Incisional Negative Pressure Wound Therapy Does Not Affect Deep Surgical Site Infection Rates in Neuromuscular Scoliosis Surgery.

Surgical site infection (SSI) is a devastating complication in patients with neuromuscular scoliosis (NMS) undergoing posterior spinal instrumented fusion (PSIF) for progressive scoliosis. Incisional negative pressure wound therapy (INPWT) has been used in other surgical fields to reduce SSI. Our purpose was to examine the prophylactic use of INPWT after NMS surgery to decrease SSI. At a single institution, 71 consecutive patients with NMS underwent PSIF from 2015 to 2019. Starting in 2017, all patients with NMS received INPWT postoperatively until discharge. Rates of deep SSI were compared between the two cohorts of patients. Additionally, patient demographic and operative factors such as American Society of Anesthesiologists score, number of levels instrumented, need for an anterior spinal release, need for spinal fusion to pelvis, blood loss, operative time, fluoroscopy time, length of stay, and transfusion requirement were analyzed for potential influence on deep SSI. There was no significant difference in deep SSI rates between patients who received INPWT (2 of 41) and those treated with a standard postoperative dressing (2 of 30; P=1.0). Although INPWT theoretically can stabilize the wound environment and prevent deep SSI, our findings do not support this. More research is needed to evaluate the efficacy of INPWT after PSIF for NMS. [Orthopedics. 2023;46(6):373-378.].

A Two-Surgeon Approach Improves Performance for Young Surgeons in Adolescent Idiopathic Scoliosis.

Adolescent idiopathic scoliosis (AIS) is a complex 3-dimensional deformity. Previous studies have suggested a learning curve in the successful execution of this technically demanding procedure. A 2-surgeon model may be helpful for less experienced surgeons by facilitating greater consistency in surgical metrics. The objective of this study was to show no significant difference in the parameters examined for surgeries done by inexperienced primary surgeons with a 2-surgeon model compared with those done by their more experienced cohorts. All surgeries with a primary diagnosis of AIS that were performed from January 2012 to December 2015 and had a minimum of 2-year follow-up were included for analysis. Three groups were created based on surgeon experience: inexperienced surgeons (IS) group, experienced surgeons (ES) group, and a third group where the primary surgeon was in the experienced group and the assistant surgeon was in the inexperienced group (EIS). Variables included for analysis were age, Lenke classification, number of levels fused, length of surgery, length of stay, percent curve correction, ratio of estimated blood loss to levels fused, surgical blood loss, and complications. There were no significant differences between the groups in terms of operative time, blood loss, number of levels fused, lower estimated blood loss ratio to the number of levels fused, or percent curve correction (P>.05). The IS group was found to have a significant shorter length of stay (P=.004). The 2-surgeon model is an effective tool for inexperienced surgeons to achieve consistent and reproducible operative performance that is comparable with their more experienced peers. [Orthopedics. 2021;44(3):e347-e352.].

Post-traumatic pseudoaneurysm of brachial artery in multiple hereditary exostoses.

Pseudoaneurysms adjacent to exostoses have been commonly reported in the femoral and popliteal arteries and only rarely in the upper extremity. We describe a case of an 18-year-old man with multiple hereditary exostoses who developed a brachial artery pseudoaneurysm after minor trauma to his right upper arm, adjacent to a known lesion. He was referred to a vascular surgeon who removed the pseudoaneurysm and repaired the artery with a saphenous vein graft. We encourage a high suspicion of vascular injury even after minor trauma when an osteochondroma is adjacent to a vascular structure.

The Factors Influencing the Refracture of Pediatric Forearms.

PURPOSE: Pediatric forearm fractures are common and usually heal uneventfully. The purpose of this study was to review the refracture rate and to identify trends and risk factors that may lead to a refracture. METHODS: Using current procedure terminology code and subsequent chart review we retrospectively identified 2590 patients who sustained forearm fractures over the past 10 years (2000 to 2010) and were treated at a single, large pediatric orthopaedic practice. RESULTS: We identified 37 patients who met our search criterion which yielded a refracture rate of 1.4%. Average length of immobilization was 72.2 days for initial fractures and 98.2 days for refractures. Average time to refracture after declared healing of initial injury was 128.7 days with 36% of refractures occurring within 6 weeks of clinical clearance. Fractures with ≥ 15 degrees angulation refractured earlier (mean 40 d). Seventy-one percent (71%) of patients with refractures had ≥ 10 degrees residual angulation at the time of union of the initial fracture. There was complete radiographic healing in 72% of patients that subsequently refractured. Forearm fractures that refractured most commonly occurred in the middle third (72%), with 24% in the proximal third and 4% in the distal third. Only 2 of 28 patients required surgical instrumentation of the forearm to achieve union of the refracture. We identified a trend toward longer immobilization and time to clinical clearance following a refracture, 76.4 versus 104.2 days. CONCLUSIONS: Over the past 10 years, our clinical data identifies a 1.4% refracture rate, which is significantly less than the previously published rate of 5%. Fractures with greater residual angulation (> 15 degrees) showed a tendency toward earlier refracture and may warrant longer immobilization. Forearm refractures united in most instances with closed treatment. Our treatment with cast or protective brace immobilization and limitation of activity until complete radiographic union likely influences our improved refracture rates.

The risk of bisphosphonate-related osteonecrosis of the jaw in children. A case report and literature review.

UNLABELLED: Bisphosphonate use has been described in children diagnosed with osteogenesis imperfecta (OI), fibrous dysplasia, neuromuscular disorders, bone dysplasia, idiopathic juvenile osteoporosis, rheumatologic disorder and even Crohn's disease. In OI patients, bisphosphonates have become an important symptomatic therapy for moderate and severe forms of the disease, because their inhibitory effect on osteoclasts increases bone mineralization and density, thereby reducing the risk of bone fractures. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) has become an increasingly common complication as the use of these drugs is becoming more widespread in adults. However, the evidence for BRONJ in paediatric patients is scarce. We present a case of a patient with OI on IV bisphosphonate therapy who required dental extractions and review the literature of the risk of BRONJ in this group of patients. CLINICAL RELEVANCE: Dental clinicians need to be aware of the potential risk of BRONJ in paediatric patients who have had intravenous bisphosphonate therapy. It is important that these patients are identified and managed appropriately.

Use of the Sheffield telescopic intramedullary rod system for the management of osteogenesis imperfecta: clinical outcomes at an average follow-up of nineteen years.

BACKGROUND: Elongating intramedullary rods have been used in the management of osteogenesis imperfecta for the past fifty years. The complication rates reported in many reviews of the available techniques have been high. This study reviews the long-term functional outcomes and complications following the use of the Sheffield system of telescopic intramedullary rods. METHODS: We conducted a retrospective analysis of patients with osteogenesis imperfecta who were at least eighteen years of age and who had at least thirteen years of follow-up. Complications, reoperations, and data from a disease-specific questionnaire and the Short Form-36 questionnaire were recorded. RESULTS: Data for twenty-two patients with osteogenesis imperfecta who had been treated with Sheffield telescopic intramedullary rods were available at an average of nineteen years after the initial surgery. Reoperations involving thirty-three (50%) of the sixty-six rods were performed: ten rods (15%) were exchanged because of rod disengagement due to growth, thirteen rods (20%) were exchanged because of complications, and ten rods (15%) required further surgery other than exchange because of complications. Mobility was significantly improved at the initial postoperative visit (p = 0.0015), and this improvement was maintained into adulthood (p = 0.0077). Back pain was the most frequent symptom. Symptoms related to rod insertion across the knee and ankle were rare, but symptoms related to proximal femoral trochanteric entry were common. Physeal damage was not seen following surgery, and all rods elongated with growth. All patients were satisfied with the outcome of the surgical procedures. Short Form-36 scores for all physical domains and for social function and vitality were significantly worse than those in a normal population. CONCLUSIONS: The outcomes of this technique are satisfactory in adulthood; reoperation rates are high but are most commonly related to the patient outgrowing the rods. Concerns regarding insertion of this fixed device at the knee and ankle were unfounded, although proximal femoral fixation remains a problem.

Ipsilateral supracondylar humerus fracture and Monteggia lesion: a case report.

Two to 13% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, most of which are distal radius fractures. We present an unusual case of a 2-year-old girl with an ipsilateral supracondylar humerus fracture and a Monteggia lesion. Our management consisted of percutaneous K-wire fixation of the supracondylar humerus fracture and percutaneous insertion of an intramedullary K-wire for stabilization of the ulna fracture. Our patient had an excellent result, and we would recommend this method of fixation for similar injuries.