Faculty Bibliography

The traditional surgical exposure for a Salter or Chiari pelvic osteotomy involves splitting the iliac apophysis to facilitate subperiosteal separation of the muscles of the inner and outer table of the ilium. With healing, the iliac crest frequently becomes broad and prominent, and the iliac wing hypoplastic. We addressed this issue by separating the whole iliac apophysis laterally at the junction of cartilage and bone and displacing it medially. The ilium was then exposed by subperiosteal dissection of the inner and outer table musculature. From February 1988 to June 2000, twenty-five pelvic osteotomies were performed utilizing this approach. Satisfactory exposure was achieved in each case. All osteotomies healed without iliac growth disturbances, leaving excellent cosmetic results. Resuturing the previously elevated external oblique abdominus over the iliac apophysis further improved contour and appearance, Iliac apophyseal displacement rather than splitting provided appropriate access and consistently good function and cosmesis

Toe flexor tightness becomes apparent in the plantigrade attitude achieved by isolated tendoachilles lengthening in cerebral palsy. This frequently persists, resulting in abnormal weight-bearing on the tips of the toes. To address this problem, at the time of limited tendoachilles lengthening, we performed Z-lengthenings of the flexor hallucis longus and the flexor digitorum longus tendons above the medial malleolus, preserving the pulley mechanism. From January 1998 to October 2001, 41 children (74 feet) with cerebral palsy underwent lengthening of the tendoachilles and long toe flexor tendons. The mean age at surgery was 7 years. The correction achieved was successfully maintained long-term, permitting a normal heel-metatarsal head weight-bearing pattern. Lengthening of the long toe flexors, in conjuction with tendoachilles lengthening, is an effective means of achieving a balanced foot in cerebral palsy

Traditional methods of correcting malunited distal humeral fractures in children involve complex wedge osteotomies held with pins or internal fixation devices. These require a large exposure and challenging fixation. We elected to perform simple transverse osteotomies, without wedges, using a lateral incision. These were maintained by the small AO external fixator. Between 1987 and 2004, five children with malunited distal humeral fractures were treated. Angular and rotational correction was obtained in each case. Bony union occurred at an average of 8 weeks. A simple osteotomy held by the small AO external fixator provides accurate correction, precise adjustability, and solid stability

A 9-year-old girl with multiple osteochondromatosis presented with a 1 year history of a gradually enlarging surface lesion originating from the midsection of the right humerus, distal to an osteochondroma. Radiographically and histologically this lesion proved to be a periosteal chondrosarcoma adjacent to an osteochondroma

Torsional problems of the femur have been traditionally treated by a proximal osteotomy with internal fixation. We elected to perform femoral derotational osteotomies distally. Between September 1994 and April 2001, supracondylar osteotomies were performed on 38 femora in 21 children with torsional and angular deformities. The average age was 9 years (range 5-15 years). Twenty-three femora had excessive anteversion and fifteen, retroversion. All osteotomies were maintained by the small AO external fixator. Bony union occurred at an average of 10 weeks. Distal femoral osteotomy is an effective site for correcting rotational and associated angular deformities. The small AO external fixator provides precise adjustability, solid stability, and avoids a second procedure for hardware removal

Internal fixation in proximal femoral osteotomies using traditional devices may be sub-optimal in children with neuromuscular disorders who have small or osteopenic bone. In this population, between 1988 and 2000, we performed 36 proximal femoral varus osteotomies in 28 patients. These were controlled by the AO external fixator. The average age at surgery was 7 years (range, 2-13 years). A mean varus correction of 34 degrees (range, 15-90 degrees) was obtained. Complications consisted of one superficial pin tract infection, one skin breakdown, and one non-union. Other than the non-union, all osteotomies were stable at the time of the fixator removal. The AO external fixator is an effective alternative in maintaining corrective proximal femoral osteotomies in children with fragile bones

The fundamental pathology in rigid clubfoot appears to be a neuromuscular defect. In order to test this hypothesis, 90 muscle biopsies were obtained from the posteromedial, peroneal, and some intrinsic muscles at surgical correction of 13 clubfoot patients. All were examined ultrastructurally, and 48 biopsies in nine of these patients were studied using enzyme specific histochemical stains at the light microscopic level. Neuromuscular junctions were isolated in the latter group. Consistent ultrastructural abnormalities were observed in all specimens. Histochemistry revealed a dominant Type I fiber population and Type I fiber grouping. A correlated increase in Type I neuromuscular junctions occurred in these areas. Since these changes are recognized as being neurogenically determined, a neuromuscular abnormality may be significant in the etiology of clubfoot