Biomedical subjects

Robert M Kay

Publications and source records attributed to Robert M Kay.

31 records · Page 2Linked to original sources

PubMedDate not supplied

Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery.

The authors retrospectively reviewed a series of 492 consecutive cerebral palsy patients undergoing computerized motion analysis. The prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia), age, and history of previous surgery (lower extremity orthopaedic surgery or rhizotomy). Stiff knee in swing, equinus, and intoeing were all seen in more than 50% of the subjects in each of the hemiplegic, diplegic, and quadriplegic groups. Increased hip flexion and crouch were also present in more than 50% of the subjects in the diplegic and quadriplegic groups, and hip adduction occurred in more than 50% of the quadriplegic subjects. The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. These findings provide important information for counseling ambulatory children with cerebral palsy and their families.

Adolescent↗

PubMedDate not supplied

Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy.

A retrospective review was performed of 46 consecutive ambulatory children with cerebral palsy and tibial torsion who underwent 72 distal tibial derotational osteotomies without concomitant fibular osteotomy. The average amount of derotation measured at surgery was 21 +/- 5 degrees. The average change in thigh-foot angle at follow-up was 21 +/- 9 degrees. There were eight perioperative complications (11%): three delayed unions, three superficial wound dehiscences, one case of osteomyelitis, and one superficial pin tract infection. There were no incidences of malunion or nonunion. Preoperative and postoperative three-dimensional gait analysis data were used to determine the effect of distal tibial osteotomy on foot progression angle in seven subjects (11 limbs). Foot progression improved significantly. This study shows that distal tibial osteotomy alone (without concomitant fibular osteotomy) is an effective and safe procedure for correcting and maintaining correction of tibial torsion in patients with cerebral palsy.

Adolescent↗

PubMedDate not supplied

Pediatric polytrauma management.

Appropriate care of pediatric polytrauma patients requires the knowledge and expertise of a variety of subspecialists. Though most of pediatric polytrauma patients survive, long-term sequelae are common. The most common causes of long-term functional deficits after pediatric polytrauma involve injuries to the central nervous and musculoskeletal systems. Orthopaedic care of polytrauma patients is important to facilitate early mobilization and care of these children, as well as to minimize late impairment.

Abdominal Injuries↗

PubMedDate not supplied

Access to orthopaedic care for children with medicaid versus private insurance: results of a national survey.

BACKGROUND: It has been documented that children insured by Medicaid in California have significantly less access to orthopedic care than children with private insurance. Low Medicaid physician reimbursement rates have been hypothesized to be a major factor. The first objective of this study was to examine whether children insured by Medicaid have limited access to orthopedic care in a national sample. The second objective was to determine if state variations in Medicaid physician reimbursement rates correlate with access to orthopedic care. METHODS: Two-hundred fifty orthopedic surgeon's offices, 5 randomly chosen in each of 50 states, were telephoned. Each office called was asked to answer questions to an anonymous, disclosed survey. The survey asked whether the office accepted pediatric patients, whether they accepted children with Medicaid, and whether they limited the number of children that they accepted with Medicaid, and if so why. Each state sets its own rate of physician reimbursement rates that were collected from individual state Medicaid agencies for 3 different CPT codes. The relationship between acceptance of patients with Medicaid and the individual state's Medicaid reimbursement rate was examined. RESULTS: Children with Medicaid insurance had limited access to orthopedic care in 88 of 230 (38%) offices that treat children, and 18% (41/230) of offices would not see a child with Medicaid under any circumstances. Reimbursement rates for CPT codes widely varied by state: 99243 for an outpatient consultation (range, $20-$176.38), 99213 for an established follow-up outpatient visit (range, $6-$77.76), and 25560 for global treatment of a nondisplaced radius and ulna shaft fracture without manipulation (range, $50-$403.94). There was a statistically significant relationship between access to medical care for Medicaid patients and physician reimbursement rates for all 3 CPT codes. CONCLUSIONS: Children insured with Medicaid have limited access to orthopedic care in this nationwide sample. Medicaid physician reimbursement significantly correlates with patient access to medical care. These data may be of value in the ongoing efforts to improve access to medical care for children on Medicaid. The logical inference from this study is that increasing physician reimbursement rates will improve access. In the authors' opinion, reimbursement rates should be made higher than office overhead to effect meaningful change.

Child↗

PubMedDate not supplied

Back pain and backpacks in school children.

OBJECTIVE: Back pain in adults is common and well studied. In contrast, back pain in children has received comparatively little scientific study, despite recent media attention. The purpose of this study is to see what factors influence the prevalence of back pain in middle school children, with particular attention to the weight of children's backpacks and the availability of school lockers. METHODS: A population-based sample of 1540 children ages 11-14 years in a large metropolitan area was studied. A questionnaire was used to determine presence and severity of back pain, availability of lockers, backpack use, use of 1 or 2 straps to carry backpack, activity limitations due to back pain, and use of pain medication for back pain. Gender, age, weight of the child, and weight of his or her backpack were recorded. Results of scoliosis screening were evaluated with regard to the above information. Data were analyzed using the chi test and univariate or multivariate logistic regression analysis as appropriate. RESULTS: Overall, 37% of the children reported back pain. Backpacks were used by 97% of children, hence there were too few students not using backpacks to treat backpack use as an independent variable. Multivariate analysis found back pain associated with use of a heavier backpack (P=0.001), younger age (P<0.001), female sex (P<0.001), and a positive screening examination for scoliosis (P=0.009). Children with lockers available reported less back pain (P=0.016). The use of 1 or 2 straps to carry the backpack did not have a significant association with back pain (P=0.588). Of the children who reported back pain, 34% limited their activity due to the pain, 14% use medication for pain relief, and 82% believed their backpack either caused or worsened their pain. CONCLUSIONS: The incidence of back pain in early adolescence approaches that seen in adults. Recommendations for an "acceptable" weight of backpacks cannot be made from this study, as the weights of students' backpacks seem directly proportional to the likelihood of back pain. This study identifies 2 factors associated with self-reported back pain in early adolescents that are amenable to change: availability of school lockers and lighter backpacks. These findings may be useful in advising families and influencing school policies.

Adolescent↗

PubMedDate not supplied

Use of flexible intramedullary nails in pediatric femur fractures.

Flexible intramedullary nails are now routinely used for stabilization of pediatric femur fractures. Few data are available regarding patients' postoperative range of motion, weight-bearing status, activity levels, use of immobilization, and radiographic leg length discrepancy measured via routine scanograms. Patients who underwent placement of flexible intramedullary nails for a pediatric femur fracture at a single institution from 1998 to 2003 were identified retrospectively. Ninety-one patients were identified with 94 femur fractures. The complication rate was 17% for the 94 fractures, with 8 patients requiring an unplanned return to surgery. The complication rate was significantly higher for patients aged 10 years or older (34%) as compared with that for younger patients (9%). Average time to full weight bearing was 10 weeks, time to radiographic union averaged 10.7 weeks, and time to return to preoperative level of activity averaged 4.9 months. Immediate postoperative weight bearing status was nonweight bearing in 57%. Immobilization or support was used postoperatively in 60% of the patients. Postoperatively, patients had minimal loss of range of motion in hip internal and external rotation and knee extension. Hip and knee flexion rapidly improved postoperatively with an average loss of hip flexion of 0 degree by 3 months and an average loss of knee flexion of 4 degrees by 6 months. Postoperatively, limb length discrepancy was greater than 1 cm in 7 patients at 6 months, 11 patients at 12 months, 3 patients at 18 months, and 2 patients at 2 years. Two patients had persistent limb length discrepancy of greater than 2 cm, but only one patient required an epiphysiodesis for his limb length inequality. Although the end results are favorable, complications are relatively frequent, particularly in older children.

Adolescent↗

PubMedDate not supplied

Insurance status and delay in orthotic treatment in children.

OBJECTIVE: To determine if the type of health insurance is associated with a delay in children obtaining orthoses. METHODS: The medical records of 60 children who were prescribed an ankle-foot orthosis (AFO) or thoracolumbosacral orthosis (TLSO) were retrospectively reviewed. Ten children were randomly chosen with either of 3 types of insurance (government, health maintenance organizations [HMOs], and preferred provider organizations [PPOs]) with an orthosis provided by a single supplier. The time interval between prescription and insurance company authorization was recorded, as well as the interval between prescription and procurement of the orthosis. RESULTS: There were significant differences in the time from prescription to authorization of orthoses between insurance types (P = 0.001) and time from authorization until brace procurement between insurance types (P = 0.01). Children with PPO insurance received authorization for an AFO faster than children with government insurance or an HMO (P < 0.05). Children with government insurance received authorization for a TLSO significantly later than children with PPO insurance (P = 0.004) or HMO insurance (P = 0.03). The difference in time between authorization and procurement of a TLSO in children with PPO insurance (36 days) was strikingly different from that of children with government insurance (123 days) (P = 0.003). DISCUSSION: This study documents that children with government insurance face delays in obtaining orthotic treatment compared with children with PPO insurance. The delay in the procurement of the more expensive brace (TLSO is approximately 4 times the cost of an AFO) correlated to more striking delays in the government-insured population.

Child↗

PubMedDate not supplied

Reliability and validity of visual assessments of gait using a modified physician rating scale for crouch and foot contact.

This study evaluates the visual assessment of gait using portions of the Physicians' Rating Scale (PRS). Thirty children with pathologic gait were evaluated "live" and using full- and slow-speed video. Interobserver reliability (weighted kappa) was 0.57 to 0.74 for foot contact, 0.69 to 0.71 for crouch, 0.30 to 0.40 for hip flexion, 0.57 to 0.65 for knee flexion, and 0.42 to 0.52 for dorsiflexion in stance. Intraobserver reliability (comparing the three conditions) was 0.50 to 0.78 for foot contact, 0.71 to 0.80 for crouch, 0.26 to 0.44 for hip flexion, 0.60 to 0.86 for knee flexion, and 0.39 to 0.61 for dorsiflexion. Observers were correct only 12% to 32% of the time when reporting less than 0 degrees of dorsiflexion and 0% to 29% of the time when reporting more than 20 degrees of hip flexion due to overestimation of hip flexion and underestimation of ankle dorsiflexion. These errors could lead some clinicians to presume the presence of contractures that do not actually exist. Visual assessment using the PRS does not appear to accurately measure what it is most commonly used to assess: ankle position in stance.

Adolescent↗

PubMedDate not supplied

Treatment of hip dislocation in Kabuki syndrome: a report of three hips in two patients.

The incidence of hip dislocation in Kabuki syndrome (KS) is thought to be between 18% and 40%. Although hip dislocation is apparently well recognized in KS, to our knowledge, its management and outcome have not previously been addressed in the literature. We report 2 children (3 hips) with KS and hip dislocation who underwent surgical treatment with a minimum of 24-month follow-up. In addition, we review the current literature on the treatment of orthopaedic problems in KS.

Abnormalities, Multiple↗

PubMedDate not supplied

Childhood diskitis.

Childhood diskitis may occur in the thoracic, lumbar, or sacral spine and can affect children of all ages, but it is most common in the lumbar region in children younger than 5 years. Physical examination, laboratory tests, and radiologic studies all aid in the diagnosis of this clinical syndrome, and proper use can prevent unnecessary invasive intervention. Presentation varies with age; the child may refuse to bear weight on the lower extremities or may present with back pain, abdominal pain, a limp, or, if an infant or toddler, with irritability. The etiology appears to be a bacterial infection, usually caused by Staphylococcus aureus. Most children improve rapidly with a 4- to 6-week course of antibiotics. Although not routinely necessary, immobilization decreases symptoms and, in the case of osseous destruction, prevents progression of spinal deformity. Biopsy of the infected disk space is reserved for children refractory to intravenous antibiotics. Follow-up should include plain radiographs at regular intervals for 12 to 18 months to ensure resolution of the destructive process.

Anti-Bacterial Agents↗

PubMedDate not supplied

Outcome of medial versus combined medial and lateral hamstring lengthening surgery in cerebral palsy.

Pre- and postoperative gait analysis and static measurements from 37 children with cerebral palsy who underwent hamstring lengthening were evaluated. Significant improvements in static and kinematic measures were noted after surgery in both groups. Although the differences were not statistically significant, there was a suggestion that combined medial/lateral hamstring lengthening may provide greater improvement in popliteal angle and maximum knee extension in stance. However, there also appears to be a greater risk of knee hyperextension during gait after combined medial and lateral hamstring lengthening than after medial hamstring lengthening alone. Postoperative calf spasticity also appears to be a risk factor for postoperative knee hyperextension. Assessment of calf spasticity may be important in patients undergoing medial and lateral hamstring lengthening. Additional treatments such as bracing and/or botulinum toxin injections to the calf to control equinus and knee hyperextension may be beneficial.

Cerebral Palsy↗

PubMedDate not supplied

Quality of evaluation and management of children requiring timely orthopaedic surgery before admission to a tertiary pediatric facility.

The purpose of this study was to investigate the quality of evaluation and management of children requiring timely orthopaedic surgery before admission to a tertiary pediatric facility. A retrospective chart review was performed on 372 consecutive children who underwent orthopaedic surgery for a diagnosis of fracture, infection, slipped capital femoral epiphysis (SCFE), or compartment syndrome during a 22-month period at the authors' facility. Of the 372 children, 142 children (38%) first received medical care elsewhere; these are the subjects of this study. Before being seen at the authors' institution, 27 children (19%) had a problem in treatment or diagnosis and 18 (13%) had a delay in diagnosis or treatment of greater than 48 hours. Problems in diagnosis included five children with unrecognized open fractures, four of whom did not receive antibiotics; six children with missed SCFE, five of whom were not made non-weight-bearing; and six missed closed fractures. Delay in treatment occurred for 15 fractures, with a mean delay of >7 days until surgical treatment. Insurance status and primary language of the family were not associated with problems or delays in treatment. Overall, 32% of children undergoing time-sensitive orthopaedic surgery at a tertiary pediatric center had problems or delays in the medical care they received before transfer.

California↗

PubMedDate not supplied

Comparison of proximal and distal rotational femoral osteotomy in children with cerebral palsy.

This study compares the complication rates and results of 27 proximal (intertrochanteric) and 51 distal femoral rotational osteotomies in 48 patients with static encephalopathy. There was no significant difference between the 14% rate of orthopaedic complications in the intertrochanteric osteotomy (ITO) group and the 10% rate in the distal osteotomy (DO) group. Loss of fixation occurred in three of 51 limbs (6%) in the DO group and in none of 27 limbs in the ITO group. If the results of one surgeon are excluded, fixation loss occurred in one of the 49 remaining DO cases (2%). There was one delayed union in the study population (1/27 limbs [4%] in the ITO group). Of the 33 limbs studied with postoperative gait analysis, overcorrection was present in two limbs (6%): one of 10 limbs (10%) in the ITO group and one of 23 (4%) in the DO group. Static and dynamic measures of femoral rotation improved in both groups, and no statistically significant differences were present between the two groups. Though variable, the mean change in dynamic and static measurements postoperatively was approximately 40% less than the amount of derotation reported at surgery.

Adolescent↗