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Biomedical subjects

P D Sponseller

Publications and source records attributed to P D Sponseller.

At least 37 records · Page 2Linked to original sources
PubMed2000

Pediatric analgesia and sedation for the management of orthopedic conditions.

Orthopedic injuries are common in the emergency department; this is especially true in children. The orthopedist must often supervise sedation and analgesia for the injured child. While the techniques of conscious sedation have improved, the therapeutic index between adequate and excessive sedation is much narrower in children than adults, especially for painful procedures. The purpose of this review is to outline a reasonable approach to sedation and analgesia in the pediatric patient. In addition, current monitoring guidelines are reviewed, as well as the basic pharmacology of the most commonly used drugs.

Adult↗
PubMed1999

Anterior only fusion for scoliosis in patients with myelomeningocele.

A series of patients with single major scoliosis curvatures attributable to spina bifida treated by anterior only spinal fusion was studied for 2 years to determine whether the infection rate could be decreased, adequate correction and pelvic balance could be provided, and posterior surgery could be avoided in these patients. Anterior surgery alone was performed for thoracolumbar scoliosis greater than 45 degrees if the compensatory thoracic curve was less than 40 degrees and there was no significant junctional kyphosis. Fourteen patients were treated at a mean age of 11.9 years (range, 7-16 years), with a mean curve of 64 degrees (range, 51 degrees-85 degrees), and motor levels distributed from T10-L4. Thirteen patients had prior neurosurgery for tether, syrinx, or Arnold-Chiari malformation. The spine was fused over a mean of seven vertebrae. A 3/16 inch Texas Scottish Rite Hospital rod was used most commonly (10 patients). Blood loss averaged 1100 cc. The mean curve correction was 57% at 40 months after surgery. Loss of correction occurred primarily by adding on outside the instrumented area. Mean pelvic obliquity was improved from 16 degrees to 9 degrees. There was one superficial infection. Results were good in five patients, fair in four, and poor in five. Failures were attributable to proximal decompensation in two patients who required revision surgery (two), neurologic deterioration in two, and screw pullout in one. Both patients with decompensation had syringomyelia. Both patients with neurologic deterioration had large curves (> 75 degrees). Both patients recovered after rod removal. Retrospectively, by eliminating patients with syrinx or with a curve greater than 75 degrees, all poor results would be eliminated. Anterior only fusion and instrumentation may have significant advantages, but only for selected patients with thoracolumbar curves less than 75 degrees, compensatory curves less than 40 degrees, no increased kyphosis, and no syrinx. Quadriceps function should be monitored. On the basis of this preliminary experience, continued use of this approach using stricter selection seems warranted.

Activities of Daily Living↗
PubMed1999

Staged closure of the pelvis in cloacal exstrophy: first description of a new approach.

PURPOSE: We describe a staged approach for pelvic closure in patients with cloacal exstrophy, and evaluate the technique for functional and cosmetic results. MATERIALS AND METHODS: Staged closure of the pelvis was performed in 5 patients 12 months to 14 years old with cloacal exstrophy at our institution, including some referred with a history of failed closure. The technique involves initial pelvic osteotomy followed by soft tissue and pelvic ring closure 2 to 3 weeks later. Clinical information is reviewed to assess the effectiveness of the technique. RESULTS: At a mean followup of 3.2 years (range 1 to 9) closure was successful in all 5 patients without technical problems or surgical complications, and with excellent functional and cosmetic results. CONCLUSIONS: This technique of staged pelvic closure may provide reliable initial or secondary repair in patients with cloacal exstrophy in whom 1-stage pelvic closure is unfeasible even with pelvic osteotomy.

Adolescent↗
PubMed1998

Age-related changes in human oestrogen receptor alpha function and levels in osteoblasts.

Oestrogen receptors (ERs) are present in human osteoblasts and mediate anti-resorptive effects on bone. Human osteoblast-like cells derived from different aged healthy female donors not on hormone replacement therapy were utilized under well-defined conditions in vitro to investigate ER function and levels. Treatment with 0.1 nM oestradiol-17beta of cell strains derived from eight young women (less than 50 years of age) increased hydroxyproline levels significantly [an average (2.2+/-0.1 S.E.M.)-fold increase], whereas cells derived from nine older women (more than 50 years of age) were not significantly affected. Similarly, cell strains, derived from younger women, transfected with a consensus oestrogen-responsive element linked to chloramphenicol acetyltransferase exhibited a greater response to oestrogen than strains derived from older women. When basal ERalpha levels were measured by enzyme immunoassay and normalized on a per cell basis, osteoblast-like strains derived from younger women (n=24) had a mean value of 2.54+/-0.16 fmol of ERalpha per 10(6) cells. In contrast, strains derived from older women (n=20) had a mean value of 5.44+/-0.48 fmol of ERalpha per 10(6) cells. An age-related increase in ERalpha number was also observed in human skin-derived fibroblasts and directly in dermal biopsies from women not on hormone replacement therapy. The results demonstrate ligand concentration-dependent ERalpha induction and indicate a loss of receptor regulation and diminution of ligand-receptor signal transduction with increasing donor age.

Adolescent↗
PubMed1998

The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head.

We have reviewed the results of 30 operations performed on 23 patients with Ficat stage-III or stage-IV osteonecrosis of the femoral head in which autogenous cortical and cancellous bone grafting had been performed through a so-called trapdoor made in the femoral head. At a mean of 56 months (30 to 60) after operation 20 of 24 stage-III hips (83%) had a good or excellent result as determined by the Harris hip-scoring system. Two of six stage-IV hips (33%) had good or excellent results. Eighteen of 21 hips (86%) with a combined necrotic angle of 200 degrees had good or excellent clinical results compared with only four of nine hips (44%) with a combined necrotic angle of more than 200 degrees. Six of the eight hips which had fair or poor results were in patients who had received corticosteroids; five of these six hips had lesions with a combined necrotic angle of greater than 200 degrees or were in a late stage (stage IV). There were no perioperative complications. Our results suggest that the trapdoor procedure with autogenous cancellous and cortical bone grafting can be successful in Ficat and Arlet stage-III osteonecrosis of the hip in patients with small- to medium-sized lesions.

Adolescent↗
PubMed1997

The cervical spine in Marfan syndrome.

STUDY DESIGN: Prospective radiographic and clinical analysis of a consecutive unselected population of persons with Marfan Syndrome. OBJECTIVES: To determine cervical spine abnormalities present in the Marfan population compared with that seen in the general population. SUMMARY OF BACKGROUND DATA: In the treatment of a large population of patients with Marfan Syndrome, three serious cervical spine disorders were noted. To the authors' knowledge, no report of cervical abnormalities in patients with Marfan Syndrome exists in the literature. Therefore, the cervical spine in these patients was studied in a systematic fashion. METHODS: An unselected group of 104 consecutive patients with Marfan Syndrome seen at a medical genetics follow-up examination underwent lateral neutral and flexion-extension cervical spine radiographs. Parameters of alignment, size, and stability were measured. Patients with Marfan Syndrome aged 35-45 years and matched controls were given a pain questionnaire to complete. RESULTS: The prevalence of focal kyphosis was 16%. A large number of patients with Marfan Syndrome (54%) had increased atlantoaxial translation. The preadolescent Marfan population has a greater range of motion than either the adolescent or adult populations. The Marfan population has an increased radiographic prevalence of basilar impression (36%), and the odontoid height (3.69 +/- 0.53 cm) was larger than reported norms (2.34 +/- 0.22 cm). Cervical stenosis was rare, with 3% having a critical Torg ratio at C3 and 2% having a critical Torg ratio at C6. Neck pain frequency did not differ significantly from that of age-matched controls. CONCLUSION: Based on the increased prevalence of several cervical bony and ligamentous abnormalities, patients with Marfan Syndrome were recommended to avoid sports with risks of high-impact loading of the cervical spine. Given the rarity of actual neurologic injuries in the Marfan population, however, radiographs for all patients with Marfan Syndrome undergoing general anesthesia is not recommended.

Adolescent↗
PubMed1997

Infantile scoliosis in Marfan syndrome.

STUDY DESIGN: A retrospective review of clinical data was conducted. OBJECTIVES: To determine the characteristics of infantile scoliosis in Marfan syndrome and the response to treatment of patients with this condition. SUMMARY OF BACKGROUND DATA: No previous study has reported the features of this condition nor the effect of treatment on patients with this syndrome. METHODS: The data on all patients seen at one institution who had Marfan syndrome and scoliosis by age three were reviewed. Fourteen of the 600 patients from the group examined who had Marfan syndrome fit the above criteria. Skeletal and general features were studied. RESULTS: Thirteen of the 14 patients had no family history of Marfan syndrome, a finding which does not fit the usual autosomal dominant inheritance pattern. All 14 patients had exaggeration of the Marfan. All but one patient had cardiac valvular insufficiency that required repair by age 11. Thirteen patients had thoracic aortic aneurysm, 10 had lens dislocation, and eight had sternal deformity. Three patients had hip dislocations, two had pyloric stenosis, and two had dural ectasia. Motor delay was evidenced by onset of walking past 18 months in nine patients; three of these patients were never able to walk independently. One patient each died at ages 1, 3, 4, and 8 years; all others have survived to present (mean age, 13 years). The mean curve of the patients' spines at presentation was 38 degrees. Eleven curves were double major, two were thoracolumbar, and one was double thoracic. Brace wear did not halt curve progression in any of the nine patients for whom it was used. Instrumentation without fusion was used in three patients for a mean of 3 years, with best results in one nonkyphotic curve. Nine patients underwent instrumented fusion at a mean age of 6.6 years (range, 3-13 years). Mean curve correction was 51% (from 72 degrees to 34 degrees). Final mean curve was 54 degrees for a mean correction of 20% at the 5-year (average, 5.4 years) follow-up examination. Acute complications occurred in three patients, and five patients needed a second surgery for late complications. Causes for curve increase after surgery included growth and loss of fixation. CONCLUSIONS: In this most severe form of Marfan syndrome, bracing has a limited role and is only to be used if the curve is less than 40 degrees. Surgery should not be performed on a patient younger than four years of age because many patients with large curves before this age will succumb spontaneously to cardiac complications. Instrumentation without fusion should be considered only for patients with no significant kyphosis. Results of fusion are better for patients who are older than five years of age.

Adolescent↗
PubMed1997

Atlanto-occipital fusion for dislocation in children with neurologic preservation. A case report.

STUDY DESIGN: A retrospective clinical review of patients with atlanto-occipital dislocations. OBJECTIVES: To determine if fusion of the occiput to C1 can be accomplished without extension to the axis. SUMMARY OF BACKGROUND DATA: Patients with atlanto-occipital dislocations who have preservation of spinal cord function are quite rare. The standard approach to stabilization has been fusion of the occiput to the axis (C2). This may compromise rotation unnecessarily, however. The authors investigated the success of attempting to fuse only the occiput to C1 in children. METHODS: Two children with atlanto-occipital dislocation who had normal neurologic function underwent fusion from the occiput to the atlas after reduction. RESULTS: Both cases showed successful fusion with no unwanted extension to lower levels. Full head rotation was preserved. CONCLUSIONS: This technique restores stability without restricting rotation.

Atlanto-Occipital Joint↗
PubMed1997

A comparison of methods of repairing the symphysis pubis in bladder exstrophy by tensile testing.

OBJECTIVE: To compare the efficacy of several fixation techniques in the reconstruction of diastasis of the symphysis pubis in bladder exstrophy. MATERIALS AND METHODS: The symphysis of 32 pelves removed from piglets about 1 month old were disrupted and repaired using one of eight methods. After repair, each pelvis was tested biomechanically for load-to-failure, stiffness and energy-to-failure. The various repair techniques were compared with one another and to a group of six pelves tested intact. RESULTS: Four of the methods tested, including a #2 nylon suture placed through bone in a horizontal mattress arrangement, several loops of #2 nylon suture tied around the pubes, Mersilene tape tied around the pubes, and Mitek G-II suture anchors placed into the superior pubic rami, showed the highest stiffness and load-to-failure. All methods were very weak compared with the intact symphysis; the best load-to-failure (#2 nylon horizontal mattress suture) was less than half of that for intact bone, and the best stiffness (mersilene tape) was less than one-third that for the intact symphysis. CONCLUSION: The repairs varied greatly in the variables tested and those which are most promising merit further investigation to assess methods of improving their performance.

Animals↗
PubMed1997

Shortening in femoral shaft fractures in children treated with spica cast.

Early spica cast treatment is one method used for children's femoral shaft fractures; it is increasingly advocated as treatment that allows early hospital discharge. The outcome of early spica cast treatment in 100 children, ages 2 to 10 years, with uncomplicated and isolated closed femoral shaft fractures treated at Johns Hopkins Hospital between October 1987 and March 1994 were analyzed. The objective was to identify those children who can be treated safely and dependably with early spica casting without excessive shortening of the fracture fragments. Eighty-one (81%) children had an acceptable outcome and 19 (19%) had an unacceptable outcome by the definition of more than 25 mm of fracture fragment overlap after clinical healing. A new clinical test, the telescope test, was statistically significant for correlation with spica cast outcome. Age, gender, fracture, location, mechanism of injury, fracture type, and resting radiograph of fracture fragment overlap were not statistically significant. The telescope test had a sensitivity of 80% and a specificity of 85% for predicting outcome. The relative risk for failure of spica cast treatment with a positive telescope test was 20.4 (95% confidence limits = 2.7-225.1). Children 2 to 10 years of age with uncomplicated femoral shaft fractures and a negative telescope test can be treated appropriately in most cases with early application of a spica cast.

Casts, Surgical↗
PubMed1997

Developmental dysplasia of the hip in Marfan syndrome.

Among 235 consecutive patients with Marfan syndrome, four cases of developmental dysplasia of the hip were found, amounting to an incidence of 2%. Harness treatment was not effective in any of the patients because of a narrow stable zone and knee laxity. One patient died of cardiac failure before further treatment could be attempted. Closed reduction and spica cast treatment was successful in all other patients. Stability was achieved within a normal period, and there were no redislocations. Consequently, the dislocated hip in patients with Marfan syndrome should be managed early with this method.

Child↗
PubMed1997

Subtrochanteric femoral fractures in children. Alignment after 90 degrees-90 degrees traction and cast application.

Fifteen children younger than 10 years of age with subtrochanteric fractures treated by a uniform method were evaluated. These patients had been treated with femoral skeletal traction, with the hip and knee flexed to 90 degrees until radiographic callus appeared, then with a hip spica cast. True neck to shaft and anteversion angles were calculated bilaterally using a biplanar method. Leg lengths were measured radiographically and clinically. Mean age at injury was 4.5 years, and mean followup was 6.5 years. Overgrowth averaged 10 mm after fracture. Anteversion at final followup differed only by a mean of 2 degrees from the contralateral side (range, -3 degrees to +4 degrees), and the mean neck shaft angle differed by only 1 degree. Remodeling of coronal angulation was 50% or more in all cases.

Adolescent↗
PubMed1997

Soleus neurectomy for dynamic ankle equinus in children with cerebral palsy.

Problems with the gastrocnemius-soleus muscle group can severely impair the gait of children with cerebral palsy. Treatments, including bracing, muscle lengthening, neurectomy, or a combination, have been used with mixed results. Soleus neurectomy was performed as the primary treatment for ankle clonus in 38 legs of 21 children with a variety of cerebral palsies. Concurrent heel cord or muscle lengthening was performed if needed. Patients were followed for an average of 9 years (range, 2 to 14 years). Clonus recurred in 4 treated ankles. In 2 cases, this was due to a nerve anomaly. Postneurectomy Achilles tendon lengthening was required in 8 of the treated ankles. Neurectomy was beneficial for 19 of 21 children. Functional improvements included better control of stopping, better balance, and less toe walking. The greatest improvement was seen in those patients who did not also have heel cord contractures.

Achilles Tendon↗
PubMed1996

Evaluating the child with back pain.

The most common causes of serious low back pain in children include spondylolysis, Scheuermann disease and musculoligamentous injury. Questions should be asked about the mechanism of onset and exacerbating factors, and the frequency, duration and severity of the pain. The examination should check gait and alignment, flexibility, strength and reflexes, and localize and evaluate the pain. Warning signs of serious problems include constant pain in a child younger than 11 years of age that lasts for several weeks or occurs spontaneously at night, repeatedly interferes with school, play or sports, or is associated with marked stiffness and limitation of motion, fever or neurologic abnormalities. Pain at the lumbosacral junction may suggest spondylolysis or spondylolisthesis. Scheuermann disease is diagnosed by the observance of wedging, irregularity or growth disturbance of three successive vertebrae. Musculoligamentous pain may result from injury to or overuse of muscles or joints of the back. Rare causes include discitis, tuberculosis, bone or spinal cord tumor, pyelonephritis and retroperitoneal infection.

Algorithms↗
PubMed1996

Long-term extracellular matrix metabolism by cultured human osteogenesis imperfecta osteoblasts.

Osteopenia due to deficient extracellular matrix synthesis is a hallmark of osteogenesis imperfecta (OI), Previous studies carried out within 72 h of osteoblast subculture, at an early stage of matrix synthesis, indicated that for osteoblasts derived from human OI patients the total amounts of collagen, osteonectin, and three proteoglycans were significantly reduced, while total amounts of thrombospondin, fibronectin, and matrix hyaluronan were elevated compared with age-matched controls. The current study was undertaken to follow OI osteoblast matrix metabolism as that matrix is synthesized, deposited, and matured. Steady-state metabolic radiolabeling was used to follow the metabolism of collagen, hyaluronan, and total proteoglycan by OI and normal osteoblasts for up to 5 weeks. Trabecular osteoblasts from non-OI controls showed an increase in total and matrix-associated collagen synthesis during the first and second week, reaching steady-state levels by week 4. In contrast, cultured OI osteoblasts did not increase either the total (medium + matrix-associated) or matrix-associated collagen during the entire 5-week period. Proteoglycan synthesis exhibited a pattern similar to that for collagen. OI-derived proteoglycans differed from controls in that levels in OI cultures did not reflect the normal time-dependent increase in total proteoglycan and proteoglycan matrix deposition. OI osteoblast hyaluronan synthesis was increased when compared with age-matched controls during 4 weeks of culture. In contrast, the ratios of calcium to phosphorus solublized from control and the OI extracellular matrix were not statistically different. Thus, with respect to the synthesis of collagen, proteoglycans, and hyaluronan, OI osteoblasts fail to parallel controls in depositing and elaborating extracellular matrix during 35 days in culture.

Adolescent↗
PubMed1996

The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder?

OBJECTIVES: To define the possible cause of failure and the eventual potential of the bladder in 23 exstrophy patients, who underwent more than two failed prior attempts at closure. METHODS: Twenty-three patients were selected from the exstrophy data base who had two or more prior closures. Eighteen patients had undergone 2 previous closures and 5 patients 3 previous closures for either complete dehiscence or significant prolapse. At the time of initial closure, 19 patients did not have an osteotomy. At secondary closure, 10 underwent osteotomy while at third closure 5 had an osteotomy. At the time of reclosure at our institution all underwent an osteotomy. RESULTS: Reoperative repair at our institution was successful in all patients. Six patients achieved a bladder size suitable for bladder neck reconstruction and of them 3 are dry. The bladder size was inadequate in 9 patients and 8 are being monitored for possible bladder growth. CONCLUSIONS: Tension-free closure with osteotomy and immobilization are important factors both in an initial or any subsequent closure. The chance of obtaining an adequate bladder capacity for bladder neck plasty and eventual continence, following multiple reclosures, is markedly diminished.

Bladder Exstrophy↗