Flexible Nail Treatment of Pediatric Both-Bone Forearm Fractures.

SUMMARY: Although most pediatric both-bone forearm fractures are treated nonoperatively, some do require surgical fixation. This article and accompanying step-by-step technique video demonstrate intramedullary fixation of a both-bone forearm fractures in a 7-year-old boy.

Use of Metagenomic Next-Generation Sequencing to Identify Pathogens in Pediatric Osteoarticular Infections.

BACKGROUND: Osteoarticular infections (OAIs) are frequently encountered in children. Treatment may be guided by isolation of a pathogen; however, operative cultures are often negative. Metagenomic next-generation sequencing (mNGS) allows for broad and sensitive pathogen detection that is culture-independent. We sought to evaluate the diagnostic utility of mNGS in comparison to culture and usual care testing to detect pathogens in acute osteomyelitis and/or septic arthritis in children. METHODS: This was a single-site study to evaluate the use of mNGS in comparison to culture to detect pathogens in acute pediatric osteomyelitis and/or septic arthritis. Subjects admitted to a tertiary children's hospital with suspected OAI were eligible for enrollment. We excluded subjects with bone or joint surgery within 30 days of admission or with chronic osteomyelitis. Operative samples were obtained at the surgeon's discretion per standard care (fluid or tissue) and based on imaging and operative findings. We compared mNGS to culture and usual care testing (culture and polymerase chain reaction [PCR]) from the same site. RESULTS: We recruited 42 subjects over the enrollment period. mNGS of the operative samples identified a pathogen in 26 subjects compared to 19 subjects in whom culture identified a pathogen. In 4 subjects, mNGS identified a pathogen where combined usual care testing (culture and PCR) was negative. Positive predictive agreement and negative predictive agreement both were 93.0% for mNGS. CONCLUSIONS: In this single-site prospective study of pediatric OAI, we demonstrated the diagnostic utility of mNGS testing in comparison to culture and usual care (culture and PCR) from operative specimens.

Orthopaedic resident preparedness for closed reduction and pinning of pediatric supracondylar fractures is improved by e-learning: a multisite randomized controlled study.

BACKGROUND: There is a need to provide more efficient surgical training methods for orthopaedic residents. E-learning could possibly increase resident surgical preparedness, confidence, and comfort for surgery. Using closed reduction and pinning of pediatric supracondylar humeral fractures as the index case, we hypothesized that e-learning could increase resident knowledge acquisition for case preparation in the operating room. METHODS: An e-learning surgical training module was created on the Computer Enhanced Visual Learning platform. The module provides a detailed and focused road map of the procedure utilizing a multimedia format. A multisite prospective randomized controlled study design compared residents who used a textbook for case preparation (control group) with residents who used the same textbook plus completed the e-learning module (test group). All subjects completed a sixty-question test on the theory and methods of the case. After completion of the test, the control group then completed the module as well. All subjects were surveyed on their opinion regarding the effectiveness of the module after performing an actual surgical case. RESULTS: Twenty-eight subjects with no previous experience in this surgery were enrolled at four academic centers. Subjects were randomized into two equal groups. The test group scored significantly better (p < 0.001) and demonstrated competence on the test compared with the control group; the mean correct test score (and standard deviation) was 90.9% ± 6.8% for the test group and 73.5% ± 6.4% for the control group. All residents surveyed (n = 27) agreed that the module is a useful supplement to traditional methods for case preparation and twenty-two of twenty-seven residents agreed that it reduced their anxiety during the case and improved their attention to surgical detail. CONCLUSIONS: E-learning using the Computer Enhanced Visual Learning platform significantly improved preparedness, confidence, and comfort with percutaneous closed reduction and pinning of a pediatric supracondylar humeral fracture. We believe that adapting such methods into residency training programs will improve efficiency in surgical training.

Pediatric radial neck fractures: when and how to fix.

This is a review of current evaluation and treatment recommendations for pediatric radial neck fractures, including a series of cases that were presented and reviewed by a panel at The Pediatric Orthopedic Society of North America annual meeting 2010. We summarize the different published techniques for closed, percutaneous, and open reduction, and review when these techniques are recommended. The potential complications that can arise from radial neck fractures and their treatment are discussed.

MR evaluation of femoral neck version and tibial torsion.

Abnormalities of femoral neck version have been associated with a number of hip abnormalities in children, including slipped capital femoral epiphysis, proximal femoral focal deficiency, coxa vara, a deep acetabulum and, rarely, developmental dysplasia of the hip. Orthopedic surgeons also are interested in quantifying the femoral neck anteversion or retroversion in children especially to plan derotational osteotomies. Historically, the angle of femoral version and tibial torsion has been measured with the use of radiography and later by CT. Both methods carry with them the risks associated with ionizing radiation. Techniques that utilize MR are used less often because of the associated lengthy imaging times. This article describes a technique using MRI to determine femoral neck version and tibial torsion with total scan times of approximately 10 min.

Advanced containment methods for Legg-Calvé-Perthes disease: results of triple pelvic osteotomy.

BACKGROUND: Although surgical containment has become a mainstay for the treatment of Legg-Calvé-Perthes (LCP) disease; traditional operations (varus osteotomy of femur, Salter osteotomy) have certain limitations, sometimes resulting in a prolonged limp or inadequate containment. This paper presents the surgical method and results of triple pelvic osteotomy for containment treatment of LCP disease. METHODS: This retrospective review of 39 children (40 hips; age 5 to 13 y) with LCP disease treated with triple pelvic osteotomy (1995 to 2005) included preoperative lateral pillar assessment and other measurements. Final follow-up films (minimum 3 y, range 3 to 9 y) were assessed using the modified Stulberg classification. Clinical follow-up evaluation assessed limp, limb-length inequality, range of motion, and activity level. RESULTS: Twenty-one (53%) hips were graded as lateral pillar B and 19 (48%) were lateral pillar C. Four patients required further treatment before the final follow-up. At final follow-up, 42% had a good outcome (Stulberg I/II), 47% had a fair outcome (Stulberg III), and 11% had a poor outcome. Thus, 89% of patients had satisfactory (good or fair) results. There was a significant difference in outcome based on the preoperative lateral pillar, with B hips more likely to have a good outcome (65%) compared with lateral pillar C hips (12.5%) (P=0.002). There were no lateral pillar B patients with a poor outcome. Seventeen percent of the lateral pillar C patients more than or equal to age 8 had a poor outcome compared with 50% being more than age 8 with a poor outcome. Four patients (3 lateral pillar C, 1 lateral pillar B) required further surgery. CONCLUSIONS: Triple pelvic osteotomy resulted in maintenance of head shape in lateral pillar B patients of all ages and in younger lateral pillar C patients. Lateral pillar C patients over age 8 were more difficult to treat, however, we still advise containment for these cases because methods are now available to deal with containment failure. Triple pelvic osteotomy is an effective treatment method for LCP patients with lateral pillar B disease and younger patients with lateral pillar C disease. This method provides effective containment, which allows prolonged remodeling while avoiding the limitations of femoral varus osteotomy (limp, short limb) and Salter osteotomy (incomplete containment). LEVEL OF EVIDENCE: Level IV.

Classification of proximal tibial fractures in children.

PURPOSE: To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns. METHODS: At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion-avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter-Harris classification. Also included were tibial tuberosity and tibial spine fractures. RESULTS: Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter-Harris type. In prepubescent children (ages 4-9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10-12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion-avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3-6 years), with tibial spine fractures occurring at age 10, Salter-Harris type I and II fractures at age 12, and Salter-Harris type III and IV physeal injuries occurring around age 14 years. CONCLUSION: We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.

Biomechanical comparison of fully and partially threaded screws for fixation of slipped capital femoral epiphysis.

BACKGROUND: Previous data have shown that an equal number of threads on each side of the physis maximizes stability for slipped capital femoral epiphysis (SCFE) fixation. The purpose of the current study was to determine if a fully threaded cancellous screw provides greater stability compared with a partially threaded screw in a porcine model. METHODS: Twenty skeletally immature porcine femurs were sectioned, and a 30-degree angular wedge was resected from the femoral neck to simulate SCFE. Femora were randomly assigned to partially threaded (16 mm) or fully threaded screw groups (n = 10/group). Kirschner wires were inserted in a retrograde fashion to stabilize the proximal fragment. Each 7.3-mm-diameter screw was placed using fluoroscopic guidance to obtain 3 threads crossing the physis. Specimens were fixed in custom fixation rigs, and the epiphyseal fragment was loaded at 0.5 mm/s in a posterior-inferior direction to simulate slip progression. Data for displacement (in millimeters) and force (in newtons) were collected for the entire test. Forces at 2, 4, 6, and 8 mm of fragment displacement were compared between groups using a 1-way analysis of variance (p < 0.05). RESULTS: Increasing epiphyseal displacements were associated with incremental increases in loading. There were no significant differences between fully threaded or partially threaded screws for loads at each displacement. Each stepwise increase in displacement was associated with approximately 325 N of force. CONCLUSION: There was no biomechanical benefit when using a fully threaded screw for stabilization of an in vitro SCFE model. CLINICAL RELEVANCE: Although there were no differences between screw types in an in vitro model, bone healing around the fully threaded screw may eventually provide greater stability. The use of fully threaded screw remains a reasonable option in the treatment of SCFE, and implant removal may be easier with such a system. Further studies are warranted to verify these 2 points.

Biomechanical stability of bioabsorbable screws for fixation of acetabular osteotomies.

The purpose of this study was to compare the biomechanical stability of triple innominate osteotomies fixed with either bioabsorbable or stainless steel screws. Triple innominate osteotomies were performed on composite hemipelves and fixed with either three 4.5-mm bioabsorbable screws or three stainless steel 4.5-mm screws. Two screws were placed from the iliac wing into the acetabular fragment, and 1 screw was placed from below the acetabular fragment into the iliac wing. Eight specimens for each screw type were biomechanically tested in an anatomical position (replicating weight bearing) and in a flexed and abducted position (replicating spica cast positioning). Specimens were cyclically loaded between 10 and 450 N to simulate the hip contact force in this population. Lower screws were then removed, and specimens were tested under identical conditions. Fragment displacement (mm) and construct stiffness (N/mm) were compared with a 2-way analysis of variance (P < 0.05). There were no significant differences between materials for fragment displacement or construct stiffness. Anatomical position showed significantly less displacement than spica position for both materials. Initial displacement in the spica position was significantly less during lower loads for stainless steel fixation. Bioabsorbable screws demonstrate comparable biomechanical stability to stainless steel screws in anatomical and spica positions at physiological loads. Flexion and abduction of the femur adversely affect the stability of the construct for both materials. Bioabsorbable screws behave similarly to steel screws when stabilizing triple innominate osteotomies and would have the advantage of not requiring a second surgery for screw removal. Confirmation of biocompatibility should be completed before widespread clinical application.

Biomechanical analysis of single screw fixation for slipped capital femoral epiphysis: are more threads across the physis necessary for stability?

PURPOSE: To evaluate single screw fixation stability, in the treatment of slipped capital femoral epiphysis, as a function of screw thread distribution across the physis. STUDY DESIGN: In vitro biomechanical study. METHODS: Thirty porcine proximal femurs were sectioned through the physeal line and stabilized with a cannulated 7.3-mm stainless steel AO screw. The distal 16 mm of each screw was threaded (5 threads). The femurs were randomized into 5 groups (1, 2, 3, 4, or 5 threads across the physis) and biomechanically tested to determine failure load (N) and stiffness (N/mm). RESULTS: Femurs with 2 or 3 threads across the physis had a significantly greater load to failure and stiffness compared with femurs with 1, 4, or 5 threads across the physis (P < 0.05). CONCLUSIONS: Thread distribution across the physis seems to be important. When using screws with a 16-mm thread, greatest strength and stiffness are achieved when 40%-60% of threads engage the epiphysis, with a significant decrease when greater than 80% of threads cross the physis. Too few threads in the epiphysis as well as too few in the metaphysis both lead to decreased stability. CLINICAL RELEVANCE: This study challenges the belief that compression across the physis maximizes slipped capital femoral epiphysis fixation stability. We recommend equal distribution of threads across the physis when using 16-mm thread screws, and we postulate that screws with a greater thread length (32 mm or fully threaded) would increase fixation stability even further. Optimizing purchase may decrease the incidence of slip progression, especially as the prevalence of obesity increases in the adolescent population.

Impingement and childhood hip disease.

Hip impingement is now recognized as a relatively common cause for hip pain in young adults. The early evolution of impingement begins in childhood in several common hip disorders (slipped capital femoral epiphysis, Perthes, early avascular necrosis due to other causes). Recognition and treatment of childhood impingement may prevent the evolution to early hip arthritis.

Shoulder arthroplasty for locked posterior dislocation of the shoulder.

Currently, there are no published series with mid- to long-term results on patients undergoing shoulder arthroplasty for locked posterior dislocation of the shoulder. We reviewed the results of patients who underwent shoulder arthroplasty for locked posterior dislocation of the shoulder to determine the results, the risk factors for an unsatisfactory outcome, and the rates of failure. Twelve shoulder arthroplasties were performed at our institution, between January 1, 1980, and December 31, 1997, in 12 patients who had a locked posterior dislocation of the shoulder. All 12 patients were followed up for a minimum of 5 years (mean, 9.0 years) or until the time of revision surgery. There was significant pain relief (P <.001) as well as improvement in external rotation from -13 degrees to 28 degrees (P =.001). On the basis of a modified Neer result rating system, there was 1 excellent, 6 satisfactory, and 5 unsatisfactory results. Three patients underwent revision surgery for posterior instability (two) and component loosening (one). Recurrent instability occurred in two patients in the early postoperative period. There were no cases of recurrent instability greater than 1 year from the time of surgery. The data from this study suggest that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Among those with recurrent posterior instability, it usually appears in the early postoperative period.

Compartment syndrome following intramedullary fixation of pediatric forearm fractures.

This study was designed to evaluate the incidence of compartment syndrome (CS) resulting from the treatment of both-bone forearm fractures in children. A retrospective analysis of 285 consecutive children who presented with both-bone forearm fractures was performed. Of 235 closed injuries, 205 were treated with closed reduction and casting; none of these patients developed CS. Thirty of the closed injuries were treated with closed reduction and intramedullary fixation; three of these patients (10%) developed CS. Fifty patients sustained open fractures and were treated with debridement and open reduction with intramedullary pinning; CS developed in three of these patients (6%). The eighty patients treated with intramedullary fixation had an increased incidence of CS compared with the 205 patients treated with closed reduction and casting (P < 0.001). Within the group of patients who had surgery, patients with longer operative times and more use of intraoperative fluoroscopy were at higher risk of developing CS.

Intraoperative electromyographic monitoring during periacetabular osteotomy.

Periacetabular osteotomy has become the procedure of choice in many centers for the treatment of symptomatic hip dysplasia. Intraoperative real-time nerve monitoring has been advocated during acetabular fracture repair and complex total hip arthroplasties to prevent iatrogenic sciatic nerve injury. To the authors' knowledge there is no information concerning the use of intraoperative electromyographic monitoring during periacetabular osteotomy. The purpose of the current study was to investigate the use of intraoperative continuous electromyographic monitoring during periacetabular osteotomy in a relatively large consecutive series of patients as a mechanism to prevent nerve injury during surgery and as a prognostic indicator of neurologic function after periacetabular osteotomy. From September 1992 to July 1999, 140 consecutive periacetabular osteotomies were done in 127 patients at the authors' institution. There were 96 females and 31 males, with an average age of 32 years at the time of surgery. All patients had intraoperative electromyographic monitoring of femoral and sciatic innervated muscles. All patients were followed up for a minimum of 1 year, until complete resolution of neurologic deficits, or both. Thirty-six patients (26%) had abnormal electromyographic activity recorded during surgery. Seven patients (5%) had peroneal nerve deficits postoperatively including extensor hallucis longus and tibialis anterior weakness with loss of sensation in the first web space. Abnormal electromyographic activity was observed intraoperatively in five of the seven patients with postoperative deficits. Six of the seven injuries resolved completely. One patient with intraoperative electromyographic activity (0.7%) had a postoperative foot drop that persisted for greater than 1 year. There were no femoral, tibial, or obturator nerve deficits observed. Electromyographic monitoring appears to provide prediction of postoperative neurologic deficit.

Treatment and outcome of recurrent pelvic chondrosarcoma.

Little has been published about the outcome of patients with recurrent chondrosarcoma of the pelvis. The current study is a review of patients with surgically treated locally recurrent pelvic chondrosarcoma at one institution. Twenty-one patients had surgical resection of recurrent pelvic chondrosarcoma between July 1974 and July 1996. There were nine women and 12 men with a mean age of 46 years (range, 24-67 years) at first recurrence. Patients were followed up for a minimum of 3.3 years and median of 12 years from first (index) recurrence or until death. The mean time to index recurrence was 27 months (range, 5-87 months). In three cases (14%), the tumor at index recurrence was a higher grade than the initial lesion. There were six additional tumors that became a higher grade during subsequent recurrences. Fifteen of the 21 patients (71%) had a second local recurrence. Five patients (24%) had distant metastasis. At death or final followup, 11 patients (52%) had no evidence of disease, two patients (10%) are alive with disease, and eight patients (38%) died of their disease. The three patients with high-grade tumors at index recurrence all died of disease. The treatment of recurrent pelvic chondrosarcoma is a challenging problem. Tumor-free margins may require radical surgery, and the best chance of cure is at the time of initial resection. With aggressive surgical intervention, approximately 50% of patients with recurrent pelvic chondrosarcoma can achieve long-term survival.