Metaphyseal Fracture Displacement is Predictive of Intra-articular Diastasis in Adolescent Triplane Ankle Fractures.

BACKGROUND: Triplane fractures are rare enough that large homogeneous series to support management decisions are lacking. During initial evaluation, the addition of computed tomography (CT) to conventional X-rays (XR) does not always alter the patient's clinical course. Therefore, routine use of CT is controversial. This study aims to: (1) clarify quantitative relationships between articular displacement measured on XR versus CT and (2) identify whether metaphyseal displacement on the lateral XR predicts clinically relevant articular displacement on a CT scan. METHODS: A 10-year retrospective review of consecutive triplane fractures was performed at a level 1 pediatric trauma center. Maximum articular and metaphyseal displacement were recorded from XR and CT. Quantitative relationships between XR and CT measurements were compared among imaging modalities and radiographically operative versus nonoperative fractures. RESULTS: Eighty-seven patients met the inclusion criteria. XR underestimated articular displacement by 229% in the sagittal plane (1 mm on XR vs 3.3 mm on CT; P < 0.05) and 17% in the coronal plane (2.3 mm on XR vs 2.7 mm on CT; P < 0.05). XR underestimated articular step-off by 184% in the coronal plane and 177% in the sagittal plane ( P < 0.05). CT measurements more often differentiated patients who did or did not undergo surgery at our institution. Metaphyseal displacement was significantly higher in patients with traditionally operative articular displacement (≥2.5 mm on CT) versus those with articular displacement below traditionally operative thresholds (2.4 vs 0.9 mm, P = 0.001). Sixty patients had metaphyseal displacement >1 mm on the lateral XR, of whom 56 had surgical-magnitude articular displacement (≥2.5 mm) on CT (positive predictive value = 94%). CONCLUSIONS: Conventional radiographs underestimate the true articular displacement of triplane fractures. Surgical-magnitude articular step-off is rare, and the largest articular gap is usually visualized on the axial CT image. Metaphyseal displacement >1 mm, which is easily measured on a lateral XR, is strongly predictive of clinically relevant articular displacement on CT. This radiographic finding should prompt advanced imaging before proceeding with nonoperative management. LEVEL OF EVIDENCE: Level III.

Bilateral Slipped Capital Femoral Epiphysis Fixation Failure Including the Prophylactic Side: A Case Report.

Slipped capital femoral epiphysis (SCFE) is a common problem treated by pediatric orthopedic surgeons. A 13-year-old male presented with right-sided hip pain. Both sides, symptomatic and asymptomatic, were treated with a single 7.3-mm screw. The patient returned with symptoms to the bilateral hips 16 months after the procedure. He was treated with removal of hardware and revision fixation with a good outcome. We report a rare case of fixation failure in bilateral SCFE with an excellent outcome. We highlight the importance of quick recognition of failure before displacement and a strategy for hardware removal.

Acetabular Coverage May Affect Radiographic and Clinical Outcomes of Osteochondral Allograft Transplantation of Focal Femoral Head Lesions: A Case Series From a Single Institution.

Osteochondral lesions of the femoral head in young people are rare and present unique management challenges. Optimal treatment for these lesions is unclear. From 2009 to 2016, clinical and radiographic outcomes were prospectively collected within a series of symptomatic focal osteochondral lesions of the femoral head with a minimum follow-up of 2 years. A surgical hip dislocation followed by implantation of a size-matched fresh osteochondral femoral head allograft was performed. Nine hips in eight patients (6 female patients) underwent surgery at an average of 17 years (11 to 21 years). Individual allograft sizes ranged from 10 to 35 mm in diameter; with 2 of 9 hips receiving two allografts in a stacked or mosaicplasty technique at the time of treatment. The average graft implantation was 3536.5 mm2. Modified Harris hip scores improved by 13.4 (P = 0.018) from preoperative to final follow-up for all patients. Significant improvements in internal rotation (12° versus 23°, P = 0.011), external rotation (32° versus 50°, P = 0.041), and abduction (28° versus 40°, P = 0.042) were also achieved. Three patients (four hips) demonstrated poor radiographic healing (<50% incorporation at 2 years), which correlated with worse clinical outcomes and was associated with a lower preoperative lateral center edge angle (21.5° versus 30.4°, P = 0.049). Fresh osteochondral allograft treatment is a good option for focal osteochondral lesions of the femoral head with improved outcomes and motion; however, higher failure rates may be seen in those with a lower center edge angle.

Two AIS spine surgeries on the same day by the same surgeon: is performance and outcome the same for the second patient?

STUDY DESIGN: Retrospective case-controlled study. OBJECTIVES: To analyze the overall performance and outcome of two-a-day surgery days for adolescent idiopathic scoliosis (AIS). As a method to improve efficiency and operating room utilization, some surgeons are now performing two surgeries for AIS in a single day. METHODS: A prospectively collected series of AIS patients who underwent posterior spinal fusion on the same day as a second AIS patient by the same surgeon and surgical team were retrospectively reviewed. Patients who underwent same-day surgery (SD) were grouped according to whether they were the first (SD1) or second (SD2) case of the day and were matched (M1 and M2) by surgeon, curve magnitude, Lenke classification, and fusion levels. Comparisons were made: SD1 vs. SD2, SD1 vs. M1, and SD2 vs. M2. RESULTS: There were 56 patients, with no differences between groups in age, gender, BMI, or curve magnitude (66° vs. 62° vs. 65° vs. 63°). Surgical time was shorter for the SD1 group (17.2 min/level) compared to M1 (20.5 min/level) for a 15% operative time reduction of 44 min (p = 0.008). There were no differences between the groups in curve correction (65.8% vs. 62.8% vs. 66.1% vs. 58.5%), estimated blood loss (EBL), length of stay, or complication rate. One SD2 patient had a malpositioned screw that required revision. There were no other complications. CONCLUSIONS: When performing two AIS surgeries on the same day, surgical time was reduced by 44 min, or 15%, on the first case compared to a matched control. This may be a reflection of the team moving along more efficiently, given the full operative day scheduled. The performance measures of curve correction, EBL, complications, and length of stay did not decline in this new model, and no increased incidence of complications was seen.

Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?

BACKGROUND: Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. METHODS: We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements. RESULTS: There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p > 0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64). CONCLUSIONS: Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.

Reducing opioid usage: a pilot study comparing postoperative selective dorsal rhizotomy protocols.

OBJECTIVE: Selective dorsal rhizotomy (SDR) is a surgical procedure used to treat spasticity in children with spastic cerebral palsy. Currently, there is a lack of work examining the efficacy of optimizing pain management protocols after single-level laminectomy for SDR. This pilot study aimed to compare the clinical outcomes of SDR completed with a traditional pain management protocol versus one designed for opioid dosage reduction. METHODS: The Texas Comprehensive Spasticity Center prospective database was queried for all patients who underwent SDR between 2015 and 2018. Demographic, surgical, and postoperative data for all patients who underwent SDR were collected from medical records. The study was designed as a retrospective study between the patient-controlled analgesia (PCA) and dexmedetomidine infusion (INF) groups with 80% power to detect a 50% difference at a significance level of 0.05. Patients in the INF group received perioperative gabapentin, intraoperative dexmedetomidine infusion, and scheduled acetaminophen and NSAIDs postoperatively. RESULTS: Medication administration records, pain scores, and therapy notes were collected for 30 patients. Patients who underwent SDR between June 2015 and the end of December 2017 received traditional pain management (PCA group, n = 14). Patients who underwent SDR between January 2018 and the end of December 2018 received modified pain management (INF group, n = 16). No patients were lost to follow-up. Differences in age, weight, height, preoperative Gross Motor Function Classification System scores, operative duration, hospital length of stay, and sex distribution were not statistically different between the 2 groups (p > 0.05). Analysis of analgesic medication doses demonstrated that the INF group required fewer doses and lower amounts of opioids overall, and also fewer NSAIDs than the PCA group. When converted to the morphine milligram equivalent, the patients in the INF group used fewer doses and lower amounts of opioids overall than the PCA group. These differences were either statistically significant (p < 0.05) or trending toward significance (p < 0.10). Both groups participated in physical and occupational therapy similarly postoperatively (p > 0.05). Pain scores were comparable between the groups (p > 0.05) despite patients in the INF group requiring fewer opioids. CONCLUSIONS: Infusion with dexmedetomidine during SDR surgery combined with perioperative gabapentin and scheduled acetaminophen and NSAIDs postoperatively resulted in similar pain scores to traditional pain management with opioids. In addition, this pilot study demonstrated that patients who received the INF pain management protocol required reduced opioid dosages and were able to participate in therapy similarly to the control PCA group.

Outcome of Conservative Management in the Treatment of Symptomatic Spondylolysis and Grade I Spondylolisthesis.

BACKGROUND: Bracing (thoraco-lumbar-sacral orthosis) has been accepted as mainstay of treatment for symptomatic spondylolysis (SP) and grade I spondylolisthesis (SPL1). However, increasing costs and patient noncompliance can make bracing prohibitive and difficult to manage. The purpose of this study was to determine if SP and SPL1 can be effectively treated using physical therapy and other non-bracing conservative management techniques in order to relieve pain and restore physical function. METHODS: We performed a cross-sectional study in which patients who presented from June 1, 2004, to May 1, 2015, with symptomatic SP and SPL1 who were treated with nonbracing conservative management, entailing a universal 6-week physical therapy program and restriction of offending activity, were considered for the study. Physical therapy included core strengthening activities, hamstrings stretching, and spine range of motion exercises. Patients meeting inclusion criteria were contacted via phone interview and asked to complete an Oswestry Disability Questionnaire (ODQ) in order to generate a disability score to assess their current pain and daily function. Patients were then stratified into groups based on their level of disability as denoted by their disability score; minimal disability = disability score of 0% to 19.9%, moderate disability = 20% to 39.9%, severe disability = 40% to 59.9%, crippled = 60% to 79.9%, and bed bound or exaggerating = 80% to 100%. RESULTS: Fourty-six patients were identified as meeting inclusion criteria (28 with SP and 18 with SPL1). Twenty-three of 46 were successfully contacted and agreed to complete the ODQ (10/23 with SP and 13/23 with SPL1). Twenty-two of 23 (96%) patients had a minimal disability score (0% to 19.9%), One of 23 (4%) patients had a moderate disability score (20% to 39.9%), and 18/23 (78%) patients had a disability score of zero, denoting no pain or limitation of function. CONCLUSION: The results of this study suggest that, in patients with symptomatic spondylolysis and grade I spondylolisthesis, pain relief and restoration of function can be achieved using conservative management techniques without use of a brace.

Which Factors Increase the Risk of Reoperation After Meniscal Surgery in Children?

BACKGROUND: Meniscal injuries in children can pose treatment challenges, as the meniscus must maintain its biomechanical function over a long lifetime while withstanding a high activity level. While the adult literature contains a plethora of studies regarding risk factors for failure of meniscal surgery, such reports are scarcer in children. PURPOSE: To determine the rate at which children undergoing meniscal surgery require subsequent reoperation as well as to define risk factors for reoperation in this population. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective institutional database of 907 first-time meniscal surgical procedures performed between 2000 and 2015 was reviewed. All patients were <18 years old. Demographic and intraoperative information was recorded, as were concurrent injuries or operations and subsequent procedures. Univariate analysis consisted of chi-square and independent-samples t tests. Multivariate logistic regression with purposeful selection was then performed to adjust for confounding factors. RESULTS: The mean ± SD patient age was 13.2 ± 2.1 years, and 567 (63%) were male. The mean postoperative follow-up duration was 20.1 ± 10.1 months. Overall, 83 patients (9%) required repeat surgery at a mean of 23.2 months after the index operation. After adjustment for confounders in a multivariate model, meniscal repair resulted in 3.1-times higher odds of reoperation when compared with meniscectomy (95% CI, 1.2-8.3; P = .02), while white-white zone tears had 2.8-times lower odds of reoperation (95% CI, 1.01-7.7; P = .04) versus red-red and red-white zone tears. CONCLUSION: Approximately 9% of children undergoing meniscal surgery will require reoperation at a mean 23.2 months after the index operation. Repair carried approximately 3-times higher odds of reoperation than meniscectomy, while white-white zone tears had nearly 3-times lower odds of requiring repeat surgery when compared with tears in other zones.

Varus Derotational Osteotomy.

Legg-Calve-Perthes disease is a multifactorial process that can lead to debilitating femoral head deformity in children. Management can range from conservative (such as nonweightbearing protocols), bracing (such as A frames), to more invasive measures involving surgical interventions. First described by Axer in 1965, the varus derotational osteotomy (VDRO) has been a staple in the surgical management of Perthes disease. The goal of the VDRO is "containment" or prevention of extrusion of the head from the acetabulum. Many variations of the technique have been described over the years since its inception, but the most important factor in outcome is timing the intervention at the appropriate stage of Perthes disease to allow for maximum benefit. Through varusization of the neck shaft angle of the proximal femur, the VDRO has been shown to be a powerful tool in the management of those afflicted. As with any operative procedure, the VDRO can be associated with complications such as premature epiphyseal closure leading to shortened extremity, albeit very rare in occurrence. The VDRO is a mainstay in the treatment algorithm for Legg-Calve-Perthes disease and will continue to remain so in the future.

Lower Extremity Abscess Formation in Premature Infants due to Routine Infant Vaccinations.

Since the introduction of vaccines, the impact of vaccinations has been immeasurable. Under the current immunization guidelines, infants receive the first of their routine infant vaccinations at 2 months of age. While the benefits of routine infant vaccinations in premature infants have been demonstrated, there is relatively little data on the dosing of these vaccines in premature infants. The medical records of two premature infants who developed intramuscular abscesses after receiving their routine infant vaccinations were reviewed. Both patients developed pain in the area of the injection after receiving their vaccinations. Magnetic resonance imaging findings confirmed the formation of an abscess. No other causes of abscess formation were observed. Both patients required surgical intervention and were treated with a course of antibiotics. To our knowledge, this is the first case report to suggest routine vaccinations as a potential cause of abscess formation in premature infants.

What's New in the Orthopaedic Treatment of Cerebral Palsy.

BACKGROUND: The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP. METHODS: We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology. RESULTS: Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings. CONCLUSIONS: Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research. LEVEL OF EVIDENCE: Level 4-literature review.

Converting the informed consent from a perfunctory process to an evidence-based foundation for patient decision making.

BACKGROUND: Standard consent forms result in highly variable communication between patients and physicians. To enhance the consent process and facilitate shared decision making, we developed a World Wide Web-based program, PREDICT (Patient Refined Expectations for Deciding Invasive Cardiac Treatments), to systematically embed patient-specific estimates of death, bleeding, and restenosis into individualized percutaneous coronary intervention informed consent documents. We then compared patients' experiences with informed consent before and after implementation of PREDICT. METHODS AND RESULTS: Between August 2006 and May 2007, patients undergoing nonemergent cardiac catheterization who received the original consent form (n=142) were interviewed and compared with those who received the PREDICT consent form (n=193). Hierarchical modified Poisson regression models were used to adjust for clustering of patients within physicians. Compared with the original consent group, those in the PREDICT group reported higher rates of reading the consent form (72% versus 44%, relative risk [RR] 1.64, 95% confidence interval [CI] 1.24 to 2.16), increased perception of shared decision making (67% versus 45%, RR 1.48, 95% CI 0.99 to 2.22), and decreased anxiety (35% versus 55%, RR 0.70, 95% CI 0.53 to 0.91). Although there were no differences between groups in patients' ability to name complications of percutaneous coronary intervention, among patients who identified either death or bleeding as a potential complication, more patients in the PREDICT group recalled being informed of their estimated risk of that complication (death: 85% versus 62%, RR 1.37, 95% CI 1.03 to 1.82; bleeding: 92% versus 71%, RR 1.28, 95% CI 1.06 to 1.56). CONCLUSIONS: In this preliminary, single-center experience, individualized consent forms with patient-specific risks were associated with improved participation in the consent process, reduced anxiety, and better risk recall. PREDICT is one potential strategy for improving the current practice of obtaining informed consent for percutaneous coronary intervention.