Rolf Burghardt - Academia.edu (original) (raw)
Papers by Rolf Burghardt
Journal of Orthopaedics, 2015
Outcome assessment after double level tibial lengthening in patients with dwarfism. Fourteen pati... more Outcome assessment after double level tibial lengthening in patients with dwarfism. Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening. Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally and 6.0 cm distally. Concomitant deformities were also addressed during lengthening. External fixation treatment time averaged 8.8 months. Healing index averaged 0.7 months/cm. Bilateral tibial lengthening for dwarfism is difficult, but the results are usually quite gratifying.
Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 2014
Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is u... more Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is usually a mild deformity that responds well to simple observation or minimal treatment with a home program of stretching. Resistant cases may need a more aggressive approach such as serial casting or special bracing to avoid the need for surgical intervention. We compared clinical outcomes using serial casting with orthoses for resistant metatarsus adductus. We prospectively treated 27 infants (43 feet) between the ages 3 and 9 months who failed home stretching treatment. Patients were randomized to either serial plaster casting or Bebax orthoses. Footprints and simulated weight-bearing anteroposterior and lateral view radiographs were made at entry and follow-up. There was no statistical difference between casting and Bebax for the following parameters: age at study entry, length of treatment, number of clinic visits, follow-up, and follow-up maintenance treatments. Both groups showed im...
Der Unfallchirurg
Delayed union or non-union of long bone shaft fractures still presents a surgical challenge. Espe... more Delayed union or non-union of long bone shaft fractures still presents a surgical challenge. Especially if there is a predisposition for pseudarthrosis such as adiposity, diabetes mellitus, local disruption of blood supply or lack of hormones, the established procedures of autologous cancellous bone grafting or plate fixation with compression often lead to insufficient results. In the following article the successful use of bone morphogenetic protein BMP-7 [recombinant human osteogenetic protein-1 (rhOP-1)], combined with autologous bone grafting for therapy of a therapy-resistant tibial non-union is described. In a patient with multiple risk factors the tibial fracture was completely cured after two attempts of osteosynthesis and autologous bone grafting had failed. The patient achieved self-mobility with full weight bearing and absence of pain 10 months after adjuvant implantation of BMP-7.
Journal of Knee Surgery Reports, 2015
Geburtshilfe und Frauenheilkunde, 2009
Strategies in Trauma and Limb Reconstruction, 2014
Limb lengthening by callus distraction is commonly performed with the use of external fixation. L... more Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.
Journal of applied biomechanics, 2011
Femoral lengthening with intramedullary nails can create alterations in the mechanical axis of th... more Femoral lengthening with intramedullary nails can create alterations in the mechanical axis of the limb. This is based on the relationship of the anatomic femur axis to the mechanical femur axis, which is typically 5-9 degrees valgus. We developed trigonometric formulas to calculate the predicted change, using the lengths of the tibia, femur, and whole limb; the amount of lengthening; and the angle between the anatomic and the mechanical axis of the femur. We recognized three patterns depending on whether the overall limb mechanical axis is lateral (valgus), medial (varus), or straight through the center of the knee. The varus and valgus patterns lead to similar formulas. When the mechanical axis goes directly through the center of the knee joint, the formula simplifies. These formulas could be incorporated into digital radiographic programs to predict the change in mechanical axis deviation that will develop from lengthening along the anatomic femur axis with an intramedullary leng...
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 2011
To examine maternal attitudes towards prenatal diagnosis of idiopathic clubfoot and to determine ... more To examine maternal attitudes towards prenatal diagnosis of idiopathic clubfoot and to determine the incidence of false-negative ultrasound examinations. Surveys were mailed to mothers of patients with clubfoot born between 2000 and 2007 who were treated at either Sinai Hospital of Baltimore or Orthopaedic Hospital Speising. Exclusion criteria were underlying syndrome, genetic abnormality and multiple pregnancy. The survey asked the mother whether she had had any ultrasound examinations before her child was born, whether any of these had shown clubfoot, and whether she would have preferred to find out about her child's clubfoot before birth or after birth. Mothers completed 220 (USA, 105 surveys; Austria, 115 surveys) of 401 mailed surveys. The prenatal detection rate was 60% in the USA compared with 25% in Austria (P = 0.001). Overall, 74% of mothers indicated a preference for prenatal diagnosis and 24% indicated a preference for postnatal diagnosis of the condition. Of 92 pati...
Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 2010
Angular deformities can be treated with corrective osteotomies and application of internal or ext... more Angular deformities can be treated with corrective osteotomies and application of internal or external fixation. In children, this major intervention can be avoided with temporary hemiepiphysiodesis (i.e., guided growth). Recently, a new device called the eight-Plate Guided Growth System, consisting of a two-hole plate and two screws, was presented as an alternative to the widely used Blount staple to perform temporary hemiepiphysiodesis in children. Forty-three patients (54 physes, 51 limbs) underwent treatment between August 2004 and December 2005 with average follow-up after plate insertion of 2 years 2 months (range, 1 year 6 months to 2 years 6 months). Rate of correction and reversibility of this intervention were calculated. Average age at eight-Plate implantation was 9 years 7 months (age range, 4 years 0 months to 14 years 3 months). eight-Plates were inserted for an average 14.2 months (range, 5.0-27.4 months). No growth disturbance was observed. Mechanical lateral distal ...
Journal of Pediatric Orthopaedics, 2011
Treating angular deformities with temporary hemiepiphysiodesis in skeletally immature patients ca... more Treating angular deformities with temporary hemiepiphysiodesis in skeletally immature patients can avoid the need for osteotomies. Recently, newer implants have been introduced as alternatives to the Blount staple, which was commonly used for the past 60 years. The purpose of this project was to develop a porcine model that can be used to compare various methods of temporary hemiepiphyseal arrest. In this pilot study, we compared the Blount staple and the eight-Plate. We hypothesized that the Blount staple, a fixed angle device, tethers growth immediately, whereas the eight-Plate, having mobile arms, has a certain lead time to take the slack out of the system until it can begin to tether growth. A porcine model was selected due to its widespread availability and because its size approximates human pediatric dimensions. Thirty-day-old, 15-kg piglets underwent surgery to insert an eight-Plate in each right proximal medial tibia and a Blount staple in each left proximal medial tibia. The insertion technique was identical to the surgical procedure performed in humans, including the use of image intensification. Anteroposterior and lateral view tibial radiographs were obtained monthly until sacrifice at 3 months after insertion to measure the medial proximal tibial angle. At 1 month follow-up, a large varus deformity up to 30 degrees had already occurred with both devices. In some piglets, the implants were even dragged, by growth, through the epiphysis during the first two months. With further follow-up, the Blount staples frequently migrated to the proximal metaphysis. We observed rebound in four tibiae after implant migration, with partial restoration of the normal limb alignment. The porcine model for temporary hemiepiphysiodesis seems to have promise for future studies. However, the unusually rapid rate of growth causes us to recommend more frequent observation periods, such as weekly instead of monthly radiographic observation.
Journal of Pediatric Orthopaedics, 2010
For decades, the Blount staple has been used to perform temporary hemiepiphysiodesis for angular ... more For decades, the Blount staple has been used to perform temporary hemiepiphysiodesis for angular deformity correction in children with open growth plates. Recently, the eight-PlateGuided Growth System (Orthofix, McKinney, TX) has gained popularity for use in this procedure. The eight-Plate is said to be superior to the Blount staple, as it is less likely to break or migrate out of the bone. However, some centers have observed mechanical failures of the eight-Plate cannulated screws. The purpose of our study was to conduct a multicenter survey to determine which factors increase the risk of mechanical failure with this device. We distributed a questionnaire in 2007 to 841 members of the Pediatric Orthopaedic Society of North America that asked about their experience with the eight-Plate and whether they had observed any mechanical failures. Follow-up surveys were distributed to determine the background of the failed cases. Of the 445 (53%) surgeons who responded, 314 (71%) reported that they use the eight-Plate in their practice. Forty-eight (15%) of the 314 surgeons who use the eight-Plate observed a total of 65 cases of mechanical failure. In every case, the screws failed, not the plate. The average body mass index of these patients was 37.8 kg/m (range, 19.2 to 70.2 kg/m). Overweight and obese patients with Blount disease were among those most likely to experience eight-Plate screw failure. Fractures occurred almost always in the metaphyseal screw-not where the head meets the shank but where the shank enters the lateral cortex, presumably because of 3-point bending. No broken plates were reported. In high-risk cases, we now consider using 2 parallel eight-Plates or using solid (not cannulated) screws for plate fixation. Level IV.
Journal of Pediatric Orthopaedics, 2008
The Ponseti method has become a popular technique to treat idiopathic clubfoot. In most cases, a ... more The Ponseti method has become a popular technique to treat idiopathic clubfoot. In most cases, a percutaneous Achilles tenotomy is required to correct residual equinus contracture. Bleeding has been reported as a complication of percutaneous tenotomy. We present a case of a baby who developed a pseudoaneurysm after undergoing an appropriate Ponseti percutaneous Achilles tenotomy at the age of 8 weeks. The diagnosis of pseudoaneurysm was confirmed by color ultrasonography, which showed active flow in the base of the mass. This complication has not been previously described after Ponseti percutaneous Achilles tenotomy. The large pseudoaneurysm mass together with an incomplete correction made bracing with straight last shoes and Denis Browne bar impossible, and the patient developed an immediate relapse of the clubfoot deformity. The relapsed deformity was successfully treated with 4 weeks of additional Ponseti casting, with an emphasis on applying pressure over the pseudoaneurysm by molding the cast. Repeat ultrasonogram at that time showed that the pseudoaneurysm completely resolved, making invasive treatment of the pseudoaneurysm unnecessary. Physicians should be aware that vascular injury could lead to pseudoaneurysm after performing this otherwise simple office procedure.
Journal of Pediatric Orthopaedics, 2008
Compartment syndrome results from pathologically elevated muscle tissue pressure within a closed ... more Compartment syndrome results from pathologically elevated muscle tissue pressure within a closed space. It is almost always related to either trauma or reperfusion after loss of arterial inflow from occlusion of a major blood vessel. We present an unusual case of nontraumatic and nonvascular compartment syndrome after hypocalcemia-induced sustained tetany in a 2-year-10-month-old male child after a neuroblastoma tumor resection. This particular cause of compartment syndrome has been described only once before in an adult patient.
Journal of Orthopaedic Trauma, 2010
Within the last decade, intramedullary nailing systems have gained popularity in the treatment of... more Within the last decade, intramedullary nailing systems have gained popularity in the treatment of unstable fractures of the trochanteric region with good clinical results. However, these implants are not free of complications. Commonly reported treatment failures include implant cutout through the femoral neck, stress-derived femur fractures at the distal end of the nail, and secondary rotational displacement and varus deformity of the femoral neck and head. Only few reports exist on primary medial migration of the lag screw after treatment with intramedullary implants. We report on a rarely described complication in 2 patients who underwent osteosynthesis with a Gamma 3 nail (Stryker, Mahwah, NJ). Both patients presented with implant failures due to primary medial migration of the lag screw. Complete separation of the implant occurred, and the lag screw penetrated through the acetabulum into the pelvis. The patient's histories and course of treatment are reported. The literature on this topic is discussed.
Journal of Children's Orthopaedics, 2012
Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight... more Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight-Plate Guided Growth System. Since its introduction, the eight-Plate has largely supplanted the traditional Blount staple. The eight-Plate offers better purchase in the bone and a more precise insertion technique. However, the Blount staple is less expensive than the various guided growth plates. Further, some surgeons feel that the Blount staple may work faster, making it more appropriate for children who are approaching skeletal maturity. Unfortunately, the original instrumentation and technique for inserting the Blount staple is over 50 years old and has not been updated. The purpose of this study was to develop new instrumentation to make Blount staple insertion as accurate and minimally invasive as eight-Plate insertion. We developed wire/drill guides to accommodate all three sizes of the Blount staple. Two wires are inserted through the wire guide under image intensifier control. After confirming the accurate position of the guidewires, a 3.2-mm cannulated step drill is used to drill over the wires to a depth of 5 mm. This creates two pilot holes for the two tines of the Blount staple. The final insertion is guided under an anteroposterior image intensifier view. We also developed a small staple holder that permits insertion through a small incision. We developed a working prototype of the new instrumentation and used it in three clinical cases. With the new staple inserter and instrumentation, Blount staples can now be inserted through a smaller incision with similar accuracy as eight-Plate insertion.
Journal of Children's Orthopaedics, 2014
Plaster casts can cause burns. Synthetic casts do not. Composite plaster-synthetic casts have not... more Plaster casts can cause burns. Synthetic casts do not. Composite plaster-synthetic casts have not been thoroughly evaluated. This study analyzed the temperature from plaster casts compared with composite casts in a variety of in vitro conditions that would simulate clinical practice. A Pyrex cylinder filled with constant body temperature circulating water simulated a human extremity. Circumferential casts, of either plaster or composite construction (plaster inner layer with outer synthetic layer), were applied to the model. Peak temperatures generated by the exothermic reactions were studied relative to the following variables: dip water temperature (24 °C versus 40 °C), cast thickness (16, 30, and 34 ply), and delayed (5-min) versus immediate application of the synthetic outer layers. Peak temperatures from the all-plaster casts were compared with the composite casts of the same thickness. Finally, the relative cast strength was determined. Potentially dangerous high temperatures were measured only when 40 °C dip water was used or when thick (30- or 34-ply) casts were made. Cast strength increased with increasing cast thickness. However, the presence of synthetics in the composite casts layers did not increase cast strength in every case. When applying composite casts, the outer synthetic layers should be applied several minutes after the plaster to minimize temperature rise. Composite casts do not routinely generate peak temperatures higher than plaster casts of similar thickness. Because the skin of children and the elderly is more temperature-sensitive than average adult skin, extra care should be taken to limit the exothermic reaction when casting children and the elderly: clean, room temperature dip water, minimal required cast thickness, avoidance of insulating pillows/blankets while the cast is drying.
Journal of Bone and Joint Surgery - British Volume, 2012
Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creatin... more Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creating lateral shift of the mechanical axis. We aimed to determine whether femoral lengthening along the anatomical axis has an inadvertent effect on lower limb alignment. Isolated femoral lengthening using the Intramedullary Skeletal Kinetic Distractor was performed in 27 femora in 24 patients (mean age 32 years (16 to 57)). Patients who underwent simultaneous realignment procedures or concurrent tibial lengthening, or who developed mal-or nonunion, were excluded. Pre-operative and six-month post-operative radiographs were used to measure lower limb alignment. The mean lengthening achieved was 4.4 cm (1.5 to 8.0). In 26 of 27 limbs, the mechanical axis shifted laterally by a mean of 1.0 mm/cm of lengthening (0 to 3.5). In one femur that was initially in varus, a 3 mm medial shift occurred during a lengthening of 2.2 cm.
The Journal of Bone and Joint Surgery (American), 2007
The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percuta... more The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percutaneous Achilles tenotomy in most cases, and bracing with an abduction orthosis to prevent relapse. Although Ponseti recommended evaluation of the infant clubfoot strictly by palpation, many orthopaedic surgeons still rely on radiographs for decision-making during treatment. The aim of this study was to document with radiographs the effect of percutaneous Achilles tenotomy as described by Ponseti. We conducted a study of idiopathic clubfeet treated, at two centers, with the Ponseti method, including percutaneous Achilles tenotomy. Cast treatment was started within three weeks after birth, and radiographs were made before and after the tenotomy. Lateral radiographs with the foot in maximal dorsiflexion at the ankle were made for all patients, and anteroposterior radiographs of the foot were made at one center. The lateral tibiocalcaneal angle, the anteroposterior talocalcaneal angle, and the lateral talocalcaneal angle were measured on the radiographs. Foot dorsiflexion at the ankle was evaluated clinically. The results from both centers were evaluated separately and in combination. Lateral dorsiflexion radiographs that showed the foot and ankle were evaluated for eighty-seven clubfeet, and anteroposterior radiographs that showed the foot were evaluated for sixty-five clubfeet. The mean improvement in the lateral tibiocalcaneal angle after the tenotomy was 16.9 degrees . The mean change in the anteroposterior talocalcaneal angle was 2.1 degrees , and the mean change in the lateral talocalcaneal angle change was 1.4 degrees . The mean increase in clinically measured dorsiflexion after the tenotomy (in sixty-five feet) was 15.1 degrees . Only the lateral tibiocalcaneal angle and dorsiflexion as measured clinically changed significantly after the Achilles tenotomy (p < 0.05). When the results at each center were analyzed separately, they were found to be nearly identical. The increase in the lateral tibiocalcaneal angle after Achilles tenotomy is essentially the same as the increase in ankle dorsiflexion seen on clinical examination. The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy. Radiographs confirmed that the additional dorsiflexion obtained from the percutaneous Achilles tenotomy is true dorsiflexion occurring in the ankle and hindfoot and not in the midfoot. Therapeutic Level IV.
The Journal of Bone and Joint Surgery (American), 2012
Background: Certain complex foot deformities can be corrected surgically with a U-osteotomy. This... more Background: Certain complex foot deformities can be corrected surgically with a U-osteotomy. This osteotomy is indicated for patients with a uniform deformity of the entire foot relative to the tibia, preexisting stiffness and/or fusion of the subtalar joint, and a pain-free ankle joint. The goal is to create a plantigrade foot through gradual osseous repositioning of the entire foot relative to the tibia by means of external fixation. If needed, foot height can be increased simultaneously.
Orthopedics, 2011
Temporary hemiepiphysiodesis is a relatively minor surgical procedure in the growing child to all... more Temporary hemiepiphysiodesis is a relatively minor surgical procedure in the growing child to allow guided growth to correct angular deformities. Blount staples (Stryker Howmedica, Kiel, Germany) have been used effectively for the past 50 years for physeal stapling; their limitations are poor mechanical purchase and easy extrusion from bone, implant breakage, and potential for physeal damage and permanent closure. Recently, an alternative device to Blount staples called the eight-Plate (Orthofix, McKinney, Texas) has been presented for hemiepiphysiodesis and guided growth. Their theoretical advantages over Blount staples include higher stability, faster correction of the deformity, and fewer complications.We performed a study in a pig model to compare the rate of angular deformity correction and implant extrusion after hemiepiphysiodesis with Blount staples and eight-Plates. In all animals, medial hemiepiphysiodesis was performed in the right proximal tibia with the eight-Plate and ...
Journal of Orthopaedics, 2015
Outcome assessment after double level tibial lengthening in patients with dwarfism. Fourteen pati... more Outcome assessment after double level tibial lengthening in patients with dwarfism. Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening. Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally and 6.0 cm distally. Concomitant deformities were also addressed during lengthening. External fixation treatment time averaged 8.8 months. Healing index averaged 0.7 months/cm. Bilateral tibial lengthening for dwarfism is difficult, but the results are usually quite gratifying.
Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 2014
Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is u... more Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is usually a mild deformity that responds well to simple observation or minimal treatment with a home program of stretching. Resistant cases may need a more aggressive approach such as serial casting or special bracing to avoid the need for surgical intervention. We compared clinical outcomes using serial casting with orthoses for resistant metatarsus adductus. We prospectively treated 27 infants (43 feet) between the ages 3 and 9 months who failed home stretching treatment. Patients were randomized to either serial plaster casting or Bebax orthoses. Footprints and simulated weight-bearing anteroposterior and lateral view radiographs were made at entry and follow-up. There was no statistical difference between casting and Bebax for the following parameters: age at study entry, length of treatment, number of clinic visits, follow-up, and follow-up maintenance treatments. Both groups showed im...
Der Unfallchirurg
Delayed union or non-union of long bone shaft fractures still presents a surgical challenge. Espe... more Delayed union or non-union of long bone shaft fractures still presents a surgical challenge. Especially if there is a predisposition for pseudarthrosis such as adiposity, diabetes mellitus, local disruption of blood supply or lack of hormones, the established procedures of autologous cancellous bone grafting or plate fixation with compression often lead to insufficient results. In the following article the successful use of bone morphogenetic protein BMP-7 [recombinant human osteogenetic protein-1 (rhOP-1)], combined with autologous bone grafting for therapy of a therapy-resistant tibial non-union is described. In a patient with multiple risk factors the tibial fracture was completely cured after two attempts of osteosynthesis and autologous bone grafting had failed. The patient achieved self-mobility with full weight bearing and absence of pain 10 months after adjuvant implantation of BMP-7.
Journal of Knee Surgery Reports, 2015
Geburtshilfe und Frauenheilkunde, 2009
Strategies in Trauma and Limb Reconstruction, 2014
Limb lengthening by callus distraction is commonly performed with the use of external fixation. L... more Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.
Journal of applied biomechanics, 2011
Femoral lengthening with intramedullary nails can create alterations in the mechanical axis of th... more Femoral lengthening with intramedullary nails can create alterations in the mechanical axis of the limb. This is based on the relationship of the anatomic femur axis to the mechanical femur axis, which is typically 5-9 degrees valgus. We developed trigonometric formulas to calculate the predicted change, using the lengths of the tibia, femur, and whole limb; the amount of lengthening; and the angle between the anatomic and the mechanical axis of the femur. We recognized three patterns depending on whether the overall limb mechanical axis is lateral (valgus), medial (varus), or straight through the center of the knee. The varus and valgus patterns lead to similar formulas. When the mechanical axis goes directly through the center of the knee joint, the formula simplifies. These formulas could be incorporated into digital radiographic programs to predict the change in mechanical axis deviation that will develop from lengthening along the anatomic femur axis with an intramedullary leng...
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 2011
To examine maternal attitudes towards prenatal diagnosis of idiopathic clubfoot and to determine ... more To examine maternal attitudes towards prenatal diagnosis of idiopathic clubfoot and to determine the incidence of false-negative ultrasound examinations. Surveys were mailed to mothers of patients with clubfoot born between 2000 and 2007 who were treated at either Sinai Hospital of Baltimore or Orthopaedic Hospital Speising. Exclusion criteria were underlying syndrome, genetic abnormality and multiple pregnancy. The survey asked the mother whether she had had any ultrasound examinations before her child was born, whether any of these had shown clubfoot, and whether she would have preferred to find out about her child's clubfoot before birth or after birth. Mothers completed 220 (USA, 105 surveys; Austria, 115 surveys) of 401 mailed surveys. The prenatal detection rate was 60% in the USA compared with 25% in Austria (P = 0.001). Overall, 74% of mothers indicated a preference for prenatal diagnosis and 24% indicated a preference for postnatal diagnosis of the condition. Of 92 pati...
Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 2010
Angular deformities can be treated with corrective osteotomies and application of internal or ext... more Angular deformities can be treated with corrective osteotomies and application of internal or external fixation. In children, this major intervention can be avoided with temporary hemiepiphysiodesis (i.e., guided growth). Recently, a new device called the eight-Plate Guided Growth System, consisting of a two-hole plate and two screws, was presented as an alternative to the widely used Blount staple to perform temporary hemiepiphysiodesis in children. Forty-three patients (54 physes, 51 limbs) underwent treatment between August 2004 and December 2005 with average follow-up after plate insertion of 2 years 2 months (range, 1 year 6 months to 2 years 6 months). Rate of correction and reversibility of this intervention were calculated. Average age at eight-Plate implantation was 9 years 7 months (age range, 4 years 0 months to 14 years 3 months). eight-Plates were inserted for an average 14.2 months (range, 5.0-27.4 months). No growth disturbance was observed. Mechanical lateral distal ...
Journal of Pediatric Orthopaedics, 2011
Treating angular deformities with temporary hemiepiphysiodesis in skeletally immature patients ca... more Treating angular deformities with temporary hemiepiphysiodesis in skeletally immature patients can avoid the need for osteotomies. Recently, newer implants have been introduced as alternatives to the Blount staple, which was commonly used for the past 60 years. The purpose of this project was to develop a porcine model that can be used to compare various methods of temporary hemiepiphyseal arrest. In this pilot study, we compared the Blount staple and the eight-Plate. We hypothesized that the Blount staple, a fixed angle device, tethers growth immediately, whereas the eight-Plate, having mobile arms, has a certain lead time to take the slack out of the system until it can begin to tether growth. A porcine model was selected due to its widespread availability and because its size approximates human pediatric dimensions. Thirty-day-old, 15-kg piglets underwent surgery to insert an eight-Plate in each right proximal medial tibia and a Blount staple in each left proximal medial tibia. The insertion technique was identical to the surgical procedure performed in humans, including the use of image intensification. Anteroposterior and lateral view tibial radiographs were obtained monthly until sacrifice at 3 months after insertion to measure the medial proximal tibial angle. At 1 month follow-up, a large varus deformity up to 30 degrees had already occurred with both devices. In some piglets, the implants were even dragged, by growth, through the epiphysis during the first two months. With further follow-up, the Blount staples frequently migrated to the proximal metaphysis. We observed rebound in four tibiae after implant migration, with partial restoration of the normal limb alignment. The porcine model for temporary hemiepiphysiodesis seems to have promise for future studies. However, the unusually rapid rate of growth causes us to recommend more frequent observation periods, such as weekly instead of monthly radiographic observation.
Journal of Pediatric Orthopaedics, 2010
For decades, the Blount staple has been used to perform temporary hemiepiphysiodesis for angular ... more For decades, the Blount staple has been used to perform temporary hemiepiphysiodesis for angular deformity correction in children with open growth plates. Recently, the eight-PlateGuided Growth System (Orthofix, McKinney, TX) has gained popularity for use in this procedure. The eight-Plate is said to be superior to the Blount staple, as it is less likely to break or migrate out of the bone. However, some centers have observed mechanical failures of the eight-Plate cannulated screws. The purpose of our study was to conduct a multicenter survey to determine which factors increase the risk of mechanical failure with this device. We distributed a questionnaire in 2007 to 841 members of the Pediatric Orthopaedic Society of North America that asked about their experience with the eight-Plate and whether they had observed any mechanical failures. Follow-up surveys were distributed to determine the background of the failed cases. Of the 445 (53%) surgeons who responded, 314 (71%) reported that they use the eight-Plate in their practice. Forty-eight (15%) of the 314 surgeons who use the eight-Plate observed a total of 65 cases of mechanical failure. In every case, the screws failed, not the plate. The average body mass index of these patients was 37.8 kg/m (range, 19.2 to 70.2 kg/m). Overweight and obese patients with Blount disease were among those most likely to experience eight-Plate screw failure. Fractures occurred almost always in the metaphyseal screw-not where the head meets the shank but where the shank enters the lateral cortex, presumably because of 3-point bending. No broken plates were reported. In high-risk cases, we now consider using 2 parallel eight-Plates or using solid (not cannulated) screws for plate fixation. Level IV.
Journal of Pediatric Orthopaedics, 2008
The Ponseti method has become a popular technique to treat idiopathic clubfoot. In most cases, a ... more The Ponseti method has become a popular technique to treat idiopathic clubfoot. In most cases, a percutaneous Achilles tenotomy is required to correct residual equinus contracture. Bleeding has been reported as a complication of percutaneous tenotomy. We present a case of a baby who developed a pseudoaneurysm after undergoing an appropriate Ponseti percutaneous Achilles tenotomy at the age of 8 weeks. The diagnosis of pseudoaneurysm was confirmed by color ultrasonography, which showed active flow in the base of the mass. This complication has not been previously described after Ponseti percutaneous Achilles tenotomy. The large pseudoaneurysm mass together with an incomplete correction made bracing with straight last shoes and Denis Browne bar impossible, and the patient developed an immediate relapse of the clubfoot deformity. The relapsed deformity was successfully treated with 4 weeks of additional Ponseti casting, with an emphasis on applying pressure over the pseudoaneurysm by molding the cast. Repeat ultrasonogram at that time showed that the pseudoaneurysm completely resolved, making invasive treatment of the pseudoaneurysm unnecessary. Physicians should be aware that vascular injury could lead to pseudoaneurysm after performing this otherwise simple office procedure.
Journal of Pediatric Orthopaedics, 2008
Compartment syndrome results from pathologically elevated muscle tissue pressure within a closed ... more Compartment syndrome results from pathologically elevated muscle tissue pressure within a closed space. It is almost always related to either trauma or reperfusion after loss of arterial inflow from occlusion of a major blood vessel. We present an unusual case of nontraumatic and nonvascular compartment syndrome after hypocalcemia-induced sustained tetany in a 2-year-10-month-old male child after a neuroblastoma tumor resection. This particular cause of compartment syndrome has been described only once before in an adult patient.
Journal of Orthopaedic Trauma, 2010
Within the last decade, intramedullary nailing systems have gained popularity in the treatment of... more Within the last decade, intramedullary nailing systems have gained popularity in the treatment of unstable fractures of the trochanteric region with good clinical results. However, these implants are not free of complications. Commonly reported treatment failures include implant cutout through the femoral neck, stress-derived femur fractures at the distal end of the nail, and secondary rotational displacement and varus deformity of the femoral neck and head. Only few reports exist on primary medial migration of the lag screw after treatment with intramedullary implants. We report on a rarely described complication in 2 patients who underwent osteosynthesis with a Gamma 3 nail (Stryker, Mahwah, NJ). Both patients presented with implant failures due to primary medial migration of the lag screw. Complete separation of the implant occurred, and the lag screw penetrated through the acetabulum into the pelvis. The patient's histories and course of treatment are reported. The literature on this topic is discussed.
Journal of Children's Orthopaedics, 2012
Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight... more Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight-Plate Guided Growth System. Since its introduction, the eight-Plate has largely supplanted the traditional Blount staple. The eight-Plate offers better purchase in the bone and a more precise insertion technique. However, the Blount staple is less expensive than the various guided growth plates. Further, some surgeons feel that the Blount staple may work faster, making it more appropriate for children who are approaching skeletal maturity. Unfortunately, the original instrumentation and technique for inserting the Blount staple is over 50 years old and has not been updated. The purpose of this study was to develop new instrumentation to make Blount staple insertion as accurate and minimally invasive as eight-Plate insertion. We developed wire/drill guides to accommodate all three sizes of the Blount staple. Two wires are inserted through the wire guide under image intensifier control. After confirming the accurate position of the guidewires, a 3.2-mm cannulated step drill is used to drill over the wires to a depth of 5 mm. This creates two pilot holes for the two tines of the Blount staple. The final insertion is guided under an anteroposterior image intensifier view. We also developed a small staple holder that permits insertion through a small incision. We developed a working prototype of the new instrumentation and used it in three clinical cases. With the new staple inserter and instrumentation, Blount staples can now be inserted through a smaller incision with similar accuracy as eight-Plate insertion.
Journal of Children's Orthopaedics, 2014
Plaster casts can cause burns. Synthetic casts do not. Composite plaster-synthetic casts have not... more Plaster casts can cause burns. Synthetic casts do not. Composite plaster-synthetic casts have not been thoroughly evaluated. This study analyzed the temperature from plaster casts compared with composite casts in a variety of in vitro conditions that would simulate clinical practice. A Pyrex cylinder filled with constant body temperature circulating water simulated a human extremity. Circumferential casts, of either plaster or composite construction (plaster inner layer with outer synthetic layer), were applied to the model. Peak temperatures generated by the exothermic reactions were studied relative to the following variables: dip water temperature (24 °C versus 40 °C), cast thickness (16, 30, and 34 ply), and delayed (5-min) versus immediate application of the synthetic outer layers. Peak temperatures from the all-plaster casts were compared with the composite casts of the same thickness. Finally, the relative cast strength was determined. Potentially dangerous high temperatures were measured only when 40 °C dip water was used or when thick (30- or 34-ply) casts were made. Cast strength increased with increasing cast thickness. However, the presence of synthetics in the composite casts layers did not increase cast strength in every case. When applying composite casts, the outer synthetic layers should be applied several minutes after the plaster to minimize temperature rise. Composite casts do not routinely generate peak temperatures higher than plaster casts of similar thickness. Because the skin of children and the elderly is more temperature-sensitive than average adult skin, extra care should be taken to limit the exothermic reaction when casting children and the elderly: clean, room temperature dip water, minimal required cast thickness, avoidance of insulating pillows/blankets while the cast is drying.
Journal of Bone and Joint Surgery - British Volume, 2012
Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creatin... more Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creating lateral shift of the mechanical axis. We aimed to determine whether femoral lengthening along the anatomical axis has an inadvertent effect on lower limb alignment. Isolated femoral lengthening using the Intramedullary Skeletal Kinetic Distractor was performed in 27 femora in 24 patients (mean age 32 years (16 to 57)). Patients who underwent simultaneous realignment procedures or concurrent tibial lengthening, or who developed mal-or nonunion, were excluded. Pre-operative and six-month post-operative radiographs were used to measure lower limb alignment. The mean lengthening achieved was 4.4 cm (1.5 to 8.0). In 26 of 27 limbs, the mechanical axis shifted laterally by a mean of 1.0 mm/cm of lengthening (0 to 3.5). In one femur that was initially in varus, a 3 mm medial shift occurred during a lengthening of 2.2 cm.
The Journal of Bone and Joint Surgery (American), 2007
The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percuta... more The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percutaneous Achilles tenotomy in most cases, and bracing with an abduction orthosis to prevent relapse. Although Ponseti recommended evaluation of the infant clubfoot strictly by palpation, many orthopaedic surgeons still rely on radiographs for decision-making during treatment. The aim of this study was to document with radiographs the effect of percutaneous Achilles tenotomy as described by Ponseti. We conducted a study of idiopathic clubfeet treated, at two centers, with the Ponseti method, including percutaneous Achilles tenotomy. Cast treatment was started within three weeks after birth, and radiographs were made before and after the tenotomy. Lateral radiographs with the foot in maximal dorsiflexion at the ankle were made for all patients, and anteroposterior radiographs of the foot were made at one center. The lateral tibiocalcaneal angle, the anteroposterior talocalcaneal angle, and the lateral talocalcaneal angle were measured on the radiographs. Foot dorsiflexion at the ankle was evaluated clinically. The results from both centers were evaluated separately and in combination. Lateral dorsiflexion radiographs that showed the foot and ankle were evaluated for eighty-seven clubfeet, and anteroposterior radiographs that showed the foot were evaluated for sixty-five clubfeet. The mean improvement in the lateral tibiocalcaneal angle after the tenotomy was 16.9 degrees . The mean change in the anteroposterior talocalcaneal angle was 2.1 degrees , and the mean change in the lateral talocalcaneal angle change was 1.4 degrees . The mean increase in clinically measured dorsiflexion after the tenotomy (in sixty-five feet) was 15.1 degrees . Only the lateral tibiocalcaneal angle and dorsiflexion as measured clinically changed significantly after the Achilles tenotomy (p < 0.05). When the results at each center were analyzed separately, they were found to be nearly identical. The increase in the lateral tibiocalcaneal angle after Achilles tenotomy is essentially the same as the increase in ankle dorsiflexion seen on clinical examination. The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy. Radiographs confirmed that the additional dorsiflexion obtained from the percutaneous Achilles tenotomy is true dorsiflexion occurring in the ankle and hindfoot and not in the midfoot. Therapeutic Level IV.
The Journal of Bone and Joint Surgery (American), 2012
Background: Certain complex foot deformities can be corrected surgically with a U-osteotomy. This... more Background: Certain complex foot deformities can be corrected surgically with a U-osteotomy. This osteotomy is indicated for patients with a uniform deformity of the entire foot relative to the tibia, preexisting stiffness and/or fusion of the subtalar joint, and a pain-free ankle joint. The goal is to create a plantigrade foot through gradual osseous repositioning of the entire foot relative to the tibia by means of external fixation. If needed, foot height can be increased simultaneously.
Orthopedics, 2011
Temporary hemiepiphysiodesis is a relatively minor surgical procedure in the growing child to all... more Temporary hemiepiphysiodesis is a relatively minor surgical procedure in the growing child to allow guided growth to correct angular deformities. Blount staples (Stryker Howmedica, Kiel, Germany) have been used effectively for the past 50 years for physeal stapling; their limitations are poor mechanical purchase and easy extrusion from bone, implant breakage, and potential for physeal damage and permanent closure. Recently, an alternative device to Blount staples called the eight-Plate (Orthofix, McKinney, Texas) has been presented for hemiepiphysiodesis and guided growth. Their theoretical advantages over Blount staples include higher stability, faster correction of the deformity, and fewer complications.We performed a study in a pig model to compare the rate of angular deformity correction and implant extrusion after hemiepiphysiodesis with Blount staples and eight-Plates. In all animals, medial hemiepiphysiodesis was performed in the right proximal tibia with the eight-Plate and ...