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ABSTRACT: Recombinant human bone morphogenetic protein (rhBMP) has been found to be a powerful adjunct to healing nonunions and obtaining fusions. Despite the apparent clinical efficacy and good safety profile reported with rhBMP use in adults, there is little data regarding the safety of this product in pediatric patients. We evaluated the use of rhBMP-2 in pediatric patients to determine if any complications were associated with its use.
We performed a retrospective review of 81 patients, all less then 18 years old, in whom rhBMP-2 was used. Theoretical complications associated with rhBMP-2 use were compiled based on a review of the published literature on rhBMP-2. A review of each patient's chart and radiographs was performed to record the occurrences of complications, which may have been associated with the use of rhBMP-2.
A total of 16 complications were found, which may have been attributed to the use of rhBMP-2. There were no incidences of systemic toxicity associated with rhBMP-2 use. Nine patients were noted to have some local operative site problem, 3 deep infections were noted, 1 patient was found to have a postoperative compartment syndrome, 2 patients were found to have neurologic complications (1 with progressive myelopathy and 1 with weakness and dural fibrosis), and 1 patient with neurofibromatosis and previously diagnosed intracranial gliomas was found to have subsequent enlargement of these gliomas. In reviewing these complications, only the case of dural fibrosis and subsequent weakness was thought to possibly be directly related to the use of rhBMP-2.
We found few complications in pediatric patients, which were felt to be directly attributable to the use of rhBMP-2. As such, rhBMP-2 use seems to be relatively safe in this young patient population. Due to the current use of this product in pediatric patients in an "off-label" fashion, we recommend a thorough discussion of the possible risks and benefits of this product with the family before its use.
Therapeutic studies-Level IV.
Journal of pediatric orthopedics 03/2010; 30(2):192-8. · 1.23 Impact Factor
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The Journal of Bone and Joint Surgery 01/2010; 92(1):177-85. · 3.27 Impact Factor
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ABSTRACT: Background: Low-energy hip fractures are markers for osteoporosis. Despite a recent call for better evaluation of this issue, there is a lack of data regarding the metabolic abnormalities found in these patients and how it relates to their bone density. Additionally, no clear guidelines have been published for the evaluation of osteoporosis in these patients. We characterize the metabolic abnormalities seen in this patient population and suggest an effective screening protocol.
Methods: Thirty-one patients with low-energy hip fractures not receiving osteoporosis treatment were evaluated with bone density scans and a serum metabolic evaluation consisting of a 25-hydroxyvitamin D level, parathyroid hormone level, and calcium level. The relationship of metabolic abnormalities to bone density values was evaluated.
Results: Most of the patients presenting with low-energy hip fractures had metabolic abnormalities associated with low bone density. The femoral neck T-scores averaged −2.3. Fifty-three percent (16/30) of patients had low levels of vitamin D and 83% (25/30) of patients had evidence of secondary hyperparathyroidism (PTH >25 nleq/ml). We also found relatively poor correlations of bone density T-scores to parathyroid hormone and vitamin D levels (r=−0.38 and −0.05).
Conclusion: Most patients presenting with low energy hip fractures have severe metabolic abnormalities associated with low bone density. Due to the poor correlation between bone density T-scores and the serum levels of parathyroid hormone and vitamin D, appropriate osteoporosis evaluation of this patient population requires both bone density evaluation and serum metabolic evaluation of 25-hydroxyvitamin D, PTH, and calcium levels.
Current Orthopaedic Practice 10/2009; 20(6):674-681.
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ABSTRACT: Retrospective review of foramen transversarium fracture morphology variables and their relationship to vertebral artery injury.
We examined the morphology of foramen transversarium fractures to determine if different patterns of these fractures predicted vertebral artery injury to more specifically identify at risk patterns in which vertebral artery evaluation may be warranted.
Risk fractures for vertebral artery injury have been previously reported to include cervical subluxation or dislocations, C1-C3 fractures, and foramen transversarium fractures. There have been no reports determining if specific foramen transversarium fracture patterns are predictive of vertebral artery injuries.
We reviewed the initial cervical CT scans of 171 patients seen in our level one trauma center between January 2002 and March 2008 and identified all patients with foramen transversarium fractures. Additionally, CT angiograms were reviewed in these patients to identify patients with vertebral artery injuries. The morphology of the foramen transversarium fractures was compared in those patients with and without vertebral artery injury to identify fracture patterns predictive of arterial injury.
Twenty-one (12%) patients were found to have foramen transversarium fractures with 5 (24%) of these patients having associated vertebral artery injury. Multilevel foramen transversarium fractures (P = 0.025) were significantly more frequent in vertebral artery injuries. Logistic regression identified multilevel fractures (odds ratio 17.33) and fracture comminution (odds ratio 10.50) as significant variables influencing vertebral artery injury after foramen transversarium fracture.
We found patients presenting with multilevel foramen transversarium fractures and foramen transversarium fracture comminution to be at significantly increased odds of vertebral artery injury. Patients with these fracture patterns should undergo further evaluation with vertebral artery imaging.
Spine 01/2009; 33(25):E957-61. · 2.08 Impact Factor
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ABSTRACT: Core needle biopsy is a powerful tool used to diagnose and develop a treatment strategy for musculoskeletal tumors. With accuracy rates reported between 69% and 99%, it is evident that errors in diagnosis occur, and they can lead to devastating consequences. We reviewed pathology reports of preoperative core needle biopsies in an attempt to determine factors associated with false negative diagnoses for the purpose of improving surgical planning. We retrospectively reviewed all office-based core needle biopsies accomplished in our practice over a 6-year period. One hundred nineteen biopsies were identified, of which 82 fulfilled criteria to be included in the study population. The pathologist's report of each biopsy was reviewed and categorized based on the findings into 1 of 2 diagnostic groups: neoplastic or nonneoplastic. The results of the biopsies were then compared to the pathology results of the final surgical resection, and the rates and nature of false negative biopsy results (unrecognized malignant pathology) were compared for each group. Seventy-one biopsies were categorized as neoplastic based on the pathology report. No false negative results were found in this group when compared to the final surgical resection pathology. Eleven biopsies were categorized as nonneoplastic, of which 6 were found to be false negatives when compared to the final surgical pathologic diagnosis. The rate of false negative results significantly increased in biopsies whose reports were categorized as nonneoplastic compared to biopsies categorized as neoplastic (P<.0001). We found core needle biopsies of musculoskeletal lesions to be safe and effective in diagnosing pathologic processes. In cases in which analysis of the biopsy specimen did not identify a specific neoplastic process, we found a high incidence of undiagnosed malignancy upon definitive surgical resection. Pathology reports of core needle biopsies that specify only normal, inflammatory, or other nonspecific tissue descriptions should alert the clinician to the increased possibility of a false negative result, and require further tissue analysis.
Orthopedics 01/2009; 31(12). · 2.66 Impact Factor
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ABSTRACT: Although osteoporosis is strongly associated with hip fractures, the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5% and 30%. Currently, most patients receiving treatment have been referred back to their primary care physician for osteoporosis management. The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months.
A prospective randomized trial was conducted to assess the difference in the rate of osteoporosis treatment when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and "usual" care.
Sixty-two patients were enrolled in the study. Thirty-one patients each were in the control and intervention groups. The percentage of patients who were on pharmacologic treatment for osteoporosis at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic (58%) than when treatment was managed by a primary care physician (29%) (p = 0.04).
An active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture.
The Journal of Bone and Joint Surgery 12/2008; 90(11):2346-53. · 3.27 Impact Factor
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American journal of orthopedics (Belle Mead, N.J.) 10/2008; 37(9):E159-62.
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ABSTRACT: Advancements in our knowledge of fracture healing have occurred in large part by the understanding of this process on a microscopic level. The ability to develop experimental non-union models in animals will assist in the investigation of this problem and are likely to lead to novel treatments. We report on a technique for developing experimental non-unions in mice.
Femoral fractures were created in 48 CD1 mice, 24 mice underwent standard closed femoral fractures, and 24 mice underwent creation of a femoral non-union through an open osteotomy and fracture devascularisation method. All fractures were subsequently rodded. Histological examinations of the fractures were then conducted at eight time points post-operatively.
The control group showed normal fracture healing with histological evidence of bony fracture bridging by 28 days and mature bony remodelling at 63 days. The non-union group showed delayed fracture healing at all time points and no evidence of bony healing at 63 days.
This is the first report of a reliable method to develop fracture non-union in mice. We believe this technique will be critical to further the investigation of fracture non-union in normal mice and provides the great advantage of using the plethora of transgenic and knockout mouse models to analyse non-union at the cell and molecular level.
Injury 10/2008; 39(10):1119-26. · 1.98 Impact Factor
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ABSTRACT: A variety of femoral stem designs have been reported to be successful in revision total hip arthroplasty without consensus as to optimal design. We evaluated the clinical and radiographic outcomes in a consecutive series of femoral revisions using a wedge-shape, tapered-stem design at medium and long-term follow-up.
We performed a retrospective review of clinical and radiographic outcomes of twenty-eight consecutive femoral revisions arthroplasties, which were done using the Zweymuller femoral stem.
The mean follow-up was 7.4 years (range 2-15 years). No stem re-revision was necessary. All stems were judged to be stable by radiographic criteria at the most recent follow-up. The final mean Harris hip score was 90. There was no difference in Harris hip scores, implant stability, or radiological appearance (distal cortical hypertrophy or proximal stress shielding) of the implants between medium-term (mean 5.7 years) and long-term (mean 12.4 years) follow-up.
We found the Zweymuller femoral stem design to be durable for revision hip arthroplasty when there is an intact metaphyseal-diaphyseal junction for adequate press-fit stability at surgery.
Journal of Orthopaedics and Traumatology 07/2008; 9(2):57-62.
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ABSTRACT: Trigger finger is a common finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. Although it can occur in anyone, it is seen more frequently in the diabetic population and in women, typically in the fifth to sixth decade of life. The diagnosis is usually fairly straightforward, as most patients complain of clicking or locking of the finger, but other pathological processes such as fracture, tumor, or other traumatic soft tissue injuries must be excluded. Treatment modalities, including splinting, corticosteroid injection, or surgical release, are very effective and are tailored to the severity and duration of symptoms.
Current Reviews in Musculoskeletal Medicine 07/2008; 1(2):92-6.
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ABSTRACT: Finger fractures are common injuries with a wide spectrum of presentation. Although a vast majority of these injuries may be treated non-operatively with gentle reduction, appropriate splinting, and careful follow-up, health care providers must recognize injury patterns that require more specialized care. Injuries involving unstable fracture patterns, intra-articular extension, or tendon function tend to have suboptimal outcomes with non-operative treatment. Other injuries including terminal extensor tendon injuries (mallet finger), stable non-articular fractures, and distal phalanx tuft fractures are readily treated by conservative means, and in general do quite well. Appropriate understanding of finger fracture patterns, treatment modalities, and injuries requiring referral is critical for optimal patient outcomes.
Current Reviews in Musculoskeletal Medicine 07/2008; 1(2):97-102.
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Orthopedics 02/2008; 31(1):16-8. · 2.66 Impact Factor
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ABSTRACT: Congenital knee dislocation (CDK) is a rare congenital deformity, which often requires surgery for treatment. Little objective data exist characterizing the outcome of patients who require operative treatment for this condition. The purposes of this study were to objectively evaluate the functional, clinical, and gait outcomes of patients who underwent surgical treatment of CDK; and compare the results of outcome between 2 surgical approaches for this condition: quadricepsplasty and femoral shortening.
We performed a retrospective review of all patients (7) treated surgically for CDK. Patients were evaluated at an average follow-up of 12+6 years. Each patient underwent a clinical examination, functional evaluation using the Lysholm Knee Questionnaire and Pediatric Outcomes Data Collection Instrument, and a 3-dimensional gait evaluation. The results of the total group were compared with normal controls. Additionally, results of the patients treated with quadricepsplasty were compared with patients treated with femoral shortening.
Total knee range of motion for the entire group averaged 112 degrees, with 8 of the 9 knees having flexion>90 degrees. Seven of the 9 knees were found to have some degree of instability on examination, yet none of the patients reported using any form of brace for ambulation. Functional evaluation showed good knee specific and overall function, comparable to normal controls. There were no differences in clinical or functional outcomes between the 2 surgical approaches. Gait analysis revealed a stiff-knee gait pattern to the congenital knee dislocation group, as compared with normal controls, and subtle differences in knee function between the surgical approaches.
The function of patients after surgical treatment for CDK seems to be quite good compared with normal controls. Good knee specific and overall function scores are reported with limitations seen only in higher demand activities. Despite instability of the knee noticed on clinical examination, patients ambulate without braces and have a functional knee range of motion. Little difference in outcome was seen between the 2 surgical approaches used to treat this condition.
Therapeutic Study, Level III.
Journal of pediatric orthopedics 30(3):216-23. · 1.23 Impact Factor
