Outcomes in Early Versus Delayed Management of Pediatric Femoral Shaft Fractures.

OBJECTIVE: There is a paucity of literature regarding the timing of treatment for pediatric femur fractures. The purpose of this study was to analyze whether early versus delayed management of pediatric femoral shaft fractures would impact outcomes regarding time to union and return to baseline function. METHODS: Pediatric patients presenting with femoral shaft fractures, from January 1, 2010 to January 1, 2021, were identified using the Pediatric Trauma Database at a single Level One Trauma Center and retrospectively reviewed. Demographic information, surgical details, associated injuries, length of follow-up, time to union, and return to baseline function were collected. Patients were then divided into 2 groups; the early intervention group underwent treatment within 24 hours of admission versus the delayed group, which underwent treatment after 24 hours. Patients with neuromuscular disease, pathologic fracture, slipped capital femoral epiphysis, nonambulatory, younger than 6 months old, or had follow-up of <8 weeks posttreatment were excluded. χ 2 and unpaired Student t tests were used to compare outcomes. A P value ≤0.05 was used as the threshold of statistical significance. RESULTS: Of the 169 cases reviewed, 137 met the inclusion criteria. The mean age was 8.0 ± 5.0 (6 mo to 16 y). The average follow-up time was 1.4 ± 1.4 years. Thirty-two (19%) patients did not meet the inclusion criteria and were excluded from the study. One hundred twenty-two (89%) patients were in the early intervention group versus 15 (11%) in the delayed intervention group. There were no statistically significant differences between the early and the delayed arms in regard to time to union, quality of final reduction, and return to baseline function. CONCLUSION: The findings of this study support that the timing of surgical intervention of femoral shaft fractures in the pediatric population is not correlated to time to union and final function. Clinically, prompt treatment of pediatric femoral shaft fractures should not supersede medical methods of resuscitation and likely has no bearing on the final outcome. LEVEL OF EVIDENCE: Level III.

Development of a Saw Bones Model for training pedicle screw placement in scoliosis.

OBJECTIVE: The purpose of this study was to determine if a Sawbones Scoliosis Model could be used as a simulator to train residents in placing pedicle screws-a complex procedure with a steep learning curve. Surgical simulation, a common tool teaching residents complex procedures in a safe environment, was staged using a Sawbones Scoliosis Model. Ten junior and ten senior residents out of 25 total possible residents (80%) were instructed how to place pedicle screws using the free-hand technique. They were then asked to place them unilaterally from T4 to L4 and were assessed on completion time, accuracy placement accuracy, and overall competency using an objective rating scale. RESULTS: Senior residents had an average time to completion of 38.9 ± 4.7 min vs. junior's 50.1 ± 11.7 min, and a pedicle screw accuracy of 43.6 ± 6.4% vs. junior's 44.4 ± 17.4%. Overall competency scores were similar for both groups; however, senior residents scored higher in the time and motion subdomain. Senior residents had a faster completion time and were more efficient, suggesting greater experience in spine surgery. The low rate of screw accuracy in both groups validates that simulation is a safe way for trainees to learn complex tasks.

Heterotopic Ossification of the Peroneus Brevis Tendon in a Pediatric Patient.

Heterotopic ossification (HO) is abnormal formation of mature lamellar bone in soft tissues. HO is most commonly diagnosed in the setting of localized trauma, which results in improper differentiation of progenitor cells, leading to aberrant tissue formation. In the pediatric population, nongenetic causes of HO have rarely been reported, especially HO involving the tendons of the ankle. We present a case of HO of the peroneus brevis tendon without systemic disease in a pediatric patient. The patient was a 7-year-old female with a normal birth and developmental history who first presented 6 weeks after a right ankle sprain with pain localized to the lateral calcaneus. Prominent swelling and tenderness to palpation were noted over the peroneal tubercle. Radiographic imaging showed dystrophic calcification within the peroneus brevis tendon. After failed conservative management, the heterotopic ossified mass (1.5 × 0.3 cm) was excised from the peroneus brevis tendon. The tendon was primarily repaired. The patient was followed up for 12 weeks postoperatively and achieved full resolution of her pain with a return to normal activity. HO has been theorized to be the result of an imbalance between bone mineralization and demineralization. In the setting of localized trauma, inductive agents have been implicated in pathologic bone formation. In the pediatric population, HO has rarely been diagnosed in the absence of genetic causes. In patients presenting with lateral foot and ankle pain, HO of the peroneal tendons should be considered in the differential diagnosis. In a patient with pain secondary to HO, surgical excision of the heterotopic mass can achieve symptom resolution.

Biomechanical Comparison of Spinopelvic Fixation Constructs: Iliac Screw Versus S2-Alar-Iliac Screw.

STUDY DESIGN: Biomechanical cadaveric study. OBJECTIVE: To compare the biomechanical properties of the iliac and S2-Alar-Iliac (S2AI) screw in a similar spinopelvic fixation construct. SUMMARY OF BACKGROUND DATA: Spinopelvic fixation is used in the correction of pelvic obliquity, high-grade spondylolisthesis, and long spinal fusions. With the development of pedicle screw fixation, the iliac screw has been used as an anchor point to the pelvis. The associated morbidity with this fixation has led to the development of the S2AI screw. Many studies have examined the biomechanical properties of iliac and S2AI screws; however, a direct comparison has not been performed. METHODS: Eight cadaveric spines were instrumented with pedicle screws bilaterally at L5 and S1. Four specimens were further instrumented with iliac screws placed with a starting point at the posterior superior iliac spine, and four specimens were instrumented with S2AI screws placed with a starting point 1 mm inferolateral to the S1 foramen. Screws were connected with 6.35 mm rods. Subfailure testing was performed by loading at 1°/second to a torque of 10 Nm in four directions: left bending, right bending, extension, and flexion. Specimens then underwent a monotonic load to failure under flexion at a rate of 1°/second. RESULTS: There were no significant differences for torsional stiffness in extension, flexion, left bending, or right bending between S2AI and iliac screw constructs. There were no significant differences in S2AI versus iliac screws for failure torque (30.9 ± 12.00 Nm vs. 22.61 ± 6.25 Nm) and yield torque (11.86 ± 0.41 Nm vs. 12.01 ± 1.70 Nm). CONCLUSION: Iliac screws have been associated with increased dissection, wound complications, an additional construct failure point, and hardware prominence. The S2AI screw was developed as an alternative and has been associated with less morbidity. The iliac and S2AI screw demonstrate no statistical difference in stiffness and load-to-failure in a spinopelvic fixation model. LEVEL OF EVIDENCE: Level V.