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The word retirement is going out of fashion. Many orthopaedic surgeons want to work in some capacity when they stop performing surgery. Making a smooth transition from a busy orthopaedic practice to alternative work demands advanced planning. The surgeon must consider personal issues that involve how to use human capital (his or her accumulated knowledge and experience). New ventures, hobbies, travel, and spending time with family and friends are some possibilities. Plans for slowing down or leaving the practice should be discussed and agreed on well ahead of time. Agreements for buyouts may be difficult to work out and will require creative thinking. The solo practitioner can close the practice or hire a successor. Financial planning is perhaps the most important consideration and should be started by approximately age 40. It is recommended that the surgeon develop a portfolio of secure investments and annuities to provide adequate income for as long as is needed and then to turn the residual income to one's family, favorite charities, or other desired cause. A team of competent advisors is needed to help develop and achieve one's goals, create financial security, and provide the discipline to carry out the needed planning for life after orthopaedics.

Objective: To compare the safety and efficacy of midazolam given intranasally with diazepam given intravenously in the treatment of children with prolonged febrile seizures. Design: Prospective randomised study. Setting: Paediatric emergency department in a general hospital. Subjects: 47 children aged six months to five years with prolonged febrile seizure (at least 10 minutes) during a 12 month period. Interventions: Intranasal midazolam (0.2 mg/kg) and intravenous diazepam (0.3 mg/kg). Main outcome measures: Time from arrival at hospital to starting treatment and cessation of seizures. Results: Intranasal midazolam and intravenous diazepam were equally effective. Overall, 23 of 26 seizures were controlled with midazolam and 24 out of 26 with diazepam. The mean time from arrival at hospital to starting treatment was significantly shorter in the midazolam group (3.5 (SD 1.8) minutes, 95% confidence interval 3.3 to 3.7) than the diazepam group (5.5 (2.0), 5.3 to 5.7). The mean time to control of seizures was significantly sooner (6.1 (3.6), 6.3 to 6.7) in the midazolam group than the diazepam group (8.0 (0.5), 7.9 to 8.3). No significant side effects were observed in either group. Conclusion: Seizures were controlled more quickly with intravenous diazepam than with intranasal midazolam, although midazolam was as safe and effective as diazepam. The overall time to cessation of seizures after arrival at hospital was faster with intranasal midazolam than with intravenous diazepam. The intranasal route can possibly be used not only in medical centres but in general practice and, with appropriate instructions, by families of children with recurrent febrile seizures at home.

The objective of this study was to evaluate a new method for the treatment of acute hyperammonemia with a helium-oxygen mixture (heliox). We conducted a prospective, randomized, controlled study of male Sprague-Dawley rats. Experimental hyperammonemia was induced by 7 days of a high-ammonia diet. Subsequently, the animals were randomly divided into two groups: the study group treated with heliox breathing for 24 hours and a control group breathing room air for 24 hours. A prospective, randomized, controlled laboratory animal study was conducted at an animal research facility. The baseline plasma ammonia level was 9.49 ± 10.96 μmol/L. After 7 days of a high-ammonia diet, the plasma ammonia level rose to 31.53 ± 8.86 μmol/L. There was a significant statistical difference between the plasma ammonia level following 24 hours of heliox therapy ( 23.14 ± 13.97 μmol/L) and the ammonia level in the control group (42.31 ± 24.25 μmol/L) (P < .05). Heliox breathing was found to be an efficient treatment modality for decreasing plasma ammonia levels in an animal model. Further studies are required to evaluate its potential application in the treatment of patients with hyperammonemia. (J Child Neurol 2001;16:456-458).

We report a child with craniosynostosis, partial absence of the corpus callosum, developmental delay, precocious puberty, and deletion of chromosome 9(p 12p 13,3). A review of the literature did not reveal any previous combination of the same kind. Craniosynostosis and partial absence of the corpus callosum, separately or in conjunction, may be part of the spectrum of malformations in the chromosome 9p deletion syndrome, and its presence, in combination with other known features, should prompt a search for this particular deletion as part of the differential diagnosis. (J Child Neurol 2002;17:50-51).

Summary The incidence of wound infection following hip nailing is unacceptably high in many hospitals. Many of these infections go unrecognized temporarily or permanently owing to absence of the typical signs of sepsis. A high degree of suspicion must be accompanied by clinical acumen and the use of physical examination, radiography, laboratory studies, aspirate examination, and at times surgical biopsy to diagnose or exclude the possibility of infection. Bacteriologic cultures must be properly plated and carefully interpreted. Organisms that are normally saprophytic often become pathogenic with a metallic implant. Treatment consists of the proper surgical procedure properly timed with extensive debridement, appropriate antibiotics, and immobilization of the tissues postoperatively. The prophylactic use of antibiotics, improved surgical technique, and a cleaner operating room environment should decrease the incidence of these infections to a more acceptable level.

Early tendon transplantations were confined to the foot following Nicoladoni's original operation in 1881. The knee offered the next logical site for experimentation and Goldthwait in 1897 reported on successful sartorius transplants to strengthen weak quadriceps muscles. Subsequently all the thigh muscles, individually or in combination, have been so employed. In this end-result study we have evaluated thirty-eight patients in whom thirty-nine transplantations at the knee were done between 1922 and 1946 with an average followup of nine and two-tenths years. The subjective results were similar to those in other reports and were in general good, but on objective grounds the results were disappointing. Knee-extension power following tendon transplantation was rated fair or better in only 30 per cent. of the cases. Seven of twelve patients using braces preoperatively were enabled to discard their braces. Even in these apparently successful cases the effect of the tendon transplantation and of other operative procedures could not be evaluated separately. Comparison of the transplantation cases with control groups with similar patterns of muscle weakness leads us to draw certain important conclusions. The function of the extremity, as well as the ability to walk without apparatus, is dependent on a number of factors. There has been a tendency to assume that the most important factor is quadriceps or extensor power. Our study suggests that other factors are of equal importance. Good hip, posterior thigh, and calf musculature will permit excellent function, even when the quadriceps is paralyzed. On the contrary, the extremity with good quadriceps power and poor posterior musculature usually requires bracing. Good power in extension of the knee is less important in brace-free walking than is a stable foot and good posterior musculature. Tendon transplantation at the knee in some instances impairs function by the production of hyperextension deformities, dislocation of the patella, or lateral instability. Although a number of cases in this series have apparently been greatly benefited by muscle transplants, others must be rated as failure. The indications for tendon transplantation to improve extensor power of the knee are not easy to formulate. It is our belief that in the past such operations have been done too frequently. Poliomyelitis has been described as a subtractive disease, and ill-advised tendon transplantation at the knee in some instances is a subtractive operation.

Early tendon transplantations were confined to the foot following Nicoladoni's original operation in 1881. The knee offered the next logical site for experimentation and Goldthwait in 1897 reported on successful sartorius transplants to strengthen weak quadriceps muscles. Subsequently all the thigh muscles, individually or in combination, have been so employed. In this end-result study we have evaluated thirty-eight patients in whom thirty-nine transplantations at the knee were done between 1922 and 1946 with an average followup of nine and two-tenths years. The subjective results were similar to those in other reports and were in general good, but on objective grounds the results were disappointing. Knee-extension power following tendon transplantation was rated fair or better in only 30 per cent. of the cases. Seven of twelve patients using braces preoperatively were enabled to discard their braces. Even in these apparently successful cases the effect of the tendon transplantation and of other operative procedures could not be evaluated separately. Comparison of the transplantation cases with control groups with similar patterns of muscle weakness leads us to draw certain important conclusions. The function of the extremity, as well as the ability to walk without apparatus, is dependent on a number of factors. There has been a tendency to assume that the most important factor is quadriceps or extensor power. Our study suggests that other factors are of equal importance. Good hip, posterior thigh, and calf musculature will permit excellent function, even when the quadriceps is paralyzed. On the contrary, the extremity with good quadriceps power and poor posterior musculature usually requires bracing. Good power in extension of the knee is less important in brace-free walking than is a stable foot and good posterior musculature. Tendon transplantation at the knee in some instances impairs function by the production of hyperextension deformities, dislocation of the patella, or lateral instability. Although a number of cases in this series have apparently been greatly benefited by muscle transplants, others must be rated as failure . The indications for tendon transplantation to improve extensor power of the knee are not easy to formulate. It is our belief that in the past such operations have been done too frequently. Poliomyelitis has been described as a subtractive disease, and ill-advised tendon transplantation at the knee in some instances is a subtractive operation.

THE ankle joint — to function properly — must have smooth articular cartilage, proper weight- bearing alignment, intact supporting ligaments and good musculature under adequate voluntary control. A variety of pathologic changes are of frequent occurrence. Trauma, infection and certain other processes may cause such damage to the cartilaginous surfaces of the joint that a painful arthritis prevents normal function. Gross deformities of the foot — congenital or acquired — such as a clubfoot or the late sequelae of poliomyelitis and hemiplegia result in inability to place the sole of the foot flat on the floor and to carry out, . . .

Of 166 adults in whom poliomyelitis developed before the age of eleven, varying degrees of muscle power and shortening were present in the lower extremities. There was no specific relationship between the age of onset and the amount of discrepancy in limb length. There was, however, a definite relationship between the relative muscle strength in the two extremities and the discrepancy in limb length. These data may be utilized clinically in predicting the amount of shortening that will occur in a patient having poliomyelitis before the age of eleven.

As the result of an end-result study of forty-four veterans who had fractures of the carpal navicular, recognized while in Military Service during World War II, the following conclusions seemed warranted: 1. If healing by primary union occurs, there is minimal residual disability which does not interfere with the performance of duty. 2. About 50 per cent. of the ununited fractures were surveyed from the Service for wrist symptoms. If non-union is established before induction, this injury should be disqualifying for full-duty status. 3. The incidence of non-union in Military Service was 22 per cent. The factors tending to produce non-union appeared to be insufficiently prolonged immobilization and delay in instituting treatment. Immobilization must be maintained until there is union as shown by x-ray. This may require more than eight weeks, even in acute fractures promptly diagnosed and treated. 4. The treatment of non-union in this series was unsatisfactory. Of the fourteen men with non-union, nine were treated conservatively without improvement; five were operated upon, union and a satisfactory result being obtained in two. 5. Persistent non-union results in partial absorption, displacement and fragmentation of the fragments, cyst formation in the navicular, and degenerative arthritic changes. Functional impairment was present in every case, but earning power was impaired in only 42 per cent. of the cases. 6. A psychiatric study of these patients revealed the personalities to be heterogeneous with no particular trait outstanding. In only six instances were there clearly discernible psychological factors related to the fracture or the veteran's adjustment following the fracture. 7. The work capacity of these injured wrists, as determined by a specially designed recording ergograph, in cases with primary union showed little or no impairment. Only one of the fourteen wrists with non-union showed a normal work capacity. The ergographic tracing in the uncooperative patient was characteristic and proved to be an aid in detecting lack of cooperation.

Summary and ConclusionsTwenty-two albino rats were given small amounts of elementary phosphorus supplementary to an adequate diet. Roentgenograms taken before and during the experimental period demonstrated the development of an area of increased density in the subepiphyseal region.Histologic studies revealed a failure of resorption of the usual number of primary epiphyseal trabeculae. Since bone was deposited upon these persistent spicules in an otherwise normal fashion an apparent sclerosis was produced. Although the degree of ossification was distinctly greater than normal there was no evidence of direct stimulation of osteoblastic activity. The lesion was dependent entirely upon the unusual preservation of mineralized cartilage. It was thought that the persistence of these primary trabeculae was related to the influence of elementary phosphorus deposited in this region.

The immediate postamputation plaster prosthesis was supplied as a central community service in a large metropolitan area in 75 lower-extremity amputations. The overall healing rate was 90%. Half the patients were ready for discharge in four weeks or less; 85% eventually walked with a prosthesis. Although this record is satisfactory, the spread of responsibility for the 75 amputations among 53 different surgeons forced the conclusion that, because of difficulties in communication, a central service of this type was not practical in that community as now constituted. Where continuity of the whole patient care team could be established, the value of the immediate postamputation plaster was confirmed. Experience with various types of going-home prostheses emphasized the need in this and other communities for facilities to enable safe provision of early, total-contact prostheses.

THE WORD "HEMOPHILIA" frequently conjures up the picture of a severely disabled boy or adult man, crippled by damage to his joints, and suffering from recurrent life-threatening hemorrhages. Such patients have the disease in its severe form, usually having less than 1% of normal antihemophilic factor (AHF) (factor VIII) plasma thromboplastin component or (PTC) (factor IX). Less well known is the fact that hemophiliacs with a mild form of the disease may be entirely unaware of their disability. These patients usually have more than 5% of the deficient factor, rarely have trouble with their joints, and are often able to lead a full and normal life. They are nevertheless susceptible to severe bleeding, particularly after surgery or major injury; sometimes ignorance of their inherent bleeding tendency can lead to results more serious than those in a known severe hemophiliac with the same type of bleeding because of delay in instituting

To the Editor.— Drs. Murphy and Devers (227:1123, 1974) are correct in emphasizing that one must be alert to avoid the problem of ulnar neuropathy during the time a patient is anesthetized and defenseless. However, in my experience, it is much more common to see this complication occur several days or more postoperatively. The seriously ill patient or the orthopedic patient in traction cannot move much in bed, and often lies with the hands on the abdomen and the elbows flexed. This puts direct pressure on the ulnar groove and the ulnar nerve. Many hospital mattresses are covered with a firm layer of plastic; this adds to the pressure on the ulnar nerve. The condition is diagnosed easily by the location of the symptoms (fourth and fifth fingers) and by tenderness over the ulnar nerve behind the medial epicondyle. It is helpful to place a pillow at the patient's side

The data and conclusions of this paper are derived from the study of the records and roentgen examinations of 106 consecutive cases admitted to the New England Peabody Home for Crippled Children with a diagnosis of tuberculosis of the hip. DIAGNOSIS In 15 per cent it was later found that an incorrect admission diagnosis had been made. It is most important to exclude such cases, as they have in general a much more favorable prognosis than tuberculosis of the hip. The ninety remaining cases were accepted as tuberculosis for one or more of the following reasons: Positive guinea-pig test from material removed by aspiration or operation. Twenty-nine cases, or 32 per cent, were proved by this method. Positive evidence of tuberculosis on pathologic examination of material removed at operation. In seventeen of the twenty-two cases in which pathologic material was examined, the histologic diagnosis was tuberculosis. The remaining

Cases of cerebral spastic birth palsy not infrequently present the problem of the management of a flexion-internal rotation deformity of the thigh. In spite of prolonged training of muscles, it may be necessary to resort to operative procedures to improve muscle balance and relieve the deformity. In this paper I shall describe an operation used by me for the past ten years for the relief of this type of deformity. In this operation the muscles causing the deformity are transposed from their site of origin and attached to a new site on the ilium. In the new position they act as abductors, external rotators and extensors of the thigh. MUSCLES INVOLVED IN SPASTIC DEFORMITY OF THE THIGH The cerebral lesion of spastic birth palsy is usually sufficiently diffuse to impair the function of groups of muscles. A single deformity is not as common as is a compound one in which

The purpose of this paper is to review briefly the literature and to report five additional cases of what is referred to by various writers as congenital, infantile or cervical coxa vara. Coxa vara is an anatomic term now used to indicate a diminution from normal of the angle between the neck and the shaft of the femur. Since coxa vara is caused by the strain of weight-bearing on a weakened femoral neck, one finds that the cases fall into certain groups, depending on the etiology of the weakness. A classification now generally used is as follows: 1. Congenital coxa vara (the infantile or cervical type of Elmslie and Fairbanks). 2. Acquired coxa vara. ( a ) Due to local pathologic processes such as cervical fracture, tuberculous or pyogenic infection, metastatic malignancy and similar conditions. ( b ) Adolescent coxa vara, which Noble and Hauser believe is due to pituitary dysfunction. ( c ) Coxa vara

To the Editor:— I would agree that brucellosis is a possible cause of hydrarthrosis and that it should be included in the differential diagnosis. There can be no question of the diagnosis when the Brucella organism is recovered from the synovial fluid. In the absence of such findings, considerable reservation should be exercised in making the diagnosis.

CONGENITAL DEFCRMITIES Congenital Dislocation of the Hip. —Bradford,1in a comprehensive paper, has reviewed the history of the treatment of congenital dislocation of the hip. After a wide experience, he considers that the attempt at reduction should be made as early as is possible and before the actual locomotion of the child begins. Any treatment before this should consist of the employment of a traction splint, which in rare cases may accomplish reduction. Bradford advocates reduction by forcible manipulation, under an anesthetic, and he believes that the open method should be reserved for the cases in which this closed method has failed. In the older resistant cases, he advocates the use of the mechanical aids which fix the pelvis and, by use of traction and levers, give the surgeon's hands greater power, accurately applied. He emphasizes the importance of prolonged after-treatment. [Ed. Note —Since plaster of Paris is the