sustained during posterior iliac crest bone graft harvesting. OBJECTIVES: To show a simple and effective method of obtaining hemostasis of the iatrogenic superior gluteal vessel injury associated with posterior iliac crest bone graft harvesting. SUMMARY OF BACKGROUND DATA: Management of superior gluteal vessel injury has included direct pressure, enlargement of the sciatic notch to allow for exposure of bleeding vessels, retroperitoneal or transperitoneal approaches, and angiographic embolization to obtain hemostasis. The authors present several cases and a cadaveric study to show a simple and effective technique used to control hemorrhage secondary to iatrogenic superior gluteal vessel injury sustained at the time of posterior iliac crest bone graft harvesting. METHODS: The management of iatrogenic superior gluteal vessel injury secondary to posterior iliac crest bone graft harvesting involved the extension of the surgical incision, detachment of the origin of the gluteus maximus, lateral retraction of the gluteus maximus along with the tethered superior gluteal vessels, and visualization and ligation of the injured vessels. RESULTS: Hemostasis was achieved quickly with minimal loss of blood. Additional surgery or angiographic embolization was not required. CONCLUSIONS: In the cases presented, extension of the posterior iliac bone graft incision, detachment of the origin, and reflection of the gluteus maximus provided excellent exposure and hemostasis of the iatrogenic laceration of the superior gluteal artery. This technique is simple and effective and may prevent the need for transperitoneal and retroperitoneal approaches or angiographic embolization.
Pyogenic infectious spondylitis in children. The evolution to current thought.
The historic evolution of pyogenic infectious spondylitis from its initial descriptions to its current characterization illustrates the degree to which our means of perception and evaluation influence our understanding of an illness. As new concepts resulting from medical innovations challenge traditional beliefs regarding the etiology and optimum treatment of pyogenic infectious spondylitis in children (commonly termed discitis), controversies have arisen. This review attempts to clarify these issues by reconstructing their historic basis and delineating the limitations of our current knowledge. In our opinion, this exercise demonstrates the similarities between pyogenic infectious spondylitis in children and adults and provides support for the management of this illness at all ages with parenteral antibiotics, cast or brace immobilization when needed for symptomatic relief, and, rarely, operative débridement.
The "sagging rope sign" in avascular necrosis in children's hip diseases--confirmation by 3D CT studies.
Growth disturbance of the proximal femoral epiphysis and physis secondary to avascular necrosis (AVN) in a variety of children's hip disorders produces changes in the femoral head and neck that make radiographic interpretation difficult. The enlarged overhanging femoral head produces radiographic markings on the femoral neck which are sometimes confusing. These have sometimes been misinterpreted as growth arrest lines. Apley and Wientroub reintroduced Perkins' description of the "sagging rope" sign in AVN of the femoral head, and Clarke clarified that this puzzling radiographic transverse metaphyseal line overlying the femoral neck in fact represents the margin of the femoral head rather than a growth arrest line. Their report was made after studying plain and stereoscopic radiographs alone. Our review of 23 cases of femoral head AVN in children, documented by 3 dimensional computerized tomographic (3D CT) radiographs of the femoral head and pelvis, confirms Clarke's view of the nature of the "sagging rope" sign. These sophisticated radiographic studies provide new detail and understanding of head-neck relationship in AVN which allows better planning for surgical correction of hip disorders in children.
Magnetic resonance-imaging scans in discitis. Sequential studies in a child who needed operative drainage: a case report.
Explore the source record for details and available documents.
Managing complications of posterior spinal instrumentation and fusion.
Complications of posterior spinal instrumentation for adolescent idiopathic scoliosis are often preventable. Preoperative planning helps to minimize intraoperative and postoperative problems. Late recurrence of rotational deformity (crankshaft) in skeletally immature patients can be prevented by adding anterior surgery. Intraoperative complications are minimized by controlled hypotensive anesthesia and sequencing of surgical steps to allow for autocoagulation, reducing blood loss. Use of spinal cord monitoring, Stagnara wakeup test, and careful distraction decreases the risk of neurologic deficit. Good hook-site preparation helps avoid dural tears. The incidence of postoperative pneumothorax and hemothorax is decreased by careful hook attachment, avoiding pleural penetration, judicious use of rib excision thoracoplasty, and roentgenographic verification of central venous pressure line position. Postoperative recommendations include bed position at 30 degrees, frequent log rolling, incentive spirometry, early sitting and standing, early Foley catheter and nasogastric tube removal, prophylactic antibiotics, and prompt attention to wound infections. Postoperative orthotic wear, prescribed exercise, and activity restriction decrease the risk of early instrumentation failure and help correct early postoperative trunk imbalance. The late complications include suspected pseudarthrosis; this should be surgically treated again if there is persistent pain or marked loss of curve correction.
One-stage correction of the spastic dislocated hip. Use of pericapsular acetabuloplasty to improve coverage.
We performed a combined one-stage approach for the treatment of eighteen spastic subluxated or dislocated hips in eleven children who had cerebral palsy. All patients were between five and thirteen years old and had spastic subluxation or dislocation of the hip and severe acetabular dysplasia. The operation consisted of release of the adductors, psoas, and proximal hamstrings; a femoral-shortening varusderotation osteotomy; and a pericapsular pelvic osteotomy. The pelvic osteotomy was designed to increase superolateral coverage of the femoral head in the elongated acetabulum, which had erosion of the superior and lateral aspects. At the latest follow-up (mean duration, six years and ten months), seventeen of the eighteen hips remained anatomically reduced.
Corrective shoes and inserts as treatment for flexible flatfoot in infants and children.
We performed a prospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment with a Helfet heel-cup; or Group IV, treatment with a custom-molded plastic insert. All of the patients in Groups II, III, and IV had a minimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstrated a significant improvement in all groups (p less than 0.01), including the controls, and no significant difference between the controls and the treated patients (p greater than 0.4). We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.
Congenital hip dislocation: techniques for primary open reduction including femoral shortening.
Combining primary open reduction, femoral shortening, capsulorrhaphy, and acetabuloplasty in a single operation allows predictable treatment of congenital dislocation of the hip in older children without the time and expense of preliminary traction. In addition to the bony abnormalities of congenital hip dislocation, the complex pathologic anatomy of the hypertrophied capsule and associated soft tissues must be recognized and corrected. Failure to treat all components of this condition often leads to reduction that is apparently satisfactory in the intraoperative and early postoperative periods but is followed by hip subluxation or redislocation with weightbearing. Correcting all components of the congenital hip dislocation deformity in a single operation provides the best opportunity for early return of normal hip mechanics and function in the older child.
One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening.
We reviewed the results of primary operative treatment in twenty-five patients (thirty-three hips) who were two years or older and had congenital dislocation of the hip. None of the patients had had previous treatment for the dislocation. Preliminary traction was not used in any patient. Femoral shortening and, in twenty-one hips, pelvic osteotomy were performed at the time of open reduction. At the most recent follow-up (average, three years and seven months), according to the radiographic classification system of Severin, there were seven excellent, seventeen good, and eight fair results; one hip had a poor result. Avascular necrosis developed in three of the thirty-three hips. At follow-up, these hips had a radiographic result of excellent, good, and fair, respectively. Twenty-one patients (twenty-eight hips) were reviewed with respect to range of motion and recovery from limb-length discrepancy. According to the rating system of Ferguson and Howorth, there were seventeen excellent, seven good, and three fair results; one hip had a poor result. It was concluded that children who are two years or older and who have a congenital dislocation of the hip can safely be treated with an extensive one-stage operation consisting of open reduction combined with femoral shortening and, often, pelvic osteotomy, without increasing the risk of avascular necrosis. The limb-length discrepancy that is produced by the shortening does not appear to cause a clinical problem.
Obstruction of the colon due to protrusio acetabuli in osteogenesis imperfecta: treatment by pelvic osteotomy. Report of a case.
Explore the source record for details and available documents.
Foot deformities in infants and children.
Foot deformities may reflect a generalized disorder, especially a neurologic problem; thus, the child should have a brief general examination. Many infantile foot deformities, such as calcaneovalgus, are postural and self-correcting. Metatarsus varus is not referred for treatment until age 2 months and then only if the deformity is moderate or severe. Fixed forefoot equinus and heel varus characterize a clubfoot, which requires immediate treatment. Corrective shoes are not advised as the primary treatment for metatarsus varus or clubfoot but often are prescribed to maintain the corrected position after serial casts. Flexible flatfoot is a manifestation of a constitutional laxity affecting all ligaments and joints. The feet appear abnormal because of weight-bearing stresses. Most children with flatfoot achieve a partial correction spontaneously. Current research does not document that treatment with corrective shoes or inserts produces a result better than the partial correction that occurs naturally.
Childhood hip sepsis: improving the yield of good results.
With the increasing availability of well-trained orthopaedic surgeons and pediatricians, early diagnosis and effective treatment of hip sepsis is now common. Despite these advances, poor results still occur. The principle of early surgical drainage and appropriate antibiotics must continue to be emphasized. Empiric surgical drainage in cases with equivocal aspiration results is advised. Postsurgical residual subluxation remains a significant problem in subacute cases with preoperative subluxation (lateralization) and is best avoided by an anterior approach for drainage, which can include adductor or psoas release, or both, followed by cast positioning of the hip to maintain reduction. Careful and thoughtful application of the recently accepted concept of early transition to oral antibiotics can significantly reduce the psychological and economic cost of hip sepsis treatment. Hip sepsis occasionally occurs in juveniles, adolescents, and teen-agers. Because of a low index of suspicion in this age group, diagnosis and treatment are often greatly delayed resulting in a poor outcome in many patients.