Guided growth for the Treatment of Infantile Blount's disease: Is it a viable option?

INTRODUCTION: Guided growth with temporary hemiepiphysiodesis has gained interest as a less invasive means for the treatment of coronal plane lower extremity deformities as well as leg length discrepancies. Its application to infantile Blount's disease has been less reported. The object of this study was to identify predictive factors of guided growth for treatment of infantile Blount's. METHODS: A retrospective review was performed of children undergoing guided growth for the treatment of infantile Blount's disease over an eight-year period. Inclusion criteria included treatment with THE for infantile Blount's disease. Clinical information, preoperative Langenskiold classification, and intra-operative and post-operative data. Preoperative variables were used to identify risk factors for speed of correction and the need for subsequent surgery. RESULTS: A total of 11 patients, 17 extremities, meeting inclusionary criteria. Preoperatively, 7 extremities were classified as Langenskiold stage ≥3, with 12 being classified as stage ≤2. Overall, the Drennan's angle improved from 18.3° to 0.3° by final follow-up at an average of 4.31 years. Eight extremities demonstrated deformity recurrence/persistence (stage ≤2:33% vs stage ≥3: 100%), requiring 24 reoperations. Children with Langenskiold stage ≥3 demonstrated a significantly higher rate of reoperation. CONCLUSION: Guided growth is a viable treatment option for Infantile Blount's disease presenting with Langenskiold stage ≤2 disease at treatment initiation. The treatment course can expect a 33% rate of recurrent deformity, treated successfully with repeat THE. No child stage ≤2 required corrective osteotomy. Caution should be used when considering guided growth for children presenting with Langenskiold stage ≥3.

Salvage Treatment Options for Painful Hip Dislocations in Nonambulatory Cerebral Palsy Patients.

Hip dislocation is a common occurrence in nonambulatory patients with cerebral palsy, occurring in up to 70% of patients. However, only 15% to 57% of chronic dislocations progress to become painful. In these patients, several salvage treatment options are available, including proximal femoral resection, subtrochanteric valgus osteotomy, hip arthrodesis, and prosthetic arthroplasty. Of the options, proximal femoral resection, subtrochanteric osteotomy, and prosthetic arthroplasty have been shown to provide reliable pain relief with improved sitting balance, with no evidence of one technique being superior to another. However, each technique has unique aspects to its postoperative care and potential complication profile that requires thorough understanding and communication with parents/caregivers when considering surgical intervention.

A Cost-Effective Technique for Spinal Instrumentation in the Treatment of Adolescent Idiopathic Scoliosis.

Surgical treatment for adolescent idiopathic scoliosis (AIS) has evolved over the past decades to the point where instrumented arthrodesis with all pedicle screw and rod constructs is commonplace. Although these constructs provide superb correction and fixation, their financial burden is substantial. Here, we present a more cost-effective technique using a combination of pedicle screws (serving as the construct base), a sagittal precontoured unit rod, and sublaminar wires to provide segmental correction for the surgical treatment of AIS. Retrospective analyses of 42 patients treated with this construct were reviewed with a minimum 2-year follow-up. Correction in both coronal and sagittal planes was assessed radiographically and blood loss, operative time, complications, and cost were reviewed from hospital records. We conclude that this technique provides comparable correction to all pedicle screw constructs with similar blood loss and operative time, but with substantially decreased implant cost. The mean implant cost was $8910.83 ± $184.26.

Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons.

BACKGROUND: Supracondylar humerus fractures are common injuries in the pediatric population. The most severe, type III injuries, have seen the most debate on treatment regimens. Traditionally, these fractures were treated as surgical emergencies, most often fixed with percutaneous pinning in a cross-pin configuration. The recent literature shows that delayed fixation is comparable to emergent fixation as long as there is no vascular compromise with the injury. METHODS: A short survey was sent to Pediatric Orthopaedic Society of North America (POSNA) members using an online survey and questionnaire service. The purpose of the survey was to establish an overview of current practices in the United States concerning treatment of type III supracondylar humerus fractures and the influence of the recent literature on the management of these injuries. RESULTS: A total of 309 members, representing a wide range of locations and years in practice, responded to our survey. About 81% preferred to splint type III supracondylar humerus fractures and plan for fixation the following morning, assuming there was no issue necessitating emergent fixation. The preferred method of percutaneous fixation was fairly evenly distributed between cross-pin configuration (30%), 2 lateral pins (33%), and 3 lateral pins (37%). About 56% of those surveyed stated that the recent literature showing comparable outcomes with 2 lateral pins versus a cross-pin configuration had not changed their approaches to management of these fractures concerning the method of fixation. CONCLUSIONS: The trend in management of type III supracondylar humerus fractures in children is progressing toward delayed treatment and lateral pin configuration. The results provide an overview of the current practice of POSNA members concerning management of these fractures. We believe this information is beneficial to both pediatric-trained and nonpediatric-trained orthopaedic surgeons to help guide their decisions when dealing with these injuries. LEVEL OF EVIDENCE: This study is a Level V Therapeutic Study reviewing trends in the management of type III supracondylar humerus fractures in children. The previously described experts represent various levels of expertise in their preferred method of fixation.

Stringent patient selection in bulk allograft reconstructions.

We hypothesized that stringent patient selection in the use of large bulk structural allografts for limb preservation would positively affect outcomes and decrease complication rates by eliminating certain comorbid or social factors known to contribute to the most detrimental sources of allograft failure: infection, fracture, and nonunion.Our selection criteria included patients who were younger than 50 years, nonsmokers, non-obese (body mass index <40), who did not receive radiation therapy to the recipient site perioperatively, and who underwent intercalary allograft reconstruction except in the upper extremity where osteoarticular allografts were permitted. Outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Score (TESS) scoring systems. Twenty-three patients fulfilled our cohort inclusion criteria. The overall survival rate for the 23 allografts was 91% (21/23). Average MSTS and TESS scores were 76% and 87%, respectively. Eleven of 23 patients experienced at least 1 complication requiring a second procedure. Musculoskeletal Tumor Society scores among patients experiencing no complications averaged 83% vs 71% for patients experiencing at least 1 complication. Average TESS scores were 89% and 86%, respectively.The results of our early experience indicate there is no appreciable difference in complication rates among our series of patients stringently selected for bulk allograft reconstruction compared to other previously reported studies.