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ABSTRACT: Background and purpose Leg-length discrepancy (LLD) can be a sequela of slipped capital femoral epiphysis (SCFE). We tried to identify factors that affect the development of LLD following SCFE. Patients and method We evaluated 85 patients who had been treated using percutaneous screw fixation. The average age of the patients at the time of surgery was 12 (8-16) years. The relationship of LLD and various clinical and radiographic parameters was evaluated: the degree of slip, articulotrochanteric distance (ATD), and articulotrochanteric distance difference (ATDD) (healthy side minus the side with SCFE). We assessed the relationship between ATDD and LLD based on scanogram. Results The average LLD was 1.4 (0.1-3.8) cm at 6 (2-15) years postoperatively. 48 of 85 patients had an LLD of greater than 1 cm and 10 patients had an LLD of greater than 2 cm. There was a correlation between the magnitude of LLD and the severity of the slip. There was no statistically significant correlation between LLD and the stability of the slip, age, BMI, sex, or race. There was a significant correlation between LLD and ATDD. Interpretation Patients with a high degree of slip are prone to develop clinically significant LLD. Although ATDD does not give the exact LLD, it can be used as a primary measurement, which should be supplemented with scanogram in cases of clinically significant differences in length.
Acta Orthopaedica 04/2013; · 2.17 Impact Factor
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ABSTRACT: The clinical and radiographic abnormalities of the lower limb in children with Blount disease are well known. However, there is controversy regarding the intra-articular morphologic changes in the involved knee joint. The purpose of our study was to evaluate the meniscal and articular surface morphology in children with Blount disease with use of magnetic resonance imaging and to compare these findings with similar measurements in a control group.
Preoperative magnetic resonance imaging scans of the knee of children with Blount disease were compared with those of a control group. Coronal and sagittal morphometric parameters including the height and width of the menisci, thickness of the unossified proximal tibial epiphysis, tibial condylar and meniscal inclination, and presence of signal changes and/or tears of the menisci were documented.
Twenty-six children (thirty-three) knees with Blount disease (mean age, 10.5 years) and twenty children without Blount disease (mean age, 9.6 years) were identified. The midcoronal medial meniscal height and width were greater in the Blount disease group (p < 0.0001). Abnormal signal changes were noted in the medial meniscus in twelve limbs (39%) in the Blount group and one limb (5%) in the control group (p = 0.008). The mean thickness of the unossified cartilage of the proximal medial tibial epiphysis was also greater in the Blount disease group (p = 0.0005). The morphology of the menisci and unossified cartilage in the lateral compartment did not differ between the two groups. The mean tibial condylar and bimeniscal inclinations in the coronal and sagittal planes were also similar in both groups. In a multivariate regression analysis, only body mass index correlated with the height of the medial meniscus in the coronal plane (p = 0.0035) and of the posterior horn of the medial meniscus in the sagittal plane (p = 0.0037) in children with Blount disease.
Children with Blount disease have increased thickness of the chondroepiphysis of the proximal medial aspect of the tibia, increased height and width of the medial meniscus, and greater frequency of abnormal signals in the posterior horn of the medial meniscus. These morphologic changes may compensate for the diminished height of the ossified portion of the medial proximal aspect of the tibia in patients with Blount disease.
The Journal of Bone and Joint Surgery 05/2012; 94(10):883-90. · 3.27 Impact Factor
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ABSTRACT: With advances in chemotherapy, long-term survival for childhood leukemia is improving. However, chemotherapy-induced osteonecrosis of the proximal femur remains a challenging problem. We present a case of an adolescent female with advanced osteonecrosis of the proximal femur after chemotherapy for acute lymphoblastic leukemia. She underwent an Ilizarov hip reconstruction with a subtrochanteric valgus extension osteotomy and distal femoral lengthening with varus angulation using an external fixator. At a 3-year follow-up, her symptoms and gait had markedly improved. On the basis of this preliminary report, Ilizarov hip reconstruction is a viable alternative for advanced osteonecrosis of the proximal femur in an adolescent.
Journal of pediatric orthopaedics. Part B / European Paediatric Orthopaedic Society, Pediatric Orthopaedic Society of North America 07/2011; 21(3):252-9. · 0.66 Impact Factor
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ABSTRACT: The utility of intraoperative radiographs after posterior spinal segmental instrumentation for adolescent idiopathic scoliosis (AIS) is debatable. A retrospective review of 74 patients with moderately severe AIS revealed the main thoracic Cobb measurements of 57° preoperatively, 17° intraoperatively, 18° on initial postoperative, and 20° on final postoperative radiographs. On the basis of the extent and type of instrumentation (pedicle screws vs. hybrid construct), there was no clinically significant difference in curve magnitude between intraoperative and postoperative radiographs. After posterior segmental instrumentation for moderate AIS, frontal plane correction measured on intraoperative supine radiographs are comparable with similar measurements made on full-length postoperative standing radiographs.
Journal of pediatric orthopaedics. Part B / European Paediatric Orthopaedic Society, Pediatric Orthopaedic Society of North America 06/2011; 20(6):389-96. · 0.66 Impact Factor
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ABSTRACT: The purpose of this study was to determine the optimum pin configuration and the number of pins needed to stabilize the Milch type II lateral humeral condyle fractures in a pediatric bone model.
Forty synthetic pediatric humeri were sectioned through the lateral distal humerus to simulate a Milch type II lateral condyle fracture. Each fracture was stabilized with 0.062-in K-wires in 1 of 5 configurations: 2 convergent pins, 2 parallel pins, 2 divergent 30-degree pins, 2 divergent 60-degree pins, and 3 divergent pins (n=8/group). Models were tested in extension, flexion, varus, and valgus by applying a translational force through the distal fragment at 0.5 mm/sec oscillating between 5 N and 50 N for 10 cycles. For internal and external rotation, constructs were tested at 0.5 degree/sec between ±1 Nm more than 10 cycles. The maximum force and torque values were also recorded. For bending loads, stiffness was calculated between 0.5 and 5 mm of displacement, whereas torsional stiffness was calculated between 1 degree and 10 degrees of rotation. Data for stiffness were analyzed with a 1-way analysis of variance and a 2-sample t test (P<0.05).
Among 2-pin configurations, divergent (60 degrees) pins provided statistically greater stability than less divergent pins in torsional loading, and greater stability than parallel pins in valgus loading. Three divergent pins had statistically greater stability than all the 2-pin configurations in valgus and torsional loading, and tended to provide more secure fixation in varus loading.
For 2-pin constructs, maximizing pin divergence at the fracture site provided greater stability in torsional loading and valgus loading. The addition of a third pin in a divergent orientation increases stability compared with 2-pin constructs in valgus, internal, and external rotation loading.
Bicortical pins placed with maximum divergence and spread at the fracture site maximizes stability for 2-pin constructs in Milch type II lateral condyle fractures. If the stability of the fracture is questionable after 2 pins are inserted, the addition of a divergent third pin enhances the stability.
Journal of pediatric orthopedics 03/2011; 31(2):130-7. · 1.23 Impact Factor
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The Journal of Bone and Joint Surgery 01/2011; 93(2):213-21. · 3.27 Impact Factor
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ABSTRACT: BACKGROUND: Health literacy is the single best predictor of an individual's health status. It is important to customize health-related education material to the individual patient's level of reading skills. Readability of a given text is the objective measurement of the reading skills one should possess to understand the written material. QUESTIONS/PURPOSES: In this article, some of the commonly used readability assessment tools are discussed and guidelines to improve the comprehension of patient education handouts are provided. Where are we now? Several healthcare organizations have recommended the readability of patient education materials be no higher than sixth- to eighth-grade level. However, most of the patient education materials currently available on major orthopaedic Web sites are written at a reading level that may be too advanced for comprehension by a substantial proportion of the population. WHERE DO WE NEED TO GO?: There are several readily available and validated tools for assessing the readability of written materials. While use of audiovisual aids such as video clips, line drawings, models, and charts can enhance the comprehension of a health-related topic, standard readability tools cannot construe such enhancements. HOW DO WE GET THERE?: Given the variability in the capacity to comprehend health-related materials among individuals seeking orthopaedic care, stratifying the contents of patient education materials at different levels of complexity will likely improve health literacy and enhance patient-centered communication.
Clinical Orthopaedics and Related Research 05/2010; 468(10):2572-80. · 2.53 Impact Factor
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ABSTRACT: Analysis of spine-related websites available to the general public.
To assess the readability of spine-related patient educational materials available on professional society and individual surgeon or practice based websites.
The Internet has become a valuable source of patient education material. A significant percentage of patients, however, find this Internet based information confusing. Healthcare experts recommend that the readability of patient education material be less than the sixth grade level. The Flesch-Kincaid grade level is the most widely used method to evaluate the readability score of textual material, with lower scores suggesting easier readability.
We conducted an Internet search of all patient education documents on the North American Spine Society (NASS), American Association of Neurological Surgeons (AANS), the American Academy of Orthopaedic Surgeons (AAOS), and a sample of 10 individual surgeon or practice based websites. The Flesch-Kincaid grade level of each article was calculated using widely available Microsoft Office Word software. The mean grade level of articles on the various professional society and individual/practice based websites were compared.
A total of 121 articles from the various websites were available and analyzed. All 4 categories of websites had mean Flesch-Kincaid grade levels greater than 10. Only 3 articles (2.5%) were found to be at or below the sixth grade level, the recommended readability level for adult patients in the United States. There were no significant differences among the mean Flesch-Kincaid grade levels from the AAOS, NASS, AANS, and practice-based web-sites (P = 0.065, ANOVA).
Our findings suggest that most of the Spine-related patient education materials on professional society and practice-based websites have readability scores that may be too high, making comprehension difficult for a substantial portion of the United States adult population.
Spine 11/2009; 34(25):2826-31. · 2.08 Impact Factor
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ABSTRACT: It is well recognized that the alignment of the lower limb changes during early childhood. The hip-knee-ankle angle is often referred to as the mechanical femoral-tibial angle and is measured on a full-length radiograph of the lower extremity. While several authors have independently reported consistent reference values for the hip-knee-ankle angle in adults, such values have not been well documented for children. The purpose of our study was to establish reference values for the hip-knee-ankle angle and assess the relationship between it and the anatomic femoral-tibial angle in children.
A database at a single institution was searched for patients who were between one and less than eighteen years old at the time that a standing full-length radiograph of the lower extremities was made. Radiographs of the uninvolved extremity (the limb without any radiographic abnormalities or documented clinical concerns) were analyzed. The angle between a line connecting the center of the ossified femoral head and the center of the distal femoral epiphysis and another line connecting the center of the distal femoral epiphysis and the center of the talar dome was measured. Simple regression analyses were performed to determine the relationship between this angle and the anatomic femoral-tibial angle.
A total of 354 unaffected lower extremities of 253 children were analyzed. The mean hip-knee-ankle angle was +3.6 degrees (varus) in children between one and two years old and -2.5 degrees (valgus) in those between two and three years old. After the age of seven years, the mean value was +0.3 degrees (varus), which was within 1 degrees of the reference values available for the adult population (mean, +1.2 degrees [varus]). There was a linear relationship between the hip-knee-ankle and anatomic femoral-tibial angles in the children (r = 0.87, p < 0.0001). Despite varying hip-knee-ankle angles at different ages, the mean absolute difference between that angle and the anatomic femoral-tibial angle remained relatively constant (mean, 6.7 degrees ) and was not associated with changing age (r = -0.09).
In our study sample, reference values for the hip-knee-ankle angle in children older than seven years of age approached those reported for adults in North America. Although this angle and the anatomic femoral-tibial angle in children younger than seven were distinct from those reported for the adult population, the difference between the two angular measurements remained essentially unaffected. The use of age-specific reference values for both the hip-knee-ankle and the anatomic femoral-tibial angle is recommended for children younger than seven years old.
The Journal of Bone and Joint Surgery 10/2009; 91(10):2461-8. · 3.27 Impact Factor
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Sanjeev Sabharwal
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ABSTRACT: Two clinically distinct forms of Blount disease (early-onset and late-onset), based on whether the lower-limb deformity develops before or after the age of four years, have been described. Although the etiology of Blount disease may be multifactorial, the strong association with childhood obesity suggests a mechanical basis. A comprehensive analysis of multiplanar deformities in the lower extremity reveals tibial varus, procurvatum, and internal torsion along with limb shortening. Additionally, distal femoral varus is commonly noted in the late-onset form. When a patient has early-onset disease, a realignment tibial osteotomy before the age of four years decreases the risk of recurrent deformity. Gradual correction with distraction osteogenesis is an effective means of achieving an accurate multiplanar correction, especially in patients with late-onset disease.
The Journal of Bone and Joint Surgery 08/2009; 91(7):1758-76. · 3.27 Impact Factor
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ABSTRACT: The use of accurate and reliable clinical and imaging modalities for quantifying leg-length discrepancy (LLD) is vital for planning appropriate treatment. While there are several methods for assessing LLD, we questioned how these compared. We therefore evaluated the reliability and accuracy of the different methods and explored the advantages and limitations of each method. Based on a systematic literature search, we identified 42 articles dealing with various assessment tools for measuring LLD. Clinical methods such as use of a tape measure and standing blocks were noted as useful screening tools, but not as accurate as imaging modalities. While several studies noted that the scanogram provided reliable measurements with minimal magnification, a full-length standing AP computed radiograph (teleoroentgenogram) is a more comprehensive assessment technique, with similar costs at less radiation exposure. We recommend use of a CT scanogram, especially the lateral scout view in patients with flexion deformities at the knee. Newer modalities such as MRI are promising but need further investigation before being routinely employed for assessment of LLD. Level of Evidence: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 11/2008; 466(12):2910-22. · 2.53 Impact Factor
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ABSTRACT: One of the goals of the American Academy of Orthopaedic Surgeons (AAOS) is to disseminate patient education materials that suit the readability skills of the patient population. According to standard guidelines from healthcare organizations, the readability of patient education materials should be no higher than the sixth-grade level. We hypothesized the readability level of patient education materials available on the AAOS Web site would be higher than the recommended grade level, regardless when the material was available online. Readability scores of all articles from the AAOS Internet-based patient information Web site, "Your Orthopaedic Connection," were determined using the Flesch-Kincaid grade formula. The mean Flesch-Kincaid grade level of the 426 unique articles was 10.43. Only 10 (2%) of the articles had the recommended readability level of sixth grade or lower. The readability of the articles did not change with time. Our findings suggest the majority of the patient education materials available on the AAOS Web site had readability scores that may be too difficult for comprehension by a substantial portion of the patient population.
Clinical Orthopaedics and Related Research 06/2008; 466(5):1245-50. · 2.53 Impact Factor
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ABSTRACT: Coronal plane fractures of the lateral femoral condyle can be difficult to diagnose, especially in children with open physis. Two adolescents who sustained this uncommon Salter-Harris III fracture of the knee were misdiagnosed after initial clinical examination and standard x-rays. Oblique x-rays, computed tomography, and magnetic resonance imaging were valuable in arriving at the correct diagnosis and in decision making.
American journal of orthopedics (Belle Mead, N.J.) 03/2008; 37(2):100-3.
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ABSTRACT: While experts recommend that the readability of patient education materials should be less than the sixth grade level, the available information pertaining to orthopaedic diseases may be excessively complex for some to read and comprehend. The Flesch-Kincaid grade level is the most widely used tool to evaluate the readability score of a given text, with a lower grade level suggesting easier readability. The goal of our study was to assess the readability of pediatric orthopaedic patient education materials that were developed by the American Academy of Orthopaedic Surgeons (AAOS) and the Pediatric Orthopaedic Society of North America (POSNA) and were accessible to the general public through the Internet. Materials and
All articles from the "Children" section of the patient education library, "Your Orthopaedic Connection," on the AAOS web site and the "Parent/Patient" section on the POSNA web site were identified. The Flesch-Kincaid grade level of each article was determined with use of Microsoft Office Word software. The mean grade levels of articles that were available in 2001 were compared with those accessible in 2007.
Fifty-seven unique articles were available in 2007 on both web sites compared with twenty-five articles available in 2001. The readability score of only one (2%) of the currently available articles was less than sixth grade level. The mean Flesch-Kincaid grade level of the currently available articles was 8.9 compared with 8.7 for the articles available in 2001 (p = 0.71).
Our findings suggest that most of the pediatric orthopaedic patient education materials available on the AAOS and POSNA web sites have readability scores that may be too high, making comprehension difficult for a substantial portion of the United States population.
The Journal of Bone and Joint Surgery 02/2008; 90(1):199-204. · 3.27 Impact Factor
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ABSTRACT: While a full-length standing anteroposterior radiograph of the lower extremity provides the best radiographic method for assessing limb alignment, other methods must be used intraoperatively. We have employed intraoperative fluoroscopy with use of an electrocautery cord to assess limb alignment in the supine patient.
We retrospectively compared the measurements of lower limb alignment that were obtained with use of supine intraoperative fluoroscopy with those that were obtained with use of a full-length standing anteroposterior radiograph of the lower extremity. A single examiner compared 102 sets of supine fluoroscopy images and full-length standing anteroposterior radiographs of the lower extremity to assess mechanical axis deviation and the joint line convergence angle. For the intraoperative fluoroscopic examination, an electrocautery cord was positioned overlying the center of the femoral head and the tibial plafond and an anteroposterior radiograph of the knee was made. The effect of age, gender, diagnosis, body mass index, pelvic height difference, joint line convergence angle, and the magnitude and direction of malalignment (varus or valgus) on the discrepancy in the observed mechanical axis deviation with use of the two methods was assessed.
The mean absolute difference between the two techniques was 13.4 mm for the measurement of mechanical axis deviation (p < 0.0001) and 2.8 degrees for the joint line convergence angle (p < 0.0001). The correlation coefficient (r) for the measurement of mechanical axis deviation with use of the two radiographic methods was 0.88. An increase in body mass index was associated with a greater magnitude of discrepancy in the measurement of mechanical axis deviation between the two techniques (p = 0.0014). Age, gender, pelvic height difference, and the direction of malalignment had no effect on the discrepancy in the measurement of mechanical axis deviation. Limbs with >2 cm of mechanical axis deviation and those with a joint line convergence angle of >3 degrees on the standing radiograph were significantly more likely to have >10 mm of discrepancy in the measurement of mechanical axis deviation with use of the two imaging techniques (p < 0.005).
Intraoperative fluoroscopy with use of the electrocautery cord method is a useful tool for assessing lower limb alignment in patients with a normal body mass index and </=2 cm of mechanical axis deviation and </=3 degrees of joint line convergence angle on the standing anteroposterior radiograph. However, the results obtained with fluoroscopy should be interpreted with caution in patients who are obese or who have substantial residual mechanical axis deviation or pathologic laxity of the knee joint.
The Journal of Bone and Joint Surgery 01/2008; 90(1):43-51. · 3.27 Impact Factor
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The Foot and Ankle Online Journal 09/2007; 28(8):942-8. · 1.22 Impact Factor
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ABSTRACT: The disparity in access to and delivery of health care among children has become increasingly apparent. The purpose of our study was to analyze demographic information, including health insurance status, of children with extremity injuries seen at a University Hospital emergency department (UH ED) after visiting another ED for the same complaint.
A database of pediatric orthopaedic consults requested for extremity injuries at UH ED was reviewed. Information regarding patients' age, ethnicity, orthopaedic diagnosis, type of health insurance, time from injury to presentation at the first ED and at UH ED, mode of transportation to UH ED, and orthopaedic treatment rendered was analyzed. All patients with Medicaid, health maintenance organization-Medicaid, no insurance, or charity care were classified as having public insurance, whereas those with commercial insurance, including health maintenance organization and preferred provider organization plans, were placed in the private insurance category.
Over a 30-month period, 125 children, of whom 18% had private health insurance, were noted to have recently visited another ED seeking treatment for an extremity injury. A closed fracture was diagnosed in 117 patients, 94% of whom were discharged from UH ED after cast application. There was no difference with regard to patients' age, sex, ethnicity, diagnosis, and time to presentation at the initial ED between private and public insurance groups. However, 52% of children with private insurance received orthopaedic care within 24 hours compared with 22% with public insurance (P = 0.013). Children with public insurance were more likely to have visited another health facility besides the initial ED before presenting to UH ED (P = 0.004). Moreover, 74% of privately insured patients presenting to UH ED arrived via ambulance compared with 34% with public insurance (P < 0.001).
Most children with an extremity injury who received orthopaedic consultation at a tertiary-level ED after visiting another ED had an isolated fracture requiring cast treatment only. There was a trend for delay in receiving definitive orthopaedic care for patients with public health insurance compared with those with private insurance.
Journal of Pediatric Orthopaedics 09/2007; 27(6):690-4. · 1.16 Impact Factor
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Journal of Orthopaedic Science 08/2007; 12(4):385-9. · 0.84 Impact Factor
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ABSTRACT: Children with Blount disease tend to be heavier than their peers; however, the relationship between the magnitude of obesity and the severity of limb deformities in Blount disease has not been well studied.
A retrospective review of the preoperative medical records and radiographs of patients with previously untreated Blount disease was conducted. Demographic information including gender, ethnicity, the age when deformity was first noted, the age at the examination, and the body mass index was recorded. Frontal and sagittal plane deformities were analyzed by one examiner using full-length standing radiographs. The association of body mass index with various demographic and deformity parameters was then analyzed.
Over an eight-year period, forty-five patients with sixty-five limbs affected by Blount disease were identified. Seventeen children (twenty-seven limbs) had early-onset Blount disease, and twenty-eight children (thirty-eight limbs) had late-onset disease. Fifteen of the children with early-onset disease and twenty-six of those with late-onset disease were overweight. There was no significant relationship between body mass index and gender, ethnicity, or laterality. The children with early-onset disease tended to have a lower body mass index but a greater magnitude of radiographic deformities compared with the children with late-onset disease. Greater varus malalignment (r = 0.74, p < 0.0001) and tibial procurvatum (r = -0.79, p = 0.002) were noted with an increasing body mass index in the early-onset, but not the late-onset, group of patients. Irrespective of the age at onset, the correlation of body mass index with frontal and sagittal plane deformities was stronger in extremely obese children (body mass index of > or =40).
There is a significant relationship between the magnitude of obesity and biplanar radiographic deformities in children with the early-onset form of Blount disease and in those with a body mass index of > or =40. These clinical findings are consistent with the literature concerning the effect of compressive forces on growth at the proximal tibial physis.
Prognostic Level II.
The Journal of Bone and Joint Surgery 07/2007; 89(6):1275-83. · 3.27 Impact Factor
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ABSTRACT: Various methods of performing proximal femoral realignment in adolescents with severe slipped capital femoral epiphysis exist. We report the technique and early results of a percutaneous, opening wedge subtrochanteric femoral osteotomy using an external fixator for correcting multiplanar deformities in such patients. Nine adolescents with severe slipped capital femoral epiphysis underwent a percutaneous osteotomy at an average age of 14.5 years. Mean operative blood loss was 61 ml, with 2 days of inpatient stay and 129 days of external fixation time. At an average follow-up of 23 months, hip flexion improved from 74 to 106 degrees, internal rotation from -5 to +17 degrees, external rotation from 71 to 41 degrees and abduction from 29 to 36 degrees. Radiographs revealed an improvement in anteroposterior head shaft angle from 112 to 134 degrees and lateral head shaft angle from 72 to 15 degrees. One patient had transient chondrolysis. No fixation-related problems, deep infection, avascular necrosis or refracture occurred. On the basis of our preliminary results, this percutaneous technique offers several advantages over currently available methods for surgical correction of severe slipped capital femoral epiphysis deformities.
Journal of Pediatric Orthopaedics B 12/2006; 15(6):396-403. · 0.47 Impact Factor
