David Feldman, M.D.

Limited atlantooccipital and cervical range of motion in patients with familial dysautonomia
Henderson, Eric R; Schweitzer, Mark E; Sala, Debra A; Feldman, David S
2011 Nov;20(6):404-407, Journal of pediatric orthopaedics. Pt. B
Familial dysautonomia (FD) is a rare neurological disease with autosomal recessive inheritance and is associated with severe kyphoscoliosis. Investigators have reported subjective observation of decreased cervical motion and high rates of proximal instrumentation failure in this population. A radiographic study of sagittal plane cervical spine motion was performed with 15 patients with FD. Measurements were compared with normal values. Patients with FD had decreased sagittal motion at all cervical levels (P<0.05). Intervertebral translation was also decreased significantly at C3-C6. FD is associated with decreased sagittal motion in the cervical spine
— id: 138106, year: 2011, vol: 20, page: 404, stat: Journal Article,

Pelvic Positioning Creates Error in CT Acetabular Measurements
van Bosse, Harold J P; Lee, Duron; Henderson, Eric R; Sala, Debra A; Feldman, David S
2011 Jun;469(6):1683-1691, Clinical orthopaedics & related research
BACKGROUND: CT allows for accurate measurement of acetabular orientation and shape, but malpositioning of the pelvis may lead to measurement variance. PURPOSE: We therefore sought to determine: (1) whether acetabular anteversion measurements using the femoral head centers differed from those using the posterior ischia, and (2) the extent to which changing obliquity, rotation, and tilt of a pelvis in a CT scanner affected the measurement of acetabular variables. METHODS: A radiopaque human pelvis model with articulated hips was suspended from a plastic sheet as part of an adjustable frame. Changes in the transverse and sagittal planes created rotation and tilt, while rotating the frame in the coronal plane created obliquity. CT scans were obtained, varying the combinations of obliquity, rotation, and tilt by intervals of 5 degrees , up to 20 degrees . Acetabular anteversion (AA), anterior acetabular sector angle (AASA), posterior acetabular sector angle (PASA), and horizontal acetabular sector angle (HASA) were measured. RESULTS: The two methods for measuring AA yielded values differing by 1 degrees to 4 degrees but correlated (r = 0.981) across the spectrum of pelvis positioning. Pelvic obliquity and tilt were linearly associated with changes in the measurements. For each 1 degrees -increase in pelvic obliquity, AA changed -0.4 degrees , and AASA, PASA, and HASA changed 1.93 degrees , 0.99 degrees , and 2.80 degrees , respectively. For each 1 degrees -increase in pelvic tilt, AA changed 0.8 degrees , and AASA, PASA, and HASA changed -1.07 degrees , 0.52 degrees , and -0.51 degrees , respectively. Rotation had no affect on the variables. CONCLUSIONS: Small changes in pelvic obliquity and tilt were associated with variances in acetabular measurements. The measured changes were directly proportional to the changes in obliquity and tilt, and were additive. Pelvic rotation created no changes in measurement. CLINICAL RELEVANCE: Incorrect interpretation of acetabular anteversion and coverage may lead to unsatisfactory acetabular fragment positioning during reorientational surgery. Although intraoperative positioning of an acetabular fragment may not be as precise as the tools for preoperative planning, it is important for a surgeon to have the most precise data available for planning a procedure, and know where error can occur in collecting the data
— id: 134285, year: 2011, vol: 469, page: 1683, stat: Journal Article,

Thoracic adolescent idiopathic scoliosis: selection of fusion level
Badra, Mohammad I; Feldman, David S; Hart, Robert A
2010 Sep;19(5):465-472, Journal of pediatric orthopaedics. Pt. B
Selection of the appropriate fusion levels in thoracic adolescent idiopathic scoliosis has been traditionally a subject of debate among surgeons. Landmarks that have been suggested include the end vertebra, stable vertebra and neutral vertebra. Various results have been reported with multiple theories proposed to explain them. The clinical appearance of the patient, the type of the curve and its flexibility, the surgical technique and the instrumentation used all seem to play major roles in selecting the appropriate levels of fusion
— id: 111357, year: 2010, vol: 19, page: 465, stat: Journal Article,

Orthopaedic manifestations of neurofibromatosis type 1
Feldman, David S; Jordan, Charles; Fonseca, Lauren
2010 Jun;18(6):346-357, Journal of the American Academy of Orthopaedic Surgeons
Neurofibromatosis type 1 (NF-1) is an autosomal dominant disease that affects 1 in 3,000 persons worldwide. Cafe-au-lait macules and peripheral nerve sheath tumors (ie, neurofibromas) are the most commonly recognized manifestations of NF-1. However, NF-1 affects multiple organ systems, and a multidisciplinary approach to treatment is required. Management of the orthopaedic manifestations of NF-1 is often difficult. The most complex manifestations are scoliosis (dystrophic and nondystrophic), congenital pseudarthrosis of the tibia, and problems related to soft-tissue tumors. Metabolic bone disease is common; many patients are frankly osteopenic, which further complicates treatment. Dystrophic scoliosis, which may be caused by either bony dysplasia or intraspinal pathology, is characterized by early presentation and rapid progression. Pseudarthrosis is common even after instrumented fusion. Nondystrophic scoliosis tends to behave like adolescent idiopathic scoliosis, although it may present earlier and is associated with a higher rate of pseudarthrosis. Congenital pseudarthrosis of the tibia is a long-bone dysplasia that afflicts patients with NF-1. Management of this osseous deformity is challenging. Failure to achieve union and refracture are common
— id: 110079, year: 2010, vol: 18, page: 346, stat: Journal Article,

Major intraoperative neurologic monitoring deficits in consecutive pediatric and adult spinal deformity patients at one institution
Kamerlink, Jonathan R; Errico, Thomas; Xavier, Shaun; Patel, Ashish; Patel, Amar; Cohen, Alexa; Reiger, Mark; Dryer, Joseph; Feldman, David; Lonner, Baron; Beric, Aleksandar; Schwab, Frank
2010 Jan 15;35(2):240-245, Spine
STUDY DESIGN: Retrospective review. OBJECTIVE: The purpose of this study was to assess the preoperative neurologic risk in a consecutive series of spinal deformity patients undergoing correction surgery at one institution. SUMMARY OF BACKGROUND DATA: During spinal deformity correction surgery, neurologic monitoring techniques are commonly applied to reduce the risk of neurologic deficits. While previous studies have demonstrated risk factors for neurologic changes in the setting of spinal surgery, these involved long time spans and heterogeneous patient populations. METHODS: Of 301 cases performed over 1 year, 281 cases were monitorable. Patients were grouped according to diagnosis: neuromuscular (NM) scoliosis, Sagittal Plane deformity, and Scoliosis. Demographic and surgical data were collected for neurologically monitorable patients. Coronal and sagittal parameters were measured using digital images of radiographs. Neurologic status was measured with somatosensory-evoked potentials and/or motor-evoked potentials. RESULTS: Primary NM scoliosis cases had the highest incidence of neurologic monitoring changes (NMC) (10%) while revision sagittal plane deformity had the second highest (9.8%). Sensitivity and specificity were both 100%. Overall incidence of neurologic deficit was 1.1%. Of the 13 NMCs patients, 3 patients had persistent neurologic deficit. Majority of NMCs occurred before deformity correction. In patients with NM scoliosis, NMCs increased with hybrid constructs with wires (P < 0.01). In patients with scoliosis, NMCs increased with increased body mass index, estimated blood loss, operative time, and postoperative coronal thoracolumbar curve magnitude (P < 0.04). In patients with primarily sagittal plane deformity, NMCs increased with preoperative proximal curve, postoperative proximal and thoracolumbar curves, and postoperative kyphosis and lordosis (P < 0.04). CONCLUSION: Primary NM scoliosis and revision sagittal plane deformities appear to carry greatest incidence of NMCs during surgical intervention. Most observed NMCs did not result in a permanent neurologic deficit. Neuromonitoring should be assessed throughout the entire surgical procedure. This study may aid surgeons and patients to better assess neurologic risks related to spinal deformity surgery
— id: 106280, year: 2010, vol: 35, page: 240, stat: Journal Article,

Peripheral arthropathy in hereditary sensory and autonomic neuropathy types III and IV
Feldman, David S; Ruchelsman, David E; Spencer, Daniel B; Straight, Joseph J; Schweitzer, Mark E; Axelrod, Felicia B
2009 Jan-Feb;29(1):91-97, Journal of pediatric orthopedics
BACKGROUND: To determine the features of the underlying destructive arthropathy in the peripheral joints of children with hereditary sensory and autonomic neuropathy (HSAN) type III and to compare and contrast this to the arthropathy noted in HSAN type IV, as both groups experience decreased pain perception. METHODS: From a database of 547 patients with HSAN type III and 32 patients with HSAN type IV, we performed a retrospective chart review and radiographic analysis of all patients who presented with joint swelling and deformity. Underlying joint pathology was classified as either osteonecrosis or Charcot arthropathy. RESULTS: In the HSAN type III population, 44 (8%; 22 males and 22 females) of the 547 patients had clinical evidence of arthropathy. In 42 patients, 48 joints demonstrated radiographic evidence of osteonecrosis; 45 (94%) of the 48 joints with osteonecrosis occurred in the lower extremity. In each case of osteonecrosis of the knee (n = 19), isolated involvement of the lateral distal femoral condyle was seen consisting of varying sizes of posterolateral osteochondral fragmentation. In the 32 patients comprising the HSAN type IV population, 18 (56%) were found to have radiographic findings consistent with Charcot arthropathy in a total of 30 affected joints. One patient demonstrated Charcot arthropathy of the spine and subsequent progressive spondylolisthesis. Nine patients (12 joints) also demonstrated osteomyelitis. CONCLUSIONS: In patients with HSAN type III, osteonecrosis is the initial lesion preceding destructive arthropathy. Osteonecrosis and osteochondral fragmentation were always isolated at the lateral distal femoral condyle in the knee. This pathology may be amenable to surgical reconstruction and fixation to stabilize the knee and prevent further degeneration. Hereditary sensory and autonomic neuropathy type IV was most commonly associated with Charcot arthropathy or joint subluxation and dislocation. Late secondary changes at the articular surface may make radiographic distinction difficult. Charcot arthropathy affected both sides of the involved joint with evidence of collapse and fragmentation. With osteonecrosis, the articular process was found to be more focal
— id: 93224, year: 2009, vol: 29, page: 91, stat: Journal Article,

Congenital scoliosis
Feldman, David S; Schachter, Aaron K; Alfonso, Daniel; Lonner, Baron S; Razi, Afshin E
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5802, year: 2009, vol: , page: ?, stat: Chapter,

Articulated hip distraction: a treatment option for femoral head avascular necrosis in adolescence
Gomez, Jaime A; Matsumoto, Hiroko; Roye, David P Jr; Vitale, Michael G; Hyman, Joshua E; van Bosse, Harold J P; Marangoz, Salih; Sala, Debra A; Stein, Matthew I; Feldman, David S
2009 Mar;29(2):163-169, Journal of pediatric orthopedics
PURPOSE: To describe the clinical outcomes of adolescent patients treated with articulated hip distraction (AHD) for avascular necrosis (AVN) of the femoral head. Outcomes were examined in order to better understand the usefulness of and indications for performing hip arthrodiastasis in this patient population. METHODS: : Retrospective review was performed on 31 hips with femoral head AVN treated with AHD. Mean age at treatment was 14.7 years. Preoperative and follow-up pain and physical limitations, as well as follow-up range of motion, were assessed. RESULTS: Follow-up assessment was obtained at 18.7 years. Time of follow-up was 57.4 months after distraction. The etiologies of AVN were the following: 10 slipped capital femoral epiphysis (SCFE), 5 idiopathic AVN, 3 with hip dysplasia, and 12 others. There was a significant difference in pain preoperatively and postoperatively (P<0.001), most patients (78.6%, n=22) had less pain after the treatment. Multivariate regression model demonstrated that patients with SCFE were likely to have less improvement in pain than patients with other etiologies (odds ratio, 22.7; P=0.035). All patients had activity limitations before the treatment; at the postoperative assessment, half of our patients (n=14) reported no limitations in their regular daily activities. Eight patients had minor complications with the fixator. At follow-up, 5 patients (17.2%) converted to total hip replacement or arthrodesis. Survival rates were 90.6% at 5 years, 77.7% at 10 years, and 38.8% at 15 years. CONCLUSIONS: Hip distraction arthroplasty in adolescent patients with symptomatic AVN reduces the amount of pain and limitation in daily activities at a follow-up of 4.7 years. Arthrodiastasis is not the final solution to AVN. With longer follow-up, patient's symptoms increases. Patients with AVN secondary to SCFE do not seem to benefit from this procedure as much as other patients do. Articulated hip distraction is a safe and appropriate procedure to perform in these patients. The procedure might be able to delay definitive surgical procedures at an early age, restoring function and improving the patient's quality of life
— id: 135231, year: 2009, vol: 29, page: 163, stat: Journal Article,

Functional outcome in adult patients following Bernese periacetabular osteotomy
Badra, Mohammad I; Anand, Ashish; Straight, Joseph J; Sala, Debra A; Ruchelsman, David E; Feldman, David S
2008 Jan;31(1):69-69, Orthopedics (Thorofare NJ)
This study evaluated functional outcome following Bernese periacetabular osteotomy. In 24 patients with mean follow-up of 3.5 years, mean dysfunction score was 15.23 on the Short Musculoskeletal Function Assessment. Eighteen patients (75%) scored = or <20, indicating a high functional level. Irrespective of preoperative Shenton line continuity, most patients demonstrated a high functional level. However, a trend toward a poorer outcome was observed in patients with preoperative noncongruent joints and Tonnis osteoarthritis grade 3. These results suggest patients with less than optimal presentation may still benefit from this surgery, delaying or eliminating the need for total hip arthroplasty
— id: 97863, year: 2008, vol: 31, page: 69, stat: Journal Article,

Presentation of low back pain in children had a low diagnosis rate
Feldman, David S
2008 Nov;90(11):2554-2554, Journal of bone & joint surgery (American volume)
— id: 95991, year: 2008, vol: 90, page: 2554, stat: Journal Article,

Mechanisms of disease: detrimental adrenergic signaling in acute decompensated heart failure
Feldman, David S; Elton, Terry S; Sun, Benjamin; Martin, Mickey M; Ziolo, Mark T
2008 Apr;5(4):208-218, Nature clinical practice. Cardiovascular medicine
Acute decompensated heart failure (ADHF) is responsible for more than 1 million hospital admissions each year in the US. Clinicians and scientists have developed therapeutic strategies that reduce mortality in patients with chronic heart failure (HF). Despite the widely appreciated magnitude of the ADHF problem, there is still a critical gap in our understanding of the cellular mechanisms involved and effective treatment strategies for hospitalized patients. Irrespective of the etiology, patients with ADHF present with similar symptoms (e.g. edema, altered hemodynamics and congestion) as multiple signaling pathways converge in a common phenotypic presentation. Investigations have shown that patients with ADHF have increased catecholamine levels, which cause chronic stimulation of beta-adrenergic receptors. This overstimulation leads to chronic G-protein activation and perturbations in myocyte signaling, as the patient's heart attempts to adapt to progressive HF. Over time, these compensatory signaling mechanisms ultimately fail, and maladaptive signaling prevails with progressive worsening of symptoms. This Review summarizes some of the changes that occur during chronic adrenergic stimulation, and examines how downstream contractile dysfunction and myocyte death can alter the prognosis of patients with HF hospitalized for acute events
— id: 95995, year: 2008, vol: 5, page: 208, stat: Journal Article,

Conformational instability of the taylor spatial frame: a case report and biomechanical study
Henderson, Eric R; Feldman, David S; Lusk, Craig; van Bosse, Harold J; Sala, Debra; Kummer, Frederick J
2008 Jun;28(4):471-477, Journal of pediatric orthopedics
BACKGROUND: The Taylor spatial frame (TSF) is a second-generation circular fixator used for limb lengthening and deformity correction. While treating a patient for pseudoarthosis, gross instability of a particular TSF construct was observed. A subsequent mechanical study of the TSF was then performed to better understand how its configurations affect frame stability. METHODS: Various conformations of the TSF were made and tested in compression, bending, and torsional loading. RESULTS: Frame stability was significantly compromised in compression and bending when shorter struts were used and the ring-strut angles were less than 30 degrees. Torsional stability was not significantly affected. Some minor instabilities were noted with an angular ring offset displacement of 25 degrees. CONCLUSIONS: Ring-strut angle, a critical factor in truss mechanics, seems to have the greatest influence on stability for the TSF. We recommend that adequate length struts be chosen when constructing a TSF so that ring-strut angles of 30 degrees or less are avoided. Clinical relevance pertains to use of the TSF in atypical conformations, especially in the pediatric population requiring deformity correction
— id: 95770, year: 2008, vol: 28, page: 471, stat: Journal Article,

Experimental validation of miRNA targets
Kuhn, Donald E; Martin, Mickey M; Feldman, David S; Terry, Alvin V Jr; Nuovo, Gerard J; Elton, Terry S
2008 Jan;44(1):47-54, Methods
MicroRNAs are natural, single-stranded, small RNA molecules that regulate gene expression by binding to target mRNAs and suppress its translation or initiate its degradation. In contrast to the identification and validation of many miRNA genes is the lack of experimental evidence identifying their corresponding mRNA targets. The most fundamental challenge in miRNA biology is to define the rules of miRNA target recognition. This is critical since the biological role of individual miRNAs will be dictated by the mRNAs that they regulate. Therefore, only as target mRNAs are validated will it be possible to establish commonalities that will enable more precise predictions of miRNA/mRNA interactions. Currently there is no clear agreement as to what experimental procedures should be followed to demonstrate that a given mRNA is a target of a specific miRNA. Therefore, this review outlines several methods by which to validate miRNA targets. Additionally, we propose that multiple criteria should be met before miRNA target validation should be considered 'confirmed.'
— id: 95996, year: 2008, vol: 44, page: 47, stat: Journal Article,

Human chromosome 21-derived miRNAs are overexpressed in down syndrome brains and hearts
Kuhn, Donald E; Nuovo, Gerard J; Martin, Mickey M; Malana, Geraldine E; Pleister, Adam P; Jiang, Jinmai; Schmittgen, Thomas D; Terry, Alvin V Jr; Gardiner, Katheleen; Head, Elizabeth; Feldman, David S; Elton, Terry S
2008 Jun 6;370(3):473-477, Biochemical & biophysical research communications
Down syndrome (DS), or Trisomy 21, is the most common genetic cause of cognitive impairment and congenital heart defects in the human population. To date, the contribution of microRNAs (miRNAs) in DS has not been investigated. Bioinformatic analyses demonstrate that human chromosome 21 (Hsa21) harbors five miRNA genes; miR-99a, let-7c, miR-125b-2, miR-155, and miR-802. MiRNA expression profiling, miRNA RT-PCR, and miRNA in situ hybridization experiments demonstrate that these miRNAs are overexpressed in fetal brain and heart specimens from individuals with DS when compared with age- and sex-matched controls. We hypothesize that trisomic 21 gene dosage overexpression of Hsa21-derived miRNAs results in the decreased expression of specific target proteins and contribute, in part, to features of the neuronal and cardiac DS phenotype. Importantly, Hsa21-derived miRNAs may provide novel therapeutic targets in the treatment of individuals with DS
— id: 95994, year: 2008, vol: 370, page: 473, stat: Journal Article,

The limbus and the neolimbus in developmental dysplasia of the hip
Landa, Joshua; Benke, Michael; Feldman, David S
2008 Apr;466(4):776-781, Clinical orthopaedics & related research
The limbus and the neolimbus are both pathological lesions that form in response to a developmentally dislocated hip. An understanding of these structures is integral to treatment of developmental dysplasia of the hip (DDH). Yet, we believe the current peer-reviewed orthopaedic literature and orthopaedic textbooks commonly fail to correctly use or define these terms. The neolimbus is best defined as a hypertrophied ridge of fibrocartilage in the superolateral region of the acetabulum caused by pressure from the dislocated hip on this region. The limbus is the labrum that is hypertrophied with fibrous and fibrocartilaginous overgrowth, and is a potential block to concentric reduction of a dysplastic hip. We review the early and current literature in an attempt to clarify the use of the terms limbus and neolimbus and provide an overview of the importance and treatment of these abnormal structures associated with DDH. LEVEL OF EVIDENCE: Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence
— id: 78739, year: 2008, vol: 466, page: 776, stat: Journal Article,

Femoral deformity correction in children and young adults using Taylor Spatial Frame
Marangoz, Salih; Feldman, David S; Sala, Debra A; Hyman, Joshua E; Vitale, Michael G
2008 Dec;466(12):3018-3024, Clinical orthopaedics & related research
The Taylor spatial frame (TSF) has been used commonly in children and young adults. Its use in the tibia is more extensively studied and applied than in the femur. We asked whether normal alignment can be achieved with accuracy during correction of femoral deformities while avoiding major complications in children and young adults. We retrospectively reviewed the clinical and radiographic records of 20 patients (22 limbs), ages 5.9 to 24.6 years, who underwent a TSF for femoral deformity. Etiology included a number of diagnoses of the pediatric age. Minimum followup was 4.5 months (mean, 15.7 months; range, 4.5-35 months). The mean time in frame was 6.2 months (range, 2.6-19 months). Frontal and sagittal plane deformities were corrected to within normal values. A mean limb lengthening of 4.9 cm (range, 1.5-9 cm) was performed in eight femora in seven of which the limb length discrepancy was a secondary concern. External fixation index in the lengthening subgroup was 2.2 months/cm. The 15 complications in 13 limbs included pin tract infection, knee stiffness, delayed union, skin irritation, and posterior knee subluxation. No complications occurred in nine limbs. Computer-assisted femoral deformity correction with six-axis deformity analysis and the TSF is an accurate and safe technique in children and young adults. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence
— id: 91445, year: 2008, vol: 466, page: 3018, stat: Journal Article,

Characteristics, drug therapy, and outcomes from a database of 500,000 hospitalized patients with a discharge diagnosis of heart failure
Ng, Tien M H; Dasta, Joseph F; Durtschi, Amy J; McLaughlin, Trent P; Feldman, David S
2008 Jul-Aug;14(4):202-210, Congestive heart failure
Knowledge related to acute heart failure (HF) and its management in 'real-world' clinical practice is limited. The authors delineated characteristics and drug therapy for hospitalized HF patients and their association with clinical and economic outcomes. The NDCHealth (National Data Corporation, Atlanta, GA) database, containing billing data from a geographically diverse sample of approximately 300 hospitals, was screened for admissions in 2003 of either a primary or secondary discharge diagnosis of HF. Of 2.5 million admissions screened, 496,534 patients (19.7%) had a primary (131,057) or secondary (365,477) discharge diagnosis of HF. Mean age was 73.1+/-13.9 years, and 55.4% were women. Mean length of hospital stay was 8.7+/-28.6 days, and in-hospital mortality was 7.1%. Mean hospital cost per admission was dollars 18,667. Admissions with HF as a secondary diagnosis were associated with a worse prognosis. HF commonly exists in hospitalized patients and is associated with significant morbidity, mortality, and economic burden, irrespective of whether it is the primary diagnosis or a secondary comorbidity
— id: 95992, year: 2008, vol: 14, page: 202, stat: Journal Article,

Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children
Reinhardt, Keith R; Feldman, David S; Green, Daniel W; Sala, Debra A; Widmann, Roger F; Scher, David M
2008 Jun;28(4):403-409, Journal of pediatric orthopedics
BACKGROUND: When operative stabilization of forearm fractures in older children is necessary, the optimal method of fixation is controversial. This study compared the radiographic and functional outcomes of intramedullary nailing to plating of forearm fractures in children between 10 and 16 years of age. METHODS: Thirty-one patients who underwent operative fixation of midshaft radius and ulna fractures were divided into nailing and plating groups and were compared retrospectively according to perioperative data and patient outcome measures (fracture union at 3 and 6 months, loss of forearm rotation, restoration of radial bow magnitude and location, and complication rates). RESULTS: The nailing group had 19 patients, with a mean age of 12.5 years (range, 10-14.6 years), and the plating group had 12, with a mean age of 14.5 years (range, 11.9-16 years). Groups were similar for sex, arm injured, fracture location, Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association classification, and number of open fractures. Duration of surgery and tourniquet use were significantly shorter in the nailing group (P = 0.037 and 0.001, respectively). No differences were found between the groups for fracture union at 3 or 6 months. At latest follow-up, radial bow magnitude was similar for the 2 groups and restored to normal in both. Radial bow location in the nailing group was significantly different from the reported normal values (P = 0.001). Despite this, there was no difference in loss of forearm rotation between groups. Complication rates were also similar between groups, with 1 ulna nonunion, 1 compartment syndrome, and 2 refractures in the nailing group and 1 radius and ulna nonunion, 1 broken plate, and 2 refractures in the plating group. CONCLUSIONS AND SIGNIFICANCE: Based on similar functional and radiographic outcomes, nailing of length-stable forearm fractures remains an equally effective method of fixation in skeletally immature patients 10 to 16 years of age when compared with plating and is our treatment of choice. LEVEL OF EVIDENCE: Therapeutic level III--retrospective comparative study
— id: 95993, year: 2008, vol: 28, page: 403, stat: Journal Article,

Interobserver and intraobserver reliability in lower-limb deformity correction measurements
Feldman, David S; Henderson, Eric R; Levine, Harlan B; Schrank, Philip L; Koval, Kenneth J; Patel, Raviraj J; Spencer, Daniel B; Sala, Debra A; Egol, Kenneth A
2007 Mar;27(2):204-208, Journal of pediatric orthopedics
Planning for surgical correction of lower-limb deformity requires assessment of the character and extent of the deformity. Deformity measurements are defined; however, the reliability of these measurements has not been evaluated. This study was conducted to assess the interobserver and intraobserver reliability of lower extremity deformity measurements in the frontal and sagittal planes. Anteroposterior and lateral lower extremity radiographs were evaluated using Paley technique. Statistical analysis included intraclass correlation coefficient (2,1), median absolute difference, range, and agreement within 3 and 5 degrees. Reliability was good to very good for all measurements except for the anterior distal tibial angle, which had moderate reliability. Intraobserver reliability was higher than interobserver reliability, and measurements in the frontal plane had better reliability than measurements in the sagittal plane. Overall, these measurements are a reliable method of assessing lower extremity deformity and should be used to guide treatment and monitor outcome.
— id: 73014, year: 2007, vol: 27, page: 204, stat: Journal Article,

Calculation of rotational deformity in pediatric supracondylar humerus fractures
Henderson, Eric R; Egol, Kenneth A; van Bosse, Harold J P; Schweitzer, Mark E; Pettrone, Sarah K; Feldman, David S
2007 Mar;36(3):229-235, Skeletal radiology
OBJECTIVE: Supracondylar humerus fractures (SCHF) are common in the pediatric population. Cubitus varus deformity (CVD) is the most common long-term complication of SCHFs and may lead to elbow instability and deficits in throwing or extension. Distal fragment malrotation in the axial plane disposes to fragment tilt and CVD; however, no simple method of assessing fracture malrotation exists. This study tested a mathematical method of measuring axial plane malrotation in SCHFs based on plain radiographs. DESIGN: A pediatric SCHF model was made, and x-rays were taken at known intervals of rotation. Five independent, blinded observers measured these films. Calculated rotation for each data set was compared to the known rotation. The identical protocol was performed for an aluminum phantom. RESULTS: The reliability and agreement of the rotation values were good for both models. CONCLUSIONS: This method is a reliable, accurate, and cost-effective means of calculating SCHF distal fragment malrotation and warrants clinical application
— id: 69347, year: 2007, vol: 36, page: 229, stat: Journal Article,

Early complications encountered using a self-lengthening intramedullary nail for the correction of limb length inequality
Kubiak, EN; Strauss, E; Grant, A; Feldman, D; Egol, KA
2007 NOV ;18(2):52-57, Eklem hastaliklan ve cerrahisi = Joint diseases & related surgery
Objectives: We evaluated early complications of self-lengthening intramedullary nails during limb lengthening in patients with post-traumatic or growth-related limb length deficiencies. Patients and methods: A retrospective review was undertaken of all patients who underwent femoral lengthening using the Internal Skeletal Distractor (ISKD Orthofix, McKinney, Texas) device beginning September 2003 at our tertiary care center. Data from the radiographic and clinical records of 11 limbs in nine patients (mean age 24 years; range 16 to 33 years) were derived. Complications were recorded and compared to the demographic data. Results: Preoperative leg length discrepancies averaged 3.7 cm (range 2.5 to 4.8 cm) and postoperative lengthening averaged 3.1 cm (range 2.3 to 4.4 cm). The mean follow-up was 16 months (range 12 to 26 months). The nails were removed after a mean of 11.5 months (range 8 to 16 months). Complications were encountered with eight ISKD nails (72.7%). Of these, seven complications necessitated the patients returning to the operating room. The average time to reoperation was 21 days (range 4 to 37 days). Two patients had two complications per ISKD. In all, there were four nails which failed to advance and required re-osteotomy, three premature consolidations which required osteoclasis, and one runaway nail advancement of 3.0 mm/day compared to the target lengthening rate of 0.8-1.0 mm/day. Conclusion: We believe that binding at the osteotomy site was responsible for failure of nail advancement in patients in whom lengthening failed. In the light of the high complication rate, surgeons' vigilance during the postoperative period is crucial
— id: 76789, year: 2007, vol: 18, page: 52, stat: Journal Article,

Mechanisms of impaired calcium handling underlying subclinical diastolic dysfunction in diabetes
Lacombe, Veronique A; Viatchenko-Karpinski, Serge; Terentyev, Dmitry; Sridhar, Arun; Emani, Sitaramesh; Bonagura, John D; Feldman, David S; Gyorke, Sandor; Carnes, Cynthia A
2007 Nov;293(5):R1787-R1797, American journal of physiology. Regulatory, integrative, & comparative physiology
Isolated diastolic dysfunction is found in almost half of asymptomatic patients with well-controlled diabetes and may precede diastolic heart failure. However, mechanisms that underlie diastolic dysfunction during diabetes are not well understood. We tested the hypothesis that isolated diastolic dysfunction is associated with impaired myocardial Ca(2+) handling during type 1 diabetes. Streptozotocin-induced diabetic rats were compared with age-matched placebo-treated rats. Global left ventricular myocardial performance and systolic function were preserved in diabetic animals. Diabetes-induced diastolic dysfunction was evident on Doppler flow imaging, based on the altered patterns of mitral inflow and pulmonary venous flows. In isolated ventricular myocytes, diabetes resulted in significant prolongation of action potential duration compared with controls, with afterdepolarizations occurring in diabetic myocytes (P < 0.05). Sustained outward K(+) current and peak outward component of the inward rectifier were reduced in diabetic myocytes, while transient outward current was increased. There was no significant change in L-type Ca(2+) current; however, Ca(2+) transient amplitude was reduced and transient decay was prolonged by 38% in diabetic compared with control myocytes (P < 0.05). Sarcoplasmic reticulum Ca(2+) load (estimated by measuring the integral of caffeine-evoked Na(+)-Ca(2+) exchanger current and Ca(2+) transient amplitudes) was reduced by approximately 50% in diabetic myocytes (P < 0.05). In permeabilized myocytes, Ca(2+) spark amplitude and frequency were reduced by 34 and 20%, respectively, in diabetic compared with control myocytes (P < 0.05). Sarco(endo)plasmic reticulum Ca(2+)-ATPase-2a protein levels were decreased during diabetes. These data suggest that in vitro impairment of Ca(2+) reuptake during myocyte relaxation contributes to in vivo diastolic dysfunction, with preserved global systolic function, during diabetes
— id: 95998, year: 2007, vol: 293, page: R1787, stat: Journal Article,

TGF-beta1 stimulates human AT1 receptor expression in lung fibroblasts by cross talk between the Smad, p38 MAPK, JNK, and PI3K signaling pathways
Martin, Mickey M; Buckenberger, Jessica A; Jiang, Jinmai; Malana, Geraldine E; Knoell, Daren L; Feldman, David S; Elton, Terry S
2007 Sep;293(3):L790-L799, American journal of physiology. Lung cellular & molecular physiology
Both angiotensin II (ANG II) and transforming growth factor-beta1 (TGF-beta1) are thought to be involved in mediating pulmonary fibrosis. Interactions between the renin-angiotensin system (RAS) and TGF-beta1 have been well documented, with most studies describing the effect of ANG II on TGF-beta1 expression. However, recent gene expression profiling experiments demonstrated that the angiotensin II type 1 receptor (AT(1)R) gene was a novel TGF-beta1 target in human adult lung fibroblasts. In this report, we show that TGF-beta1 augments human AT(1)R (hAT(1)R) steady-state mRNA and protein levels in a dose- and time-dependent manner in primary human fetal pulmonary fibroblasts (hPFBs). Nuclear run-on experiments demonstrate that TGF-beta1 transcriptionally activates the hAT(1)R gene and does not influence hAT(1)R mRNA stability. Pharmacological inhibitors and specific siRNA knockdown experiments demonstrate that the TGF-beta1 type 1 receptor (TbetaRI/ALK5), Smad2/3, and Smad4 are essential for TGF-beta1-stimulated hAT(1)R expression. Additional pharmacological inhibitor and small interference RNA experiments also demonstrated that p38 MAPK, JNK, and phosphatidylinositol 3-kinase (PI3K) signaling pathways are also involved in the TGF-beta1-stimulated increase in hAT(1)R density. Together, our results suggest an important role for cross talk among Smad, p38 MAPK, JNK, and PI3K pathways in mediating the augmented expression of hAT(1)R following TGF-beta1 treatment in hPFB. This study supports the hypothesis that a self-potentiating loop exists between the RAS and the TGF-beta1 signaling pathways and suggests that ANG II and TGF-beta1 may cooperate in the pathogenesis of pulmonary fibrosis. The synergy between these systems may require that both pathways be simultaneously inhibited to treat fibrotic lung disease
— id: 95999, year: 2007, vol: 293, page: L790, stat: Journal Article,

The human angiotensin II type 1 receptor +1166 A/C polymorphism attenuates microrna-155 binding
Martin, Mickey M; Buckenberger, Jessica A; Jiang, Jinmai; Malana, Geraldine E; Nuovo, Gerard J; Chotani, Maqsood; Feldman, David S; Schmittgen, Thomas D; Elton, Terry S
2007 Aug 17;282(33):24262-24269, Journal of biological chemistry
The adverse effects of angiotensin II (Ang II) are primarily mediated through the Ang II type 1 receptor (AT1R). A silent polymorphism (+1166 A/C) in the human AT1R gene has been associated with cardiovascular disease, possibly as a result of enhanced AT(1)R activity. Because this polymorphism occurs in the 3'-untranslated region of the human AT1R gene, the biological importance of this mutation has always been questionable. Computer alignment demonstrated that the +1166 A/C polymorphism occurred in a cis-regulatory site, which is recognized by a specific microRNA (miRNA), miR-155. miRNAs are noncoding RNAs that silence gene expression by base-pairing with complementary sequences in the 3'-untranslated region of target RNAs. When the +1166 C-allele is present, base-pairing complementarity is interrupted, and the ability of miR-155 to interact with the cis-regulatory site is decreased. As a result, miR-155 no longer attenuates translation as efficiently as demonstrated by luciferase reporter and Ang II radioreceptor binding assays. In situ hybridization experiments demonstrated that mature miR-155 is abundantly expressed in the same cell types as the AT1R (e.g. endothelial and vascular smooth muscle). Finally, when human primary vascular smooth muscle cells were transfected with an antisense miR-155 inhibitor, endogenous human AT1R expression and Ang II-induced ERK1/2 activation were significantly increased. Taken together, our study demonstrates that the AT1R and miR-155 are co-expressed and that miR-155 translationally represses the expression of AT1R in vivo. Therefore, our study provides the first feasible biochemical mechanism by which the +1166 A/C polymorphism can lead to increased AT1R densities and possibly cardiovascular disease
— id: 96000, year: 2007, vol: 282, page: 24262, stat: Journal Article,

Chronic cardiac resynchronization therapy and reverse ventricular remodeling in a model of nonischemic cardiomyopathy
Nishijima, Yoshinori; Sridhar, Arun; Viatchenko-Karpinski, Serge; Shaw, Courtney; Bonagura, John D; Abraham, William T; Joshi, Mandar S; Bauer, John Anthony; Hamlin, Robert L; Gyorke, Sandor; Feldman, David S; Carnes, Cynthia A
2007 Sep 15;81(14):1152-1159, Life sciences
While cardiac resynchronization therapy (CRT) has been shown to reduce morbidity and mortality in heart failure (HF) patients, the fundamental mechanisms for the efficacy of CRT are poorly understood. The lack of understanding of these basic mechanisms represents a significant barrier to our understanding of the pathogenesis of HF and potential recovery mechanisms. Our purpose was to determine cellular mechanisms for the observed improvement in chronic HF after CRT. We used a canine model of chronic nonischemic cardiomyopathy. After 15 months, dogs were randomized to continued RV tachypacing (untreated HF) or CRT for an additional 9 months. Six minute walk tests, echocardiograms, and electrocardiograms were done to assess the functional response to therapy. Left ventricular (LV) midmyocardial myocytes were isolated to study electrophysiology and intracellular calcium regulation. Compared to untreated HF, CRT improved HF-induced increases in LV volumes, diameters and mass (p<0.05). CRT reversed HF-induced prolongations in LV myocyte repolarization (p<0.05) and normalized HF-induced depolarization (p<0.03) of the resting membrane potential. CRT improved HF-induced reductions in calcium (p<0.05). CRT did not attenuate the HF-induced increases in LV interstitial fibrosis. Using a translational approach in a chronic HF model, CRT significantly improved LV structure; this was accompanied by improved LV myocyte electrophysiology and calcium regulation. The beneficial effects of CRT may be attributable, in part, to improved LV myocyte function
— id: 95997, year: 2007, vol: 81, page: 1152, stat: Journal Article,

Minimizing osteotomy related complications for abductor sparing periacetabular osteotomy using C-arm image intensification
Ruchelsman, David E; Feldman, David S
2007 Jun;30(6):467-471, Orthopedics (Thorofare NJ)
The purpose of this study was to determine if C-arm image intensification reliably prevents violations of the posterior column or the hip joint at periacetabular osteotomy sites independent of pelvic flexion and rotation. To assess osteotome placement at the infracotyloid groove, quadrilateral plate, and inner ischial sites, anteroposterior (AP) and false-profile C-arm image intensification views were obtained at each site during both pelvic flexion (0 degrees, 10 degrees, 20 degrees, and 30 degrees) and rotation (0 degrees, 10 degrees, 20 degrees, and 30 degrees). At the infracotyloid groove, AP and false-profile C-arm image intensification confirmed perpendicular orientation of the bifid osteotome in all degrees of pelvic flexion and rotation. On the false-profile view, pelvic flexion and rotation did not impact C-arm image intensification visualization of the posterosuperior and inferior joint spaces at the quadrilateral plate and inner ischial sites, respectively. Optimal step-off of the osteotome from the posterior column was demonstrated on all false-profile views of the quadrilateral plate. Despite varying degrees of pelvic flexion and rotation, C-arm AP and false-profile views confirm accurate osteotome placement, as well as violations of the posterior column or the hip joint at the infracotyloid groove, quadrilateral plate, and inner ischial osteotomy sites. C-arm image intensification is a reliable tool in preventing posterior column violation and an intra-articular osteotomy during an abductor sparing periacetabular osteotomy.
— id: 73034, year: 2007, vol: 30, page: 467, stat: Journal Article,

Treatment of knee flexion contractures in patients with arthrogryposis
van Bosse, Harold J P; Feldman, David S; Anavian, Jack; Sala, Debra A
2007 Dec;27(8):930-937, Journal of pediatric orthopedics
BACKGROUND: Knee flexion contractures in children with arthrogryposis are difficult to treat. The purpose of this study was to assess the effectiveness of posterior knee releases and gradual contracture distraction with an Ilizarov external fixator in correcting and maintaining correction of knee flexion contractures of 40 degrees or greater. METHODS: The medical records and radiographs of 7 consecutive pediatric patients (10 knees) with arthrogryposis and knee flexion contractures of 40 degrees or greater were reviewed. The mean age at surgery was 7.3 years, and the mean length of follow-up was 52.7 months. All patients' knee flexion contractures were treated with posterior soft tissue releases and an Ilizarov external fixator for gradual contracture distraction. Posterior soft tissue releases included hamstrings lengthenings, proximal gastrocnemius release, and release of posterior capsule. RESULTS: The mean total fixator time was 102 days, with a mean correction rate of 1 degree per day. The mean knee flexion contracture was 72.5 degrees preoperatively, and all knees were corrected to full extension, +/-5 degrees. At latest follow-up, the mean contracture was 20.5 degrees, and all knees were ligamentously stable. The mean total arc of motion was 56 degrees preoperatively and 54 degrees at follow-up. Five patients who were previously nonambulatory became ambulatory. Complications included 3 fractures, 2 posterior tibial subluxations requiring frame adjustment, and 3 contracture recurrences (1 in a patient with a popliteal pterygium). CONCLUSIONS: Posterior knee releases and flexion contracture distraction by Ilizarov fixator was effective in improving the mobility of pediatric patients with arthrogryposis. At follow-up, the gradual loss of correction that occurred did not impact on the ambulatory gains made
— id: 76342, year: 2007, vol: 27, page: 930, stat: Journal Article,

Interobserver and intraobserver reliability of radiographic evidence of bone healing at osteotomy sites
Anand, Ashish; Feldman, David S; Patel, Raviraj J; Lehman, Wallace B; van Bosse, Harold J P; Badra, Mohammod I; Sala, Debra A
2006 Jul;15(4):271-272, Journal of pediatric orthopaedics. Pt. B
Plain radiographs are commonly used to evaluate the degree of bone healing after an osteotomy and the application of an external fixator. The purpose of the study was to assess intraobserver and interobserver reliability in determining bone healing, defined as bridging callus across three of four cortices, of osteotomy sites on radiographs. Substantial intraobserver reliability and a high intraobserver percentage agreement were found. Interobserver reliability was moderate and interobserver percentage agreement was less than half for agreement between all involved orthopaedic surgeons. The lower reliability across surgeons suggests that the determination of the extent of the bone healing is subjective
— id: 69239, year: 2006, vol: 15, page: 271, stat: Journal Article,

Accuracy of correction of tibia vara: acute versus gradual correction
Feldman, David S; Madan, Sanjeev S; Ruchelsman, David E; Sala, Debra A; Lehman, Wallace B
2006 Nov-Dec;26(6):794-798, Journal of pediatric orthopedics
The purpose was to assess the accuracy of deformity correction achieved in patients with tibia vara using acute intraoperative correction compared with gradual postoperative correction. Acute correction (AC) group consisted of 14 patients (14 tibiae) with a mean age of 11.4 years and whose tibia vara was corrected acutely and held using an EBI external fixator. Gradual correction (GC) group consisted of 18 patients (18 tibiae) with a mean age of 10.2 years and whose tibia vara was corrected gradually using 6-axis deformity analysis and Taylor Spatial Frame. Deformity measurements were compared preoperatively, postoperatively, and at latest follow-up. At latest follow-up, medial proximal tibial angle deviation from normal was similar for the 2 groups; posterior proximal tibial angle was significantly greater in the AC group (5.6 degrees) than in the GC group (1.9 degrees). Mechanical axis deviation was significantly greater in the AC group (17.1 mm) than in the GC group (3.1 mm). Postoperatively, frequency of accurate translation corrections (achieved translation within 5 mm of preoperative required translation) was significantly greater in the GC group (18/18) than in the AC group (7/14). Frequency of accurate angulation corrections (medial proximal tibial angle within 3 degrees of normal and posterior proximal tibial angle within 5 degrees of normal) was significantly greater in the GC group (17/18) than in the AC group (7/14). For both groups, all tibiae with preoperative internal rotation deformity had accurate rotation correction. Correction of preoperative limb-length inequality was achieved in 5 of the 7 patients in the AC group and 11 of the 11 patients in the GC group. Gradual deformity correction is a more accurate treatment method of tibia vara than acute correction
— id: 69421, year: 2006, vol: 26, page: 794, stat: Journal Article,

Evaluation of an algorithmic approach to pediatric back pain
Feldman, David S; Straight, Joseph J; Badra, Mohammad I; Mohaideen, Ahamed; Madan, Sanjeev S
2006 May-Jun;26(3):353-357, Journal of pediatric orthopedics
Pediatric patients require a systematic approach to treating back pain that minimizes the number of diagnostic studies without missing specific diagnoses. This study reviews an algorithm for the evaluation of pediatric back pain and assesses critical factors in the history and physical examination that are predictive of specific diagnoses. Eighty-seven pediatric patients with thoracic and/or lumbar back pain were treated utilizing after this algorithm. If initial plain radiographs were positive, patients were considered to have a specific diagnosis. If negative, patients with constant pain, night pain, radicular pain, and/or an abnormal neurological examination obtained a follow-up magnetic resonance imaging. Patients with negative radiographs and intermittent pain were diagnosed with nonspecific back pain. Twenty-one (24%) of 87 patients had positive radiographs and were treated for their specific diagnoses. Nineteen (29%) of 66 patients with negative radiographs had constant pain, night pain, radicular pain, and/or an abnormal neurological examination. Ten of these 19 patients had a specific diagnosis determined by magnetic resonance imaging. Therefore, 31 (36%) of 87 patients had a specific diagnosis. Back pain of other 56 patients was of a nonspecific nature. No specific diagnoses were missed at latest follow-up. Specificity for determining a specific diagnosis was very high for radicular pain (100%), abnormal neurological examination (100%), and night pain (95%). Radicular pain and an abnormal neurological examination also had high positive predictive value (100%). Lumbar pain was the most sensitive (67%) and had the highest negative predictive value (75%). This algorithm seems to be an effective tool for diagnosing pediatric back pain, and this should help to reduce costs and patient/family anxiety and to avoid unnecessary radiation exposure
— id: 68816, year: 2006, vol: 26, page: 353, stat: Journal Article,

Detection of coronary artery disease in orthotopic heart transplant recipients with 64-detector row computed tomography angiography
Iyengar, Srinivas; Feldman, David S; Cooke, Glen E; Leier, Carl V; Raman, Subha V
2006 Nov;25(11):1363-1366, Journal of heart & lung transplantation
Cardiac transplant recipients develop coronary artery disease in the form of cardiac allograft vasculopathy (CAV), and still undergo annual left heart catheterizations for detection at most centers. We prospectively enrolled 20 cardiac transplant recipients scheduled for annual left heart catheterization with X-ray coronary angiography (XRA) to also undergo electrocardiographically gated coronary computed tomography angiography (CTA), which was performed on a 64-detector computed tomography scanner. CTA detected more CAV vs XRA in 4 patients and less CAV in 0 patient, resulting in good overall agreement between the two modalities (kappa = 0.69). CTA may be superior to conventional catheter-based angiography to identify non-obstructive vessel wall disease that may go unrecognized with catheter-based angiography alone
— id: 96001, year: 2006, vol: 25, page: 1363, stat: Journal Article,

Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation?
Kubiak, Erik N; Egol, Kenneth A; Scher, David; Wasserman, Bradley; Feldman, David; Koval, Kenneth J
2005 Aug;87(8):1761-1768, Journal of bone & joint surgery (American volume)
BACKGROUND: Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other. METHODS: We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared. RESULTS: Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons). CONCLUSIONS: When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing
— id: 57846, year: 2005, vol: 87, page: 1761, stat: Journal Article,

Hinged distraction of the adolescent arthritic hip
Thacker, Mihir M; Feldman, David S; Madan, Sanjeev S; Straight, Joseph J; Scher, David M
2005 Mar-Apr;25(2):178-182, Journal of pediatric orthopedics
From 1996 to 2000, 11 adolescents with hip joint arthritis secondary to osteonecrosis or idiopathic chondrolysis were treated with articulated hinged distraction arthroplasty. Indications for surgery were severe pain and limited ambulation. Charts and radiographs were reviewed. Clinical status was assessed preoperatively and at latest follow-up (mean 4.8 years after surgery) using criteria of pain, range of motion, and ambulation level. Ten patients showed improved clinical status, with seven having an excellent outcome and three a good outcome. One patient failed distraction. Mean joint space was 2.6 mm before surgery and 4.8 mm at latest follow-up. Average duration of fixator use was 4.4 months. Four patients (36.4%) had complications. Articulated hip distraction was effective in eliminating pain, improving function, and preventing progressive degenerative changes in young patients' hips. It should be considered a salvage procedure for arthritic hips and an alternative to arthrodesis in this difficult-to-treat group of patients
— id: 56032, year: 2005, vol: 25, page: 178, stat: Journal Article,

Use of the foot abduction orthosis following Ponseti casts: is it essential?
Thacker, Mihir M; Scher, David M; Sala, Debra A; van Bosse, Harold J P; Feldman, David S; Lehman, Wallace B
2005 Mar-Apr;25(2):225-228, Journal of pediatric orthopedics
The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique
— id: 56031, year: 2005, vol: 25, page: 225, stat: Journal Article,

Surgical technique for an 'almost' percutaneous triple pelvic osteotomy for femoral head coverage in children 6-14 years of age
Lehman, Wallace B; Mohaideen, Ahamed; Madan, Sanjeev; Atar, Dan; Feldman, David S; Scher, David
2004 Jan;13(1):57-62, Journal of pediatric orthopaedics. Pt. B
A relatively simple triple pelvic osteotomy using two cosmetically small skin incisions can provide excellent coverage of the femoral head. An adductor approach and a bikini approach are used to do the osteotomy. The 'almost' percutaneous pelvic osteotomy successfully increases femoral head coverage in a concentric hip joint. The VCA angle of Lequesne and the center-edge angle of Wiberg both show significant improvement in the coverage of the femoral head. Three-dimensional computed tomography scanograms may provide a more graphic representation before and after surgery. Preoperatively, this is especially useful in evaluating posterior acetabular coverage of the femoral head. The almost percutaneous pelvic osteotomy is another possible triple pelvic osteotomy for procedures for hip dysplasia. It has a relatively low learning curve in comparison with other triple pelvic osteotomies for hip dysplasia in children aged 6-14 years. With careful patient selection, femoral head coverage can be improved with small incisions that are cosmetically acceptable
— id: 55959, year: 2004, vol: 13, page: 57, stat: Journal Article,

Genu valgum secondary to focal fibrocartilaginous dysplasia of the distal femur
Ruchelsman, David E; Madan, Sanjeev S; Feldman, David S
2004 Jul-Aug;24(4):408-413, Journal of pediatric orthopedics
We report a case of unilateral genu valgum secondary to focal fibrocartilaginous dysplasia (FFCD) isolated in the posterolateral cortex of the distal femur. This case is the first incidence of a discrete fibrous band occurring in conjunction with a FFCD lesion in the distal posterolateral femur treated with excision of the tether and the overlying periosteum with curettage of the cortical focal fibrocartilaginous defect. Treatment was considered successful with gradual resolution of the 30 degrees valgus deformity over 24 months, and we avoided the necessity of corrective osteotomy and its associated risks. To our knowledge, resolution of genu valgum secondary to FFCD in the distal posterolateral femur after curettage has not been previously described in the literature
— id: 46113, year: 2004, vol: 24, page: 408, stat: Journal Article,

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet
Scher, David M; Feldman, David S; van Bosse, Harold J P; Sala, Debra A; Lehman, Wallace B
2004 Jul-Aug;24(4):349-352, Journal of pediatric orthopedics
The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy
— id: 46114, year: 2004, vol: 24, page: 349, stat: Journal Article,

Correction of tibia vara with six-axis deformity analysis and the taylor spatial frame
Feldman, David S; Madan, Sanjeev S; Koval, Kenneth J; van Bosse, Harold J P; Bazzi, Jamal; Lehman, Wallace B
2003 May-Jun;23(3):387-391, Journal of pediatric orthopedics
Operative correction for infantile and adolescent tibia vara has been described using both external and internal fixation. Gradual correction using a circular fixator offers the advantage of accurate coronal, sagittal, and axial plane correction without significant soft tissue dissection. This study evaluated the use of six-axis deformity analysis and the Taylor Spatial Frame (TSF) for the correction of tibia vara. Nineteen patients (22 tibias), 6 with infantile and 13 with adolescent tibia vara, underwent correction with TSF. On the basis of mechanical axis correction, 21 of 22 tibias were corrected within 3 degrees of normal. Using Schoenecker's criteria, all patients achieved good results (no pain, <5 degrees difference in tibial-femoral angle from the normal side). Complications included one intractable pin-site infection, two superficial pin-site infections, and one delayed union. Six-axis deformity analysis and TSF provide accurate and safe correction of infantile and adolescent tibia vara
— id: 36161, year: 2003, vol: 23, page: 387, stat: Journal Article,

Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame
Feldman, David S; Shin, Steven S; Madan, Sanjeev; Koval, Kenneth J
2003 Oct;17(8):549-554, Journal of orthopaedic trauma
OBJECTIVE: To determine the effectiveness of six-axis analysis deformity correction using the Taylor Spatial Frame for the treatment of posttraumatic tibial malunions and nonunions. DESIGN: Retrospectively reviewed, consecutive series. Mean duration of follow-up was 3.2 years (range 2-4.2 years). SETTING: Tertiary referral center for deformity correction. PATIENTS/PARTICIPANTS: Eighteen patients were included in the study (11 malunions and 7 nonunions). All deformities were posttraumatic in nature. The mean number of operations before the application of the spatial frame was 2.6 (range 1-6 operations). All patients completed the study. INTERVENTION: Six-axis analysis deformity correction using the Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used for correction of posttraumatic tibial malunion or nonunion. Nine patients had bone grafting at the time of frame application. One patient with a tibial plafond fracture simultaneously had deformity correction and an ankle fusion for a mobile atrophic nonunion. Two patients had infected tibial nonunions that were treated with multiple debridements, antibiotic beads, and bone grafting at the time of spatial frame application. A rotational gastrocnemius flap was used to cover a proximal third tibial defect in one patient. The average length of time the spatial frame was worn, time to healing, was 18.5 weeks (range 12-32 weeks). MAIN OUTCOME MEASUREMENTS: Assessment of deformity correction in six axes, knee and ankle range of motion, incidence of infection, and return to preinjury activities. RESULTS: Of the 18 patients treated with the Taylor Spatial Frame, with adjunctive bone graft as necessary, 17 achieved union and significant correction of their deformities in six axes (ie, coronal angulation and translation, sagittal angulation and translation, rotation, and shortening). Fifteen patients returned to their preinjury activities at last follow-up. CONCLUSION: Six-axis analysis deformity correction using the Taylor Spatial Frame is an effective technique to treat posttraumatic malunions and nonunions of the tibia, with several advantages over previously used devices
— id: 46293, year: 2003, vol: 17, page: 549, stat: Journal Article,

A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot
Lehman, Wallace B; Mohaideen, Ahamed; Madan, Sanjeev; Scher, David M; Van Bosse, Harold J P; Iannacone, Michelle; Bazzi, Jamal S; Feldman, David S
2003 Mar;12(2):133-140, Journal of pediatric orthopaedics. Pt. B
The Ponseti casting technique is reported to have a high success rate in the treatment of idiopathic clubfoot. Non-operative treatment of clubfoot provides a lower complication rate, less pain, and higher function as the patient ages than operative treatment. To demonstrate serial post-treatment change in clubfeet over time, three clubfoot rating systems were utilized in the current study. Patients compliant with the Ponseti technique and treated before the age of 7 months, had a 92% success rate at an early follow-up after casting was completed. It is not the purpose of this article to analyze the long-term clubfoot treatment result but to establish tools which can be used to judge initial success with the Ponseti technique. Complications are few and minor, limited to equipment used and cast technique
— id: 36162, year: 2003, vol: 12, page: 133, stat: Journal Article,

Percutaneous fixation in clubfoot surgery: a radiographic and gait study
Tareco, Jennifer; Sala, Debra A; Scher, David M; Lehman, Wallace B; Feldman, David S
2002 Apr;11(2):139-142, Journal of pediatric orthopaedics. Pt. B
Twenty patients with Type II clubfeet were evaluated an average of 3.1 years after complete surgical soft tissue release. A pinned group had fixation of the talonavicular and calcaneocuboid joints and a non-pinned group had no fixation. The control group consisted of 10 children without foot ailments. Radiographic measurements of talocalcaneal and talus-first metatarsal angles and frequencies of dorsal and medial navicular subluxation were not different for the two treatment groups. Foot progression angle was not significantly different for the two treatment groups, but was significantly different between all clubfoot patients (3.6 degrees of in-toeing) and the control group (5.0 degrees of out-toeing). Tourniquet time was significantly greater for the pinned than for the non-pinned group, but the duration of surgery was similar. Similar radiographic and gait measurement findings suggest that clubfoot surgery with and without percutaneous fixation have comparable outcomes
— id: 38888, year: 2002, vol: 11, page: 139, stat: Journal Article,

Subfascial implantation of intrathecal baclofen pumps in children: technical note
Kopell BH; Sala D; Doyle WK; Feldman DS; Wisoff JH; Weiner HL
2001 Sep;49(3):753-756, Neurosurgery
OBJECTIVE: Indwelling intrathecal drug delivery systems are becoming increasingly important as a method of neuromodulation within the nervous system. In particular, intrathecal baclofen therapy has shown efficacy and safety in the management of spasticity and dystonia in children. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site. The pediatric population poses particular challenges with regard to these complications because appropriate candidates for intrathecal baclofen therapy are often undernourished and thus have a dearth of soft tissue mass to cover a subcutaneously implanted baclofen pump. We report a technique of subfascial implantation that provides greater soft tissue coverage of the pump, thereby reducing the potential for skin breakdown and improving the cosmetic appearance of the implantation site. METHODS: Eighteen consecutively treated children (average age, 8 yr, 7 mo) with spasticity and/or dystonia underwent subfascial implantation of a baclofen pump. These children's mean weight of 42.9 lb is less than the expected weight for a group of children in this age group, ranging from 4 years, 8 months, to 15 years, 7 months. In all patients, the pump was inserted into a pocket surgically constructed between the rectus abdominus and the external oblique muscles and the respective anterior fascial layers. RESULTS: At an average follow-up of 13.7 months, no infection or skin breakdown had occurred at the pump surgical site in any of the 18 patients. CONCLUSION: At this early follow-up, the subfascial implantation technique was associated with a reduced rate of local wound and pump infections and provided optimal cosmetic results as compared with that observed in retrospective cases
— id: 34710, year: 2001, vol: 49, page: 753, stat: Journal Article,

Hip arthrodesis in adolescents using external fixation
Scher DM; Jeong GK; Grant AD; Lehman WB; Feldman DS
2001 Mar-Apr;21(2):194-197, Journal of pediatric orthopedics
Between 1994 and 1998, seven adolescents underwent hip arthrodesis with the use of an external fixator. Mean time of follow-up was 24.0 months after surgery. The duration of fixation and time to fusion were 6.6 months (range, 5-9.5 months) and 8.0 months (range, 5.2-15 months), respectively. At most recent follow-up, there was a significant improvement in the mean modified Harris hip score, in which the maximum score is 91 points after omitting 9 points for hip range of motion and deformity, from 25.7 before surgery to 66.7 after surgery (p < 0.01). The advantages of this procedure include (i) the ease and accuracy of obtaining the proper position for fusion, (ii) the ability to lengthen the affected leg at the same time, (iii) the diminished likelihood of compromising future hip operations, and (iv) the ability to ambulate and bear weight throughout the treatment course. We recommend this method of hip arthrodesis with external fixation for patients with intractable hip pain necessitating this procedure
— id: 26777, year: 2001, vol: 21, page: 194, stat: Journal Article,

The use of bone scan to investigate back pain in children and adolescents
Feldman DS; Hedden DM; Wright JG
2000 Nov-Dec;20(6):790-795, Journal of pediatric orthopedics
Children with back pain frequently undergo detailed investigation because of the perception that a high percentage will have a treatable spinal condition. The purposes of this study was (i) to determine the percentage of children with disabling back pain presenting to our institution who had a diagnosis (i.e., to explain their back pain), (ii) to evaluate the clinical markers that should alert clinicians to underlying pathology, (iii) and to determine the prognosis of children with back pain and no specific diagnosis. This study was a retrospective analysis of consecutive children undergoing single-photon emission computed tomography for a primary complaint of back pain. Data collection included chart review, radiographic analysis, and clinical follow-up with the Roland and Morris scale for pain and disability. Two hundred and seventeen patients with an average age of 13 years (range, 2.7-17.7) were reviewed on average 4.4 years after presentation (range, 1.1-7.2 years). One hundred and seventy children (78.3%) had no specific diagnosis to explain their back pain, 15 children (6.9%) had spondylosis, 10 children (4.6%) had tumor, and the remaining 22 children (10.1%) had various diagnoses including infection, Scheuermann's kyphosis, herniated disc, kidney disease, facet arthritis, degenerative disc disease, congenital anomalies, and tethered cord. Factors associated with positive diagnoses were constant pain and male gender. Night pain, constant pain, and duration of symptoms <3 months were associated with the diagnosis of a tumor. Although the majority of children presenting with persistent back pain had no demonstrable cause, of 132 contactable patients 94 (71%) had persisting pain at the time of clinical follow-up. In conclusion, the majority of children with disabling back pain has no demonstrable cause and the majority will continue to have pain years after initial presentation
— id: 26834, year: 2000, vol: 20, page: 790, stat: Journal Article,

Congenital pseudoarthrosis of the tibia [In Process Citation]
Lehman WB; Atar D; Feldman DS; Gordon JC; Grant AD
2000 Apr;9(2):103-107, Journal of pediatric orthopaedics. Pt. B
Congenital pseudoarthrosis of the tibia remains one of the most difficult conditions to treat in orthopedic surgery. Seven cases were treated in our hospital by different methods. Three out of seven patients were healed, two of these refractured. At follow-up, the success rate was 14% (one out of seven cases). It is our recommendation that early primary amputation with an appropriate prosthesis should be considered, and that the final evaluation should not be based on obtaining bone union, but on the level of function of the lower extremity
— id: 11635, year: 2000, vol: 9, page: 103, stat: Journal Article,

How to avoid missing congenital dislocation of the hip
Feldman DS
1999 Oct 30;354(9189):1490-1491, Lancet
— id: 30806, year: 1999, vol: 354, page: 1490, stat: Journal Article,

Results of complete soft tissue clubfoot release combined with calcaneocuboid fusion in the 4-year to 8-year age group following failed clubfoot release
Lehman WB; Atar D; Bash J; Grant A; Feldman D; Kissin Y; Gutman J; Lindsey J
1999 Jul;8(3):181-186, Journal of pediatric orthopaedics. Pt. B
A subset of postoperative recurrent clubfeet was isolated in a group of patients 4 to 8 years old. Twenty-seven consecutive patients who underwent redo surgery consisting of complete soft tissue clubfoot release combined with a calcaneocuboid fusion were reviewed for this study. Twenty-six feet of 27 feet in 20 patients had a long-term good result, suggesting that this procedure is the one of choice for this age group
— id: 56453, year: 1999, vol: 8, page: 181, stat: Journal Article,

Fracture-dislocation of the neck of the talus in a ten-year-old child: a case report and review of the literature
Pereles TR; Koval KJ; Feldman DS
1996 ;55(2):88-91, Bulletin (Hospital for Joint Diseases)
A ten-year-old female underwent open reduction and internal fixation of a Hawkins type III fracture of the talar neck. The fracture united within three months. However, avascular necrosis of the body of the talus occurred. Partial collapse of the talar body ensued despite protection from weight-bearing for eight months after surgery. This case illustrates that fracture-dislocation of the talus can occur in a child and has a guarded prognosis
— id: 65635, year: 1996, vol: 55, page: 88, stat: Journal Article,

The role of intraoperative frozen sections in revision total joint arthroplasty
Feldman DS; Lonner JH; Desai P; Zuckerman JD
1995 Dec;77(12):1807-1813, Journal of bone & joint surgery (American volume)
We performed a retrospective analysis of thirty-three consecutive total hip and knee (twenty-three hip and ten knee) revision arthroplasties during which intraoperative frozen sections were analyzed. Data for the study were collected by means of a review of the charts, radiographic analysis, and evaluation of both frozen and permanent histological sections. The frozen sections, of periprosthetic tissue at the bone-cement interface or the pseudocapsule, were considered positive for active infection if there were more than five polymorphonuclear leukocytes per high-power field in at least five distinct microscopic fields. All patients were available for follow-up, at an average of thirty-six months (range, seventeen to seventy-nine months) after the initial revision operation. The frozen sections from ten patients were positive for infection, and those from twenty-three patients were negative. Comparison of the results of the analyses of the frozen sections (both positive and negative) with those of the analyses of the permanent histological sections of similar tissue showed a correlation of 100 per cent (sensitivity, 1.00; specificity, 1.00; and accuracy, 1.00). Nine patients had positive intraoperative cultures, and all of them had positive frozen sections (sensitivity, 1.00). Of the twenty-four patients who had negative intraoperative cultures, twenty-three had negative frozen sections (specificity, 0.96). Of the nine patients who had positive intraoperative cultures, only two were found to have infection on intraoperative gram-staining. The surgeon's operative assessment regarding the presence of infection, compared with the final pathological diagnosis, demonstrated a sensitivity of 0.70, a specificity of 0.87, and an accuracy of 0.82. All ten patients who had positive frozen sections were managed with excision arthroplasty; six of them subsequently had reimplantation, and the excision was the definitive procedure in the remaining four. One patient who had had a delayed reimplantation had a secondary skin slough and eventually was managed with an arthrodesis of the knee. In the group that had negative frozen sections, eighteen patients had a primary exchange revision arthroplasty and five had a delayed reimplantation. At the time of follow-up, one patient who had had a delayed reimplantation had radiographic loosening of the femoral component and was asymptomatic. One patient who had had a primary exchange arthroplasty was managed with a second revision because of aseptic loosening. There was no clinical recurrence of infection in any patient. The data indicate that analysis of frozen sections of periprosthetic tissue is a reliable predictor of the presence of active infection during revision joint arthroplasty. We recommend its use to differentiate aseptic from septic loosening
— id: 44587, year: 1995, vol: 77, page: 1807, stat: Journal Article,

Extra-articular triplane fracture of the distal tibial epiphysis
Feldman, D S; Otsuka, N Y; Hedden, D M
1995 Jul-Aug;15(4):479-481, Journal of pediatric orthopedics
We describe an extra-articular triplane fracture of the distal tibia in the skeletally immature patient. This variant of the triplane fracture has been largely ignored in the literature. The clinical significance of recognizing this fracture is that, although it constitutes an epiphyseal fracture, it remains extra-articular. Unlike the standard triplane fracture that exists through the tibiotalar joint, this variant can be treated acceptably with less than an anatomical reduction, therefore often avoiding the need for surgical management
— id: 110765, year: 1995, vol: 15, page: 479, stat: Journal Article,

Clinical efficacy of aspirin and dextran for thromboprophylaxis in geriatric hip fracture patients
Feldman DS; Zuckerman JD; Walters I; Sakales SR
1993 ;7(1):1-5, Journal of orthopaedic trauma
The clinical efficacy of thromboprophylaxis with aspirin and dextran 40 was compared in a prospective review of 530 geriatric hip fracture patients treated surgically. All patients were also treated with early mobilization with weight bearing as tolerated and above-knee elastic stockings. In addition to clinical efficacy in preventing thromboembolic complications [deep vein thrombosis (DVT), pulmonary embolism (PE)], safety and cost-effectiveness were also assessed. The overall incidence of clinical thromboembolic disease was 2.8% (DVT = 0.4%, PE = 2.4%). The incidence of DVT (0.5%) and PE (2.6%) in the aspirin group was essentially the same as the incidence of DVT (0.3%) and PE (2.4%) in the dextran group. The inhospital mortality rate (aspirin 4.6%, dextran 3.8%), wound drainage (aspirin 1.5%, dextran 0.9%), deep wound infection (aspirin 0.5%, dextran 0.3%), gastrointestinal bleeding (aspirin 2.1%, dextran 1.5%), and congestive heart failure (aspirin 2.6%, dextran 1.8%) did not differ significantly between the two groups. The intraoperative transfusion rate was similar in both groups (aspirin .65 units, dextran .55 units). However, postoperatively, the transfusion rate was significantly higher in the dextran group (aspirin .26 units, dextran .41 units, p < .05). The treatment of thromboembolic complications was the same for each group and therefore represents similar treatment costs. However, the cost of prophylaxis with dextran was $309 per patient and with aspirin was $1.79 per patient. Our findings suggest that, based on clinical diagnostic criteria, aspirin and dextran are equally effective thromboembolic prophylactic agents in geriatric hip fracture patients. The safety, cost, and ease of administration of aspirin may make its use more desirable
— id: 44607, year: 1993, vol: 7, page: 1, stat: Journal Article,