Biomedical subjects
Publications and source records attributed to W B Lehman.
Melorheostosis is an unusual mesenchymal dysplasia, which commonly presents on radiographs as longitudinal bars of hyperostosis in osseous structures. We present a case of melorheostosis in the lower extremity of a 20-year-old woman for which detailed radiologic- pathologic correlation was achieved due to amputation of the involved limb.
Congenital pseudoarthrosis of the tibia remains one of the most difficult conditions to treat in orthopedic surgery. Seven cases were treated in our hospital by different methods. Three out of seven patients were healed, two of these refractured. At follow-up, the success rate was 14% (one out of seven cases). It is our recommendation that early primary amputation with an appropriate prosthesis should be considered, and that the final evaluation should not be based on obtaining bone union, but on the level of function of the lower extremity.
A subset of postoperative recurrent clubfeet was isolated in a group of patients 4 to 8 years old. Twenty-seven consecutive patients who underwent redo surgery consisting of complete soft tissue clubfoot release combined with a calcaneocuboid fusion were reviewed for this study. Twenty-six feet of 27 feet in 20 patients had a long-term good result, suggesting that this procedure is the one of choice for this age group.
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A rare case of a complete fracture-separation of the proximal radial epiphysis is described in a pediatric patient. A further complicating factor is the delay in diagnosis that may worsen prognosis. An emphasis on early detection by physical examination and imaging studies, as well as consideration of treatment options, are presented.
Seventeen cases of dislocated/subluxated hips in 14 cerebral palsy patients that were relocated by the combined hip procedure were reviewed. The combined hip procedure includes varus derotation osteotomy, open reduction, innominate bone osteotomy, adductor releases, and iliopsoas recession, all done at one stage. Eleven patients were spastic quadriplegic, 1 was spastic diplegic; and 2 were spastic hemiplegic. Average age at operation was 10 years. Average follow-up was 3 years. A total of 16 hips (94%) remained stable at follow-up with almost no change in center edge angle and the migration percentage, although the neck shaft angle remodeled over time. We conclude that the combined hip procedure is effective in maintaining hip reduction in cerebral palsy patients.
The records concerning 64 hips in 36 cerebral palsy patients treated with varus derotational osteotomy (VDO) alone (2 hips), VDO with muscle releases (adductors, iliopsoas, hamstrings; 46 hips), and VDO, soft-tissue release, and innominate bone osteotomy (16 hips) were reviewed. There were 23 quadriplegic and 13 diplegic patients. Average age at surgery was 7 years. Average follow-up period was 3.8 years. All hips that had VDO, soft-tissue release, and innominate osteotomy were stable at follow-up. Nine hips of the 44 treated with VDO and muscle release alone dislocated, and required second osteotomies.
An unusual case of newborn unilateral dislocated hip is presented. The condition was refractory to conservative treatment. The cause was found during surgery at the age of 1 month: the adductors were replaced by myofibromatosis. The tumor was excised and at follow-up a normal hip was noted.
A longitudinal study was performed in a series of 124 New Zealand White rabbits to determine the radiographic versus the histologic age of closure of the growth plates of the distal femur, proximal tibia, and proximal fibula. Periodic assessment was made by standard radiographs and histological studies. Histologically, growth plates in the distal femur closed at 19-24 weeks; growth plates in the proximal tibia, at 25-32 weeks; and growth plates in the proximal fibula, at 26-32 weeks. Radiographically, evidence of closure of growth plates in the distal femur occurred at 20-23 weeks; in the proximal tibia, at 22-27 weeks; and in the proximal fibula, at 23-31 weeks. A discrepancy in age between radiographic and histologic closure of the growth plate occurred in 3.6% of the femora, 10.9% of the tibias, and 16% of the fibulas.
This article discusses the unique contribution of MR imaging to the evaluation of selected pediatric disorders of the ankle and foot. MR imaging is helping to unravel the complex congenital malformation of talipes equinovarus. It is the study of choice for the examination of intraarticular abnormalities such as Trevor's disease. The MR imaging staging of osteochondritis dissecans and delineation of a tarsal coalition have shown great promise in guiding surgical management of these abnormalities.
An unusual case is presented in which minor soft tissue injury may have caused premature asymmetrical closure of the proximal tibial physis resulting in a 30 degrees genu recurvatum that necessitated corrective osteotomy. Awareness of the possibility of a hidden physeal injury in the presence of soft tissue injury and a normal radiograph may lead to its early recognition and treatment.
The use of a dome osteotomy in the treatment of infantile tibia vara is reportedly associated with insufficient intraoperative assessment of the correction achieved. This article discusses a method to overcome this problem and the long-term advantages of using a dome osteotomy in the treatment of this disease.
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Fifty-two cases of osteoid osteoma in children under 5 years of age were collected from the English literature and reviewed, along with seven cases from the Hospital for Joint Diseases. Analytic emphasis was placed on the clinical and radiologic difficulties encountered in the diagnosis of osteoid osteoma in children. Diagnosis is especially challenging in patients that are just beginning to walk. Osteoid osteoma is often confused with many other entities. Although pain was the most frequent clinical manifestation, it was absent in 12% of cases; limp tenderness, swelling, and atrophy were the next most frequent findings. When standard radiographic findings proved negative for this condition, technetium bone scans were of considerable efficacy in identifying the tumor. When used, computerized tomograms permitted visualization and precise localization of the tumors in all cases. Bone deformities and leg-length discrepancies were found in more than 25% of the cases. Mini-block excision is recommended at diagnosis.
Ninety-one cases of histologically confirmed osteoid osteoma were collected during an 11-year period; of them, seven (7.6%) had onset of symptoms while younger than five years of age. Special diagnostic difficulties were found in this specific age group: most cases were misdiagnosed or diagnosed incorrectly. The time between the onset of symptoms and the diagnosis varied from three months to five years. Although pain was present in six patients, in four cases, other concomitant signs and symptoms attracted more attention and led to a misdiagnosis and unnecessary invasive procedures. Gait disturbance (limp) was the second most frequent sign and was always present when the lower extremity was affected. In five cases, initial radiographs were not conclusive. Bone scans were very sensitive and conclusive in three cases where radiographs were atypical. Computerized tomograms always located the tumor.
Two groups of patients who underwent soft-tissue release of clubfoot are compared. In group I, internal fixation (two Kirschner wires) was used for 6 weeks to retain correction of clubfoot. In group II, no internal fixation was used. Patients from the two groups were operated on by one surgeon using the same procedure. Because there was no statistically significant difference in functional result between the two treatment groups (P = .08; Mann-Whitney Test), the authors recommend avoiding internal fixation (with all the associated problems) in cases of uncomplicated clubfoot, and encourage early removal of the cast and frequent manipulations to prevent stiffness of the joints and reduce the recurrence rate.
After a fall from a tree, a 12-year-old boy sustained a fracture of the greater trochanter and was subsequently treated by open reduction. Twenty months after surgery, the hip developed to a flexion contracture, limb-length discrepancy, a collapsed, irregular-shaped femoral head with sclerotic areas, and a metaphyseal cyst. A growing child with avascular necrosis of the femoral head after fracture of the greater trochanter seems not to have been reported in the English language literature.
The navicular position was evaluated (according to Simons' criteria) on anteroposterior and lateral roentgenograms of 45 clubfeet that were treated with complete soft-tissue release without internal fixation. The evaluation was performed an average of 28 months after surgery. Position of the navicular correlates well with the functional rating score system. Navicular position can be viewed as an indicator for clubfoot correction. Internal fixation of the talonavicular joint was correlated with favorable correction of deformity.