The American Journal of Orthopedics

MAY 2007 Volume XXXVI No. 5 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

67 Guest Editorial—E-Focus on Pediatric Orthopedics
Wallace B. Lehman, MD
Wallace B. Lehman, MD, The Center for Children, Hospital for Joint Diseases, NYU Medical Center, New York, New York (wallace.lehman@nyumc.org).
Abstract not available.
Am J Orthop. 2007;36(5):E67

68
Patient Survey of Weight-Bearing and Physical Activity After In Situ Pinning for Slipped Capital Femoral Epiphysis
Ashish Anand, MD, and Gail S. Chorney, MD
Gail S. Chorney, MD, New York University Hospital for Joint Diseases, New York, New York 10003 (tel, 212-598-6211; fax, 212-598-7625; e-mail, gail.chorney@nyumc.org).
Patients with slipped capital femoral epiphysis (SCFE) are often instructed to use crutches and restrict their activities after surgery. In the retrospective study reported here, we determined actual duration of crutch use and activity restriction in patients with SCFE treated with in situ pinning. Forty-three patients (mean age, 14.1 years) responded to a questionnaire. Four patients (9%) never used crutches, and 29 patients (67%) used crutches for 4 weeks or less. Three patients (7%) never restricted their activity, and 29 patients (67%) had resumed full activities, including sports, by 6 months. None of the patients had any postoperative complications. Although these results suggest that early resumption of activities, which would be beneficial to these typically obese patients, is possible without detrimental effects, further investigation is needed before an algorithm for postoperative rehabilitation can be presented.
Am J Orthop. 2007;36(5):E68-E70

71
Tropical Myositis (Pyomyositis) in Children in Temperate Climates: A Report of 3 Cases on Long Island, New York, and a Review of the Literature
Jacob Weinberg, MD, Samara Friedman, MD, Sunil Sood, MD, and Russell J. Crider, MD
Russell J. Crider, MD, Great Neck, New York 11021 (tel, 516-466-3131; fax, 516-466-0246; e-mail, rjcridermdpc@msn.com).
Abstract not available. Introduction provided instead.
Pyomyositis is a primary bacterial infection of skeletal muscle with initial clinical features of fever, localized muscle pain and stiffness, swelling, and tenderness.¹ This infection is most commonly seen in tropical climates and thus is also called tropical myositis. Four percent of all patients admitted to hospitals in Uganda have this disease.² Shepherd³ reported an incidence of 1 per 1000 population per year in Uganda and New Guinea. Tropical pyomyositis is usually caused by Staphylococcus aureus.⁴
Relatively few cases of this disease have been reported in temperate climates. According to a literature review, 100 cases of pyomyositis were reported in North America between 1971 and 1992.⁵ More recently, a few additional cases were found in the northeastern United States, at institutions in Boston,⁶ Rochester,⁷ Philadelphia,⁸ and New Jersey.⁹ Cases have also been reported in temperate European countries, such as Belgium^10,11 and England.^12-14 Whether pyomyositis in temperate zones is becoming more common or is simply recognized more often is not clear.
As early antibiotic treatment of infectious myositis is usually curative, it is important to entertain this diagnosis even in temperate climates. Delayed diagnosis and late institution of antibiotic treatment can lead to abscess formation, require surgical drainage, and yield poorer results.
In this article, we report 3 cases of pyomyositis in children treated at our institution in Long Island, New York, over a period of 6 months.
Am J Orthop. . 2007;36(5):E71-E75

76
Irreducible Radial Head Dislocation in a Child: A Case Report
Michael P. Bradley, MD, Robert Z. Tashjian, MD, and Craig P. Eberson, MD
Michael P. Bradley, MD, Department of Orthopaedic Surgery, Rhode Island Hospital, Providence, Rhode Island 02903 (tel, 401-444-4030; fax, 401-444-6243; e-mail, michaelbradleymd@yahoo.com).
Abstract not available. Introduction provided instead.
Pediatric elbow trauma and fractures account for a third of all limb fractures. Although the mainstay for most pediatric upper extremity fractures and dislocations remains closed treatment, certain injuries will need operative fixation. In fact, failed attempts for closed management of pediatric injuries are often the indications for surgery. We present a case of irreducible radial head dislocation in a young child.
Am J Orthop. 2007;36(5):E76-E79

80
Three Cases of Pediatric Monteggia Fracture-Dislocation Associated With Acute Plastic Bowing of the Ulna
Mitsuhiko Nanno, MD, Takuya Sawaizumi, MD, and Hiromoto Ito, MD
Mitsuhiko Nanno, MD, Nakaharaku, Kawasaki, Japan (tel, +81-44-733-5181; fax, +81-44-711-8525; e-mail, nanno-mi@ga2.so-net.ne.jp).
Abstract not available. Introduction provided instead.
Monteggia fracture-dislocation with acute plastic bowing of the ulna is rare in children. For fresh injuries, manual repositioning of the dislocated radial head is initially attempted. When this reduction fails, there are 3 treatment options: open reduction of the humeroradial joint, immobilization of the humeroradial joint or proximal radioulnar joint with a wire, and manual correction of ulna bowing. However, there is no consensus as to which option is best.
Recently, we treated 3 children with Monteggia fracture-dislocation with acute plastic bowing of the ulna. In 2 cases, we attempted to correct the ulnar bowing manually (we were successful in 1 case). In the study reported here, we evaluated the importance and the necessity of manual correction of ulnar bowing within the early postinjury period.
Am J Orthop. 2007;36(5):E80-E82

83
12-Year-Old Boy With Knee Pain
Jorge Fabregas, MD, Lubica Jenckova-Celerin, MD, Portia A. Kreiger, MD, and John P. Dormans, MD
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 diagnostic considerations and differential diagnoses as additional information is obtained, and the clinical investigation proceeds. The correct diagnosis is discussed beginning on the third page.
Am J Orthop. . 2007;36(5):E83-E86

PRINT PUBLISHING

239
Your First Job—What You Need to Know
Peter D. McCann, MD
Abstract not available.
Am J Orthop. 2007;36(5):239

241 Osteoporotic Vertebral Compression Fractures: A Review of Current Surgical Management Techniques
Michael Shen, MD, and Yong Kim, MD
Michael Shen, MD, Department of Orthopaedic Surgery, New York University/Hospital for Joint Diseases, New York, New York 10003 (tel, 212-598-6000; fax, 212-598-6581; email, drmichaelshen527@yahoo.com).
Of the estimated 1.5 million osteoporosis-related fragility fractures that occur each year in the United States, vertebral compression fractures (VCFs) are the most common. It is estimated that approximately 20% to 25% of people who sustain a VCF have symptoms severe enough to seek medical attention. However, nonoperative outpatient management for VCFs is often successful in only 75% to 80% of cases. In this article, we provide a comprehensive review of VCFs and of the surgical alternatives for VCF management, including indications for surgical intervention, overview of surgical techniques, clinical results, complications, and areas of future investigation.
Am J Orthop. 2007;36(5):241-248

249 Before and Beyond the Contract
James G. Stuart, JD
James G. Stuart, JD, Chicago, IL 60611 (tel, 312-642-5616; 312-642-5571; e-mail, jstuart@karenzupko.com).
Abstract not available. Introduction provided instead.
Approaching a first job after completing residency training, a young physician usually concentrates on the financial incentives being offered by the target practice—salary, bonus, fringe benefits, and so forth. In most cases, such financial packages lie within a narrow range dictated by the regional market, and the recruited physician has few opportunities to alter them. The employment agreement is certainly an important document—see my 3-part article, “The Employment Agreement: What Every Doctor (Junior & Senior) Needs to Know,” downloadable from www.karenzupko.com—but it likely includes only a few items that are of concern or can be negotiated.
Of much greater concern, in all probability, is the ability of the target practice to incubate you into an organization that is congenial, economically viable, and growing in all the important parameters. Assuming the recruit is attractive to several medical practices in various locations throughout the country, there are 3 key areas for performing a due-diligence examination on practices before deciding which to join.
Am J Orthop. 2007;36(5):249-251

255 Heparin-Induced Thrombocytopenia and Thrombosis
Vipul P. Patel, MD, Matthew Bong, MD, and Paul E. Di Cesare, MD
Paul E. Di Cesare, Department of Orthopaedic Surgery, University of California at Davis Medical Center, Sacramento, California 95817.
Heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are rare complications associated with use of unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). HIT is a benign clinical condition characterized by a mild drop in platelet count with no clinical significance. HITT is an immune-mediated reaction associated with a widespread “hypercoagulable” state resulting in arterial and venous thrombosis. There is a higher incidence of HITT with UFH use than with LMWH use. Orthopedic surgery patients are at higher risk for developing HITT than are patients who receive prophylactic heparin for cardiovascular surgery or medical reasons. Therapy for patients suspected of having HITT should begin with immediate discontinuation of heparin in any form followed by pharmacologic inhibition with thrombin (eg, recombinant hirudin [lepirudin], argatroban, danaparoid sodium).
Am J Orthop. 2007;36(5):255-260

261 Tape Blisters Following Hip Surgery: Can They Be Eliminated Completely?
Kenneth J. Koval, MD, Kenneth A. Egol, MD, Rudi Hiebert, BS, and Kevin F. Spratt, PhD
Kenneth J. Koval, MD, Dartmouth Hitchcock Medical Center, Hanover, New Hampshire 03756 (tel, 603-650-7590; fax, 603-650-2097; e-mail: kjkmd@yahoo.com).
It was recently reported that use of a perforated, stretchable cloth tape instead of silk tape reduced the incidence of postoperative blisters around the hip from 41% to 10%. The present prospective randomized study was conducted to determine whether use of spica bandage (vs the cloth tape) could further reduce or eliminate the incidence of these blisters. Patients were randomized to 2 treatment groups: perforated, stretchable cloth tape (Hypafix^®; Smith & Nephew, Memphis, Tenn) and elastic spica bandage that was started at the lower thigh and was extended around the hip and abdomen. After surgery, cloth tape or spica bandage was applied over the postoperative dressing, with care taken not to produce skin tension. At the first dressing change, presence or absence of blisters was recorded, along with their number, size, location, and type. All subsequent dressing changes were done much as they were at surgery, using the assigned type of dressing. Presence or absence of blisters was recorded at each subsequent dressing change. Two hundred ninety-four patients (300 hips) were enrolled. Twenty-two (7.33%) of the 300 hips developed a blister. Risk for developing a blister was 10% with the cloth tape versus 4.67% with the spica bandage (P<.09). Surgery type (arthroplasty vs open reduction and internal fixation [ORIF], P<.03) and surgery duration (P<.05) had more of an effect on postoperative blister formation than dressing type.
Am J Orthop. 2007;36(5):261-265

269 Volar Collapse After Dorsal Plating of Comminuted Distal Radius Fractures
Gamal A. Elsaidi, DO, Nicole Deal, MD, Beth P. Smith, PhD, and David S. Ruch, MD
Gamal A. Elsaidi, DO, Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157 (tel, 336-716-3949; fax, 336-716-7310; e-mail, gelsaidi@wfubmc.edu).
Between 1997 and 2001, 58 patients received dorsal plating for comminuted distal radius fractures. In 8 of these patients, subsequent collapse led to palmar flexion deformity, loss of rotation, and hardware prominence. In retrospectively reviewing this subgroup’s range of motion, radiographic volar tilt, and complications, including tenosynovitis and extensor tendon rupture, we found that (1) with both palmar and dorsal comminution of distal radius fractures, dorsal plating may not prevent palmar cortex collapse; (2) deformity of the distal radius fragment causes palmar displacement of the radius relative to the intact ulna; (3) resultant incongruity at the distal radioulnar joint causes a significant loss of supination; and (4) palmar distal radius displacement leads to dorsal hardware prominence and may contribute to tenosynovitis and attritional extensor tendon ruptures.
Am J Orthop. 2007;36(5):269-272

273 Tibial Tubercle Fracture With Avulsion of the Patellar Ligament: A Case Report
Renny Uppal, MD, and E. Dennis Lyne, MD
Renny Uppal, MD, Reno Orthopaedic Clinic, Reno, Nevada 89523 (tel, 775-786-3040; fax, 775-768-1358; e-mail, ruppal@gmail.com).
Fractures of the tibial tubercle are infrequent injuries in adolescents. A combined injury of the tibial tubercle and patellar ligament is an even more rare event. The literature includes only a few case reports of this injury pattern. In this article, we describe another case and a repair technique and try to increase awareness of this combined injury.
Am J Orthop. 2007;36(5):273-274