The American Journal of Orthopedics

FEBRUARY 2007 Volume XXXVI No. 2 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

15 Guest Editorial—Pediatric Orthopedic Imaging: More Isn't Always Better
Wilfred C. G. Peh, MD, FRCP, FRCR
Department of Diagnostic Radiology, Alexandra Hospital, Singapore, 159964, Republic of Singapore. wilfred@pehfamily.per.sg
Abstract not available.
Am J Orthop. 2007;36(2):E15

16
Foot Pain Arising From Subacute Osteomyelitis in a Child
Harish S. Hosalkar, MD, MBMS (Orth), FCPS (Orth), DNB (Orth), Lawrence Wells, MD, Emily Kolze, BA, Marta Guttenberg, MD, and John P. Dormans, MD
Harish S. Hosalkar, Division of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. hosalkar@email.chop.edu
Abstract not available. Introduction provided instead.
Osteomyelitis is known as the “great masquerader,” and this report explores the differential diagnosis that attends cases of possible subacute osteomyelitis.
Am J Orthop. 2007;36(2):E16-E20

21
Isolated Langerhans Cell Histiocytosis of the T12 Vertebra in an Adolescent
Harish S. Hosalkar, MD, MBMS (Orth), FCPS (Orth), DNB (Orth), Jared S. Greenberg, BA, Lawrence Wells, MD, and John P. Dormans, MD
Harish S. Hosalkar, Division of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. hosalkar@email.chop.edu
Abstract not available. Introduction provided instead.
Langerhans cell histiocytosis (LCH) represents a group of rare, benign, histologically similar disorders of relatively unknown etiology and pathogenesis.¹ Research suggests that the etiology is multifactorial, possibly involving the patient’s environment, infection (human herpesvirus 6), immune response, and/or genetics.² While some controversy exists over which disease subtypes should be classified within this grouping, disorders such as solitary eosinophilic granuloma, Hand-Schüller-Christian disease, and Letterer-Siwe disease are typically included,³ representing unifocal, multifocal, and disseminated variants, respectively.² Although it was once believed that these 3 diseases were separate entities, it is now recognized that they are different manifestations of the same disease process, involving a clonal proliferation of Langerhans cells.⁴
LCH is a disease of childhood, with a peak incidence between 5 and 10 years of age,⁵ although recent studies have shown a shift in the trend toward even younger children, predominantly aged 1 to 4 years.2 Nearly 85% to 90% of cases of LCH primarily affect bone, although other organ involvement has been reported.5 Despite LCH’s high percentage of bone involvement, the incidence of vertebral involvement ranges from only 7.8% to 25%.⁶ As the incidence of LCH is approximately 5.4 million children per year,² or 1:2,000,000 per year,⁶ the number of cases involving the vertebra is likely less than 1 million per year. We report the case and follow-up of a 15-year-old boy with isolated LCH of the T12 vertebrae.
Am J Orthop. 2007;36(2):E21-E24

25
Left Knee Pain in a 71/2-Year-Old Boy
Harish S. Hosalkar, MD, MBMS (Orth), FCPS (Orth), DNB (Orth), Kelly M. Axsom, BA, Lawrence Wells, MD, Leslie Moroz, BA, and John P. Dormans, MD
Harish S. Hosalkar, Division of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. hosalkar@email.chop.edu
Abstract not available. Introduction provided instead.
This case is presented to illustrate the imaging and clinical findings of a condition of interest to orthopedic surgeons. The initial findings are noted on the first 2 pages, along with the diagnostic considerations and differential diagnoses as additional information is obtained as the clinical investigation proceeds. The correct diagnosis is discussed beginning on the third page.
Am J Orthop. 2007;36(2):E25-E30

PRINT PUBLISHING

61
Editorial
AJO and “Topics of the Day”
Peter D. McCann, MD
Abstract not available.
Am J Orthop. 2007;36(2):61

62 5 Points: Surgical Management of Radial Head Fractures and Analyses
Robert W. Wysocki, MD, and Mark S. Cohen, MD
Abstract not available.
Am J Orthop. 2007;36(2):62-66

68 Maintenance of Reduction of Pediatric Distal Radius Fractures With a Sugar-Tong Splint
Alec E. Denes, Jr., MD, Richard Goding, MD, Jeffrey Tamborlane, MD, and Evan Schwartz, MD
Distal radius fractures are common injuries in children. Displaced fractures have traditionally been treated with closed reduction followed by immobilization in a long arm cast. Because of variable success rates with this technique, a trend in the literature is toward operative fixation of these fractures. A popular alternative practice involves temporary immobilization in a sugar-tong splint, though we are unaware of any studies demonstrating the efficacy of this technique in children. We present our experience in treating these injuries initially with a sugar-tong splint and then with a short arm cast. We retrospectively reviewed the cases of 53 patients (age range, 2-12 years) treated with closed reduction and a sugar-tong splint followed by conversion to a short arm cast after 2 to 3 weeks. In 51 (96%) of 53 fractures, reduction was maintained without more aggressive intervention. The sugar-tong splint is effective in maintaining reductions in pediatric distal radius fractures and has none of the added risks associated with current alternative methods.
Am J Orthop. 2007;36(2):68-70

71 Health Care Technology Assessment: Implications for Modern Medical Practice. Part II. Decision Making on Technology Adoption
Read G. Pierce, MD, Kevin J. Bozic, MD, MBA, Bruce Lee Hall, MD, MBA, PhD, and James Breivis, MD
Health care technology assessment, the multidisciplinary evaluation of clinical and economic aspects of technology, has come to have an increasingly important role in health policy and clinical decision-making. In Part I—Understanding Technology Adoption and Analyses—this review addressed the difficult challenges posed by assessment and provided a guide to the methodologies used. Part II presents the factors that drive the technology choices made by patients, by individual physicians, by provider groups, and by hospital administrators.
Am J Orthop. 2007;36(2):71-76

78 Clinical Decision Making: Doctor, When Can I Drive?
Jonathan M. Cooper, DO
The orthopedic surgeon has little evidence-based literature to refer to when deciding when a patient is “safe” to drive a car. Current advice is derived from several empirical reports on soft-tissue and bone healing. Using the terms surgery and driving, I searched Pubmed and Medline to review the relevant English-language research literature published between 1960 and the present. Of the 975 studies found and examined—all studies, surveys, and case reports involving the extremities were considered—35 had orthopedic relevance. Recommendations for return to driving are presented here. Orthopedic surgeons should find this review an aid when they use the literature to make informed decisions about patients’ return to driving and when they conduct further evidence-based investigation to determine orthopedic fitness to drive.
Am J Orthop. 2007;36(2):78-80

82 Closed Reduction for Treatment of Developmental Dysplasia of the Hip in Children
Trevor Murray, MD, Daniel R. Cooperman, MD, George H. Thompson, MD, and R. Tracy Ballock, MD
Although many studies have analyzed the success rates of closed reduction and spica casting for the treatment of developmental dysplasia of the hip (DDH) in children, the definition of success for this procedure is not standardized in the literature. We retrospectively reviewed our experience with closed reduction for treatment of DDH in 30 children (35 hips) over an 8-year period to determine the success rates of this procedure on the basis of how success is defined. In only 1 patient (2 hips, 6%) were the hips unable to be concentrically reduced with sufficient stability at the time of closed reduction. In 10 (30%) of the other 33 hips, the acetabulum failed to develop sufficiently after closed reduction, and a secondary surgery was required a mean of 22 months after cast removal. Four (12%) of the 33 hips developed radiographic evidence of avascular necrosis. Therefore, the success rate of closed reduction for DDH varies markedly depending on how success is defined.
Am J Orthop. 2007;36(2):82-84

89 Type III Acromioclavicular Separation: Results of a Recent Survey on Its Management
Carl W. Nissen, MD, and Abhishek Chatterjee, BA
The issue of managing type III acromioclavicular (AC) separations remains controversial, and decisions about using operative versus conservative management have undergone many distinct changes over the years. To review current management preferences within the orthopedic community, we sent a mail-in survey to all members of the American Orthopaedic Society for Sports Medicine (AOSSM) and approved Accreditation Council for Graduate Medical Education (ACGME) orthopedic program residency directors. Of the 664 respondents (577 AOSSM members, 87 directors), 81% (71/87 AOSSM members) to 86% (502/577 directors) continue to treat uncomplicated type III AC separations conservatively. Providing a sling for comfort remains the preferred type of conservative management (AOSSM members, 91% [456/502]; directors, 89% [63/71]). For surgical management, respondents recommended resection of the distal clavicle slightly more often than not (AOSSM members, 57% [42/74]; directors, 59% [319/538]) and rigid stabilization of the AC joint during early postoperative rehabilitation (AOSSM members, 80% [444/555]; directors, 82% [61/74]). Finally, most recommended reconstructing either the coracoclavicular ligaments (69% [330/476] and 61% [33/54], respectively) or both the coracoclavicular ligaments and the AC ligaments (27% 130/476] and 33% [18/54]) when addressing this problem. Since the early 1990s, there has been little change in initial conservative management of type III AC separations. Furthermore, the surgical approach to reconstruction, when necessary, has also undergone relatively few changes, with the exception of an increased preference for primary distal clavicle excision.
Am J Orthop. 2007;36(2):89-93