Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 470 | Issue 5 | May, 2012

Assessment Tools and Classification Systems Used For the Upper Extremity in Children With Cerebral Palsy

Lisa V. Wagner MHS, OTR/L, Jon R. Davids MD

Clinicians interested in assessment and outcome measurement of upper extremity (UE) function and performance in children with cerebral palsy (CP) must choose from a wide range of tools.

Higher Expression of Myosin Heavy Chain IIx in Wrist Flexors in Cerebral Palsy

Stefan Gantelius MD, Yvette Hedström BS, Eva Pontén MD, PhD

Children with cerebral palsy (CP) use their paretic arm less than normal but have a relative overactivity of wrist flexors, causing an impairing flexed position of the wrist. Voluntary use of a muscle downregulates myosin heavy chain (MyHC) IIx, but it is unclear whether the relative overactivity of wrist flexors and extensors in children with CP affects MyHC expression compared to normal subjects.

Are Muscle Volume Differences Related to Concentric Muscle Work During Walking in Spastic Hemiplegic Cerebral Palsy?

Jacques Riad MD, Christopher M. Modlesky PhD, E. M. Gutierrez-Farewik PhD, Eva Broström PT, PhD

Individuals with spastic hemiplegic cerebral palsy are typically high functioning and walk without assistive devices. The involved limb is usually smaller and shorter, although it is not clear whether the difference in muscle volume has an impact on walking capacity.

Better Walking Performance in Older Children With Cerebral Palsy

Elisabet Rodby-Bousquet RPT, Gunnar Hägglund MD, PhD

Children with cerebral palsy (CP) often walk with a slower speed and a higher energy cost. Their walking performance and choice of mobility method may vary in different environments. Independent mobility is important for activity and participation.

Multilevel Surgery Improves Gait in Spastic Hemiplegia But Does Not Resolve Hip Dysplasia

Erich Rutz MD, Elyse Passmore MEng, Richard Baker PhD, H. Kerr Graham MD

Multilevel orthopaedic surgery may improve gait in Type IV hemiplegia, but it is not known if proximal femoral osteotomy combined with adductor release as part of multilevel surgery in patients with hip dysplasia improves hip development.

Rectus Femoris Transfer Improves Stiff Knee Gait in Children With Spastic Cerebral Palsy

Dinesh Thawrani MD, Thierry Haumont MD, Chris Church MS, PT, Larry Holmes PhD, DrPH, Kirk W. Dabney MD, Freeman Miller MD

Stiff knee gait is common among children with ambulatory cerebral palsy (CP). When surgery is indicated, rectus femoris transfer as a primary treatment enhances knee range of motion, reduces time to peak knee flexion, increases peak knee flexion, and reduces toe drag.

Rectus Femoris Distal Tendon Resection Improves Knee Motion in Patients With Spastic Diplegia

Ana Presedo MD, Fabrice Megrot PhD, Brice Ilharreborde MD, Keyvan Mazda MD, Georges-François Penneçot MD

Children with spastic diplegia frequently show excessive knee extension (stiff-knee gait) throughout swing phase, which may interfere with foot clearance. Abnormal rectus femoris activity is commonly associated with a stiff-knee gait. Rectus femoris transfer has been recommended to enhance knee flexion during swing. However, recent studies suggest the transfer does not generate a knee flexor moment but diminishes knee extension moment in swing and MRI studies show the transferred tendons can be constrained by scarring to underlying muscles. Thus, it is possible knee flexion would be improved by distal rectus release rather than transfer since it would not be adherent to the underlying muscles.

Case Reports: The Influence of Selective Voluntary Motor Control on Gait After Hamstring Lengthening Surgery

Evan J. Goldberg PhD, Eileen G. Fowler PhD, PT, William L. Oppenheim MD

Preliminary evidence suggests selective voluntary motor control (SVMC), defined as performance of isolated voluntary joint movement on request, may be an important factor affecting functional movement tasks. Individuals with poor SVMC are unable to dissociate hip and knee synergistic movement during the swing phase of gait and have difficulty extending their knee while the hip is flexing during terminal swing regardless of hamstring length. This pattern may limit their ability to take advantage of hamstring-lengthening surgery (HLS) and may explain a lack of improved stride length postoperatively.

Coronal Plane Knee Moments Improve After Correcting External Tibial Torsion in Patients With Cerebral Palsy

Michael Aiona MD, Kosta Calligeros MBBS, BSc, Rosemary Pierce PT

External tibial torsion causes an abnormal axis of joint motion relative to the line of progression with resultant abnormal coronal plane knee moments and affects lever arm function of the foot in power generation at the ankle. However, it is unclear whether surgical correction of the tibial torsion corrects the moments and power.

Surgical Technique: Medial Column Arthrodesis in Rigid Spastic Planovalgus Feet

Patricia Maria Moraes Barros Fucs MD, PhD, Celso Svartman MD, Rodrigo Montezuma Cezar Assumpção MD, Helder Henzo Yamada MD, Simone Dota Simis MD

Treatment of spastic planovalgus feet is challenging, especially in patients with severe and rigid deformities. The available techniques do provide some correction but not at the site of the deformity and sometimes the correction is lost over time. We describe a new surgical approach at the site of the deformity.

What to Disclose? Revisiting Informed Consent

B. Sonny Bal MD, JD, MBA, Theodore J. Choma MD

The requirement of obtaining informed consent before medical procedures is well established. With patients having greater access to information through information technology and owing to other factors, disclosure that goes beyond the traditional elements of the risks, benefits, and alternatives to an intervention is demanded from physicians.

Beyond the Standard of Care: A New Model to Judge Medical Negligence

Lawrence H. Brenner JD, Alison Tytell Brenner MPH, Eric J. Awerbuch BA, Daniel Horwitz MD

The term “standard of care” has been used in law and medicine to determine whether medical care is negligent. However, the precise meaning of this concept is often unclear for both medical and legal professionals.

Sovereign Immunity: Principles and Application in Medical Malpractice

Michael Suk MD, JD, MPH, FACS

Tort law seeks accountability when parties engage in negligent conduct, and aims to compensate the victims of such conduct. An exception to this general rule governing medical negligence is the doctrine of sovereign immunity. Historically, individuals acting under the authority of the government or other sovereign entity had almost complete protection against tort liability.

Medical Malpractice Reform: The Role of Alternative Dispute Resolution

David H. Sohn JD, MD, B. Sonny Bal MD, JD, MBA

Alternative dispute resolution (ADR) refers to techniques used to resolve conflicts without going to the courtroom. As healthcare and malpractice costs continue to rise, there is growing interest in tactics such as early apology, mediation, and arbitration in the medical arena.

Medical Liability of the Physician in Training

Brian Wegman MD, James P. Stannard MD, B. Sonny Bal MD, JD, MBA

Lawsuits alleging medical negligence by postgraduate physicians in training (residents) arise from treatment received by aggrieved patients at teaching hospitals. A threshold question in determining liability is whether or not the standard of care has been violated. Courts have questioned whether the proper standard governing resident physician conduct should be that of a reasonably competent generalist physician, that of a specialty physician, or whether the standard should be some subjective determination that addresses the resident level of training.

Online Professional Networks for Physicians: Risk Management

Jon L. Hyman MD, Howard J. Luks MD, Randale Sechrest MD

The rapidly developing array of online physician-only communities represents a potential extraordinary advance in the availability of educational and informational resources to physicians. These online communities provide physicians with a new range of controls over the information they process, but use of this social media technology carries some risk.

Do Poor People Sue Doctors More Frequently? Confronting Unconscious Bias and the Role of Cultural Competency

Frank M. McClellan JD, LLM, Augustus A. White MD, PhD, Ramon L. Jimenez MD, Sherin Fahmy JD

There is a perception that socioeconomically disadvantaged patients tend to sue their doctors more frequently. As a result, some physicians may be reluctant to treat poor patients or treat such patients differently from other patient groups in terms of medical care provided.

Closed Medical Negligence Claims Can Drive Patient Safety and Reduce Litigation

Steven E. Pegalis JD, B. Sonny Bal MD, JD, MBA

Medical liability reform is viewed by many physician groups as a means of reducing medical malpractice litigation and lowering healthcare costs. However, alternative approaches such as closed medical negligence claims data may also achieve these goals.

Minimal Epicondylectomy Improves Neurologic Deficits in Moderate to Severe Cubital Tunnel Syndrome

Kang Wook Kim MD, Hyuk Jin Lee MD, Seung Hwan Rhee MD, Goo Hyun Baek MD, PhD

Previous studies of minimal medial epicondylectomy for cubital tunnel syndrome included patients with mild disease, making it difficult to determine how much this procedure improved sensory and motor impairments in patients with moderate to severe disease.

Limited Intraobserver and Interobserver Reliability for the Common Measures of Hip Joint Congruency Used in Dysplasia

A. Noelle Larson MD, Brien Rabenhorst MD, Adriana Rocha BS, MS, Daniel J. Sucato MD, MS

A congruent hip frequently is cited in the literature as a prerequisite for performing a reconstructive pelvic osteotomy for hip dysplasia. The designation as congruent is important as incongruent joints generally are regarded as requiring a salvage-type procedure. Several measures of congruency are described in the literature, but it is unclear whether these measures are reliable.

Alumina-on-alumina THA in Patients with Juvenile Idiopathic Arthritis: A 5-year Followup Study

Ana Cruz-Pardos MD, Eduardo García-Rey MD, Eduardo García-Cimbrelo MD, Jose Ortega-Chamarro MD

THA is a concern in juvenile idiopathic arthritis (JIA) owing to patients’ youth, poor bone stock, and small physical size.

Periprosthetic Bone Remodeling after 12 Years Differs in Cemented and Uncemented Hip Arthroplasties

Prakash Chandran MS, FRCS (Ortho), Mohammed Azzabi MRCS, Mark Andrews FRCS (Ortho), John G. Bradley FRCS

Different patterns of stress shielding may lead to differences in periprosthetic bone preservation around cemented and uncemented hips in the long term?

Perioperative Clopidogrel and Postoperative Events after Hip and Knee Arthroplasties

Sumon Nandi MD, Mehran Aghazadeh MD, Carl Talmo MD, Claire Robbins DPT, James Bono MD

Hip and knee arthroplasties are widely performed and vascular disease among patients having these procedures is common. Clopidogrel is a platelet inhibitor that decreases the likelihood of thrombosis. It may cause intraoperative and postoperative bleeding, but its discontinuation increases the risk of vascular events. There is currently no consensus regarding the best perioperative clopidogrel regimen that balances these concerns.

Is Unicompartmental Arthroplasty an Acceptable Option for Spontaneous Osteonecrosis of the Knee?

Danilo Bruni MD, Francesco Iacono MD, Giovanni Raspugli MD, Stefano Zaffagnini MD, Maurilio Marcacci MD

The literature suggests survivorship of unicompartmental knee arthroplasties (UKAs) for spontaneous osteonecrosis of the knee ranges from 93% to 97% at 10 to 12 years. However, these data arise from small series (23 to 33 patients), jeopardizing meaningful conclusions.

Histologic Examinations of Arthroplasty Specimens are not Cost-effective: A Retrospective Cohort Study

Michael M. Lin AB, Jeffrey D. Goldsmith MD, Stephen C. Resch PhD, Joseph P. DeAngelis MD, Arun J. Ramappa MD

Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient management and whether it is cost-effective.

High Rate of Infection Control with One-stage Revision of Septic Knee Prostheses Excluding MRSA and MRSE

Joachim Singer MD, Andreas Merz MD, Lars Frommelt MD, Bernd Fink MD

The rate of infection control for one-stage revision of infected knee arthroplasties is unclear as are the factors influencing infection control. Such factors include duration of infection and the type of infected prosthesis.

High Early Failure Rate of the Columbus® Posterior Stabilized High-flexion Knee Prosthesis

Woon-Hwa Jung MD, Jae-Heon Jeong MD, Yong-Chan Ha MD, Young-Kyun Lee MD, Kyung-Hoi Koo MD

Most studies report high survivorship rates for TKAs, however, we observed higher than anticipated rates of dislocation and femoral component loosening after implanting a Columbusposterior stabilized prosthesis.

Local Recurrence has only a Small Effect on Survival in High-risk Extremity Osteosarcoma

Chang-Bae Kong MD, Won Seok Song MD, Wan Hyeong Cho MD, Jung Moon Oh MD, Dae-Geun Jeon MD

Tumor enlargement after chemotherapy is considered one of the high-risk factors for local recurrence and survival in osteosarcoma. We hypothesized patients with this risk factor will have similar survival regardless of the development of local recurrence.

High Long-term Local Control with Sacrectomy for Primary High-grade Bone Sarcoma in Children

Alexandre Arkader MD, Christine H. Yang BA, MS, Vernon T. Tolo MD

Sacrectomy may offer curative potential for primary sarcomas of the sacrum. However, it is unclear whether and to what extent sacrectomies achieve local control.

Epithelioid Hemangioma of Bone and Soft Tissue: A Reappraisal of a Controversial Entity

Costantino Errani MD, Lei Zhang MD, David M. Panicek MD, John H. Healey MD, Cristina R. Antonescu MD

The controversy surrounding diagnosis of an epithelioid hemangioma (EH), particularly when arising in skeletal locations, stems not only from its overlapping features with other malignant vascular neoplasms, but also from its somewhat aggressive clinical characteristics, including multifocal presentation and occasional lymph node involvement. Specifically, the distinction from epithelioid hemangioendothelioma (EHE) has been controversial. The recurrent t(1;3)(p36;q25) chromosomal translocation, resulting in WWTR1-CAMTA1 fusion, recently identified in EHE of various anatomic sites, but not in EH or other epithelioid vascular neoplasms, suggests distinct pathogeneses.

CD4 Count is Associated with Postoperative Infection in Patients with Orthopaedic Trauma who are HIV Positive

George N. Guild MD, Thomas J. Moore MD, Whitney Barnes MPH, BS, Christopher Hermann BS

Since the advent of effective antiretroviral therapy, the number of people with AIDS has increased and a certain percentage of these patients will require emergent orthopaedic surgery. Little is known regarding orthopaedic infections and the association of CD4 counts with postoperative infection in patients with HIV infection who experience orthopaedic trauma.

Race May Not Effect Outcomes in Operatively Treated Tibia Fractures

Jonathan Piposar MD, John R. Fowler MD, John P. Gaughan PhD, Saqib Rehman MD

A recent review of the literature found worse outcomes and longer length of stay for minorities undergoing TKAs and THAs when compared with whites. It is unclear if this association exists for the operative treatment of tibia fractures.

Orthopaedic Case of the Month: Ossified Calf Mass in a 32-year-old Woman

Eniola T. Obadina MD, Donna G. Blankenbaker MD, Kirkland W. Davis MD, John P. Heiner MD
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