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Biomedical subjects

D R Wenger

Publications and source records attributed to D R Wenger.

89 records · Page 5Linked to original sources
PubMedDate not supplied

Protrusio acetabuli: diagnosis and treatment.

Idiopathic protrusio acetabuli is an uncommon disease process with both primary idiopathic and secondary forms. It is important to consider all etiologic possibilities before evaluating treatment options. Diagnosis is made on the basis of an anteroposterior radiograph of the pelvis that demonstrates a center-edge angle greater than 40 degrees and medialization of the medial wall of the acetabulum past the ilioischial line. For the skeletally immature patient, triradiate fusion (occasionally combined with intertrochanteric osteotomy) provides good results. For the young adult, valgus intertrochanteric proximal femoral osteotomy is recommended. In the older adult, this procedure may provide an acceptable result if there is minimal arthritis. For patients with more advanced arthritis, total hip arthroplasty with lateralization of the cup to a normal position provides a predictable long-term solution.

Acetabulum↗
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Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children.

This retrospective review evaluates the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of open or unstable diaphyseal forearm fractures in 32 children with a mean follow-up of 13 months. Thirty-one patients had an excellent result, and one patient had a good result. Average time to bridging cortex was 3 months. Four patients lacked full pronation and supination, with none lacking >20 degrees, and no patients had evidence of growth-plate arrest. Nine complications occurred in eight patients: lost reduction after K-wire removal (three), refracture (two), deep infection (one), pin-site infection (one), transient anterior interosseous nerve palsy (one), and skin ulcer over buried K-wire (one). Both infections occurred in cases in which the K-wire ends were left outside the skin. Each case of lost reduction occurred in single-bone fixation cases when the K-wires were removed before 4 weeks. In children, intramedullary fixation by using standard K-wires plus cast immobilization provides effective treatment for the problematic open or unstable diaphyseal forearm fracture when closed management has failed. Refinement of the technique may help to avoid complications. We now recommend burying the K-wires under the skin for 3-5 months and stabilizing both the radius and ulna with an intramedullary K-wire.

Adolescent↗
PubMedDate not supplied

The effect of valproic acid on blood loss in patients with cerebral palsy.

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Adolescent↗
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One-stage correction of the dysplastic hip in cerebral palsy with the San Diego acetabuloplasty: results and complications in 104 hips.

Ninety-two patients with cerebral palsy underwent a special type of pericapsular acetabuloplasty designed to correct the hip dysplasia that occurs in cerebral palsy. The osteotomy was performed as part of a combined procedure (including femoral osteotomy and soft-tissue releases). Retrospective analysis was performed on 75 of the children (104 hips from 1982 through 1995) with a mean follow-up of 6.9 years. Ninety-nine (95%) of the 104 hips remained well reduced at follow-up. There were no redislocations. If the preoperative migration percentage was >70% (severe subluxation), improved results were noted in hips that had an open reduction with capsulorrhaphy. There were 13 complications including intraarticular extension of the acetabuloplasty (one) and avascular necrosis of the femoral head (eight hips, 8%). Indications for addition of a pericapsular acetabuloplasty include an open triradiate cartilage, acetabular dysplasia (acetabular index >25 degrees), and subluxation or dislocation with a migration percentage of >40%. Even hips with relative incongruity and some deformity of the femoral head can be successfully treated with this combined approach.

Acetabulum↗
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Pre- and postoperative three-dimensional computed tomography analysis of triple innominate osteotomy for hip dysplasia.

Traditional methods of analysis and surgical techniques for hip dysplasia concentrate on frontal-plane analysis of the hip. More recent studies on imaging and operative correction of hip dysplasia recommend three-dimensional (3D) analysis, and some have mentioned but not emphasized the importance of transverse-plane acetabular anatomy (anteversion/retroversion). In this study we found that failure to analyze and understand transverse-plane acetabular anatomy can contribute to complications after triple innominate osteotomy (TIO). A subset of seven patients (eight hips) who were treated with TIO for deficient acetabular coverage resulting from hip dysplasia or Legg-Calvé-Perthes disease had both pre- and postoperative 3D computed tomography (CT) studies. Most of the postoperative studies were obtained to analyze complications (external limb rotation, nonunion). Analysis of the 3D CT studies showed a change in the position of the acetabular fragment after osteotomy into greater adduction, anterior rotation (extension), and external rotation, improving femoral head coverage. All of the hips had increased external rotation of the acetabulum after TIO. Excessive external rotation (>10 degrees) was noted in five hips, and these included two hips with pubic osteotomy nonunion, two with ischial nonunion, and one with marked external rotation of the lower limb. External rotation of the acetabular fragment during redirectional pelvic osteotomy can result in (a) excessive external rotation of the lower limb, (b) decreased posterior coverage, (c) increased gaps at the pubic and/or ischial osteotomy sites with resultant higher rates of nonunion, and (d) lateralization of the joint center. The surgical technique for TIO should be designed to avoid excessive external rotation of the acetabular fragment.

Adolescent↗
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Metachondromatosis and avascular necrosis of the femoral head: a radiographic and histologic correlation.

We report the case histories, radiographic and computed tomographic studies, and histologic findings of two children with metachondromatosis who developed avascular necrosis (AVN) of the femoral ossific nucleus. The first was a 9-year-old boy with involvement of both femoral heads; the second was an 8-year-old girl with involvement of her right femoral head. The changes were associated with either exostoses or enchondromalike lesions of the femoral neck. Interference with the integrity of the lateral epiphyseal vessels by these lesions would explain the avascular changes that occurred. The findings in these cases and other reports associating AVN with skeletal dysplasia should encourage treating physicians to analyze carefully a sudden increase in hip pain or rapid radiographic development of femoral head collapse in a child with a skeletal dysplasia. Recognition of true AVN, in contrast to the gradual evolution of head shape change in typical skeletal dysplasia, may change treatment recommendations and prognosis.

Child↗
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Brainstem evoked potentials for scoliosis surgery: a reliable method allowing use of halogenated anesthetic agents.

A predictable and accurate method of monitoring cord function during scoliosis surgery using somatosensory brainstem evoked potentials (SBEP) is described. This method allows the use of halogenated anesthetic agents, which are ideal for neuromuscular patients, but easily disrupt traditional cortical monitoring. Fifty-eight children with idiopathic, neuromuscular, and syndrome related scoliosis were monitored with 51 true negative, one false negative, four true positive and two false positive results. The SBEP method is sensitive and effective for all types of scoliosis surgery, especially neuromuscular scoliosis.

Adolescent↗
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Surgical correction of myelomeningocele scoliosis: a critical appraisal of various spinal instrumentation systems.

A retrospective review of 38 patients with myelomeningocele scoliosis, focusing on the incidence of eventual fusion, curve correction, and change in pelvic obliquity, was performed. Single stage anterior or posterior fusion was compared to combined anterior and posterior spinal fusion. Single stage anterior or posterior procedures resulted in only a 50% fusion rate compared to rates of 83 to 100% for various combinations of combined anterior and posterior fusions. Similarly, average curve correction and change in pelvic obliquity were much improved with a two-stage approach. No statistical difference in fusion rate, curve correction, or change in pelvic obliquity was noted between the various combinations of two-stage anterior and posterior fusions.

Adolescent↗
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The limping child.

Explore the source record for details and available documents.

Adolescent↗
PubMedDate not supplied

Segmental spinal instrumentation: a preliminary report of 40 consecutive cases.

Two groups of patients with complex scoliosis problems are presented. The majority of patients had neurogenic scoliosis. Thirty patients (Group A) had Harrington instrumentation with segmental wiring and were immobilized postoperatively. Instrument stability was best when sacral fixation was not required. Pseudarthrosis was especially likely when there was deficiency of posterior elements. Ten patients (Group B) had double L rod instrumentation, and six had no postoperative immobilization. Correction was maintained except in two patients with kyphotic curves. There were transient neurologic complications in both groups, nerve root contusion being the most common (four cases). It is concluded that segmental instrumentation provides significant improvement in stability over conventional Harrington instrumentation. The advantages of added stability must be weighed against the increased potential for neurologic complications.

Adolescent↗
PubMedDate not supplied

Protrusio acetabuli in Marfan's syndrome.

In an unselected series of 14 patients with Marfan's syndrome, protrusio acetabuli was documented by both presence of a center edge (CE) angle of 40 degrees or more and crossing of the teardrop by the femoral head. The disorder was unilateral in 8 patients, bilateral in 6. Since most of the CE angles were measured on scoliosis roentgenograms, the measurements were made in a control group with an average CE angle of 33.1 degree, compared with an average of 43.4 degree in the Marfan's group. One of the hips with protrusio was associated with chondrolysis. Protrusio acetabuli is a common abnormality of persons with Marfan's syndrome. It may be related to the same mesenchymal tissue disorder that predisposes these persons to scoliosis, chest wall deformities, and other skeletal malformations.

Acetabulum↗
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Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome.

The etiology of congenital muscular torticollis remains a mystery despite intensive investigation. Magnetic resonance imaging (MRI) scans of 10 infants with this condition showed signals in the sternocleidomastoid muscle similar to those observed in the forearm and leg after compartment syndrome. Cadaver dissections and injection studies defined the sternocleidomastoid muscle compartment. Injection studies and pressure measurements performed at the time of bipolar release in three patients with congenital muscular torticollis confirmed the existence of this compartment in vivo. Clinical review of 48 children with congenital muscular torticollis showed a relation between birth position and the side affected by the contracture. Because of the association of congenital muscular torticollis with other intrauterine positioning disorders, we postulate that head positioning in utero can selectively injure the sternocleidomastoid muscle, leading to development of a compartment syndrome. Congenital muscular torticollis may represent the sequela of an intrauterine or perinatal compartment syndrome.

Child, Preschool↗
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Intramalleolar triplane fractures of the distal tibial epiphysis.

The intramalleolar triplane fracture of the distal tibial epiphysis is a relatively rare injury in children. We studied five children with intramalleolar triplane fractures. Four of the five children were competitive athletes. Each child underwent computerized tomography with three-dimensional reconstruction. Delineation of the intramalleolar fracture pattern with computerized tomography with three-dimensional reconstruction demonstrated three distinct types of intramalleolar triplane fractures: I. intraarticular and within the weight-bearing zone, II. intraarticular and outside the weight-bearing zone, and III. extraarticular. Computerized tomography with three-dimensional reconstruction delineated the fracture pattern and allowed selection of the optimal treatment method. A classification scheme of the three types of intramalleolar triplane fracture is proposed.

Adolescent↗
PubMedDate not supplied

Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases.

Despite a tendency for rotational abnormalities of the lower leg in children to improve spontaneously over time, some fail to correct and require corrective derotation osteotomy. In this retrospective study, we report the technique and results of the distal transverse tibial and fibular derotation osteotomy with Kirschner-wire fixation performed in 63 limbs of children with cerebral palsy, clubfoot, idiopathic tibial torsion, and myelomeningocele, as well as other less common conditions. There were no significant infections, neurologic complications, delayed or nonunions, or compartment syndromes as a result of the osteotomy. There were three (4.8%) complications, including late fracture (one), cross-union (one), and distal physeal closure (one). We conclude that transverse, same-level, distal tibial and fibular osteotomy fixated with crossed Kirschner wires is a safe, efficient, and effective surgical approach to the treatment of children with tibial torsion in a variety of clinical conditions.

Adolescent↗