Outcomes of Late Microsurgical Nerve Reconstruction for Brachial Plexus Birth Injury.

PURPOSE: Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting. METHODS: From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months' follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. RESULTS: We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. CONCLUSIONS: Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of Fasciotomy Incisions After Acute Compartment Syndrome: Is Delayed Primary Closure More Feasible in Children Compared With Adults?

BACKGROUND: Recent adult literature has demonstrated that in the setting of acute compartment syndrome (ACS), if fasciotomy wounds are not closed after the first debridement, they are unlikely to be closed via delayed primary closure (DPC). The purpose of this study was to report the success of DPC through serial debridement in children with fasciotomy wounds secondary to ACS and to determine whether length of hospital stay is negatively affected by adopting a DPC strategy. METHODS: We identified all patients treated with fasciotomy for ACS (aged 0 to18 y). Patient, injury, and treatment characteristics were summarized by fasciotomy treatment type. Patients were grouped as: primary closure, DPC, and flap or skin graft (F/SG). For patients who required additional debridements after initial fasciotomy, treatment success was defined as closure by DPC (without requiring F/SG). Multivariable logistic regression was used to determine factors associated with additional surgeries, complications, and treatment success. RESULTS: A total of 82 children underwent fasciotomies for ACS. Fifteen (18%) patients were treated with primary closure at the time of their initial fasciotomy and were excluded from the remainder of the analysis, 48 (59%) patients underwent DPC, and 19 (23%) patients were treated with F/SG. The majority of delayed fasciotomy wounds were successfully closed by DPC (48/67, 72%) and the rate of successful closure remained consistent with each successive operative debridement. There were no differences across DPC and F/SG groups with respect to age, method of injury, or injury severity. Patients who underwent F/SG remained in the hospital for an average of 12 days compared with 8 days for those who underwent DPC (P<0.001). CONCLUSIONS: In the setting of ACS, pediatric fasciotomy wounds that are not closed after the first postfasciotomy debridement still have a high likelihood of being closed through DPC with serial surgical debridement. In children, persisting with DPC strategy for fasciotomy closure after ACS is more successful than it is in adults. LEVEL OF EVIDENCE: Level III.

Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review.

PURPOSE: To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries. METHODS: We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed. RESULTS: We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain. CONCLUSIONS: Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity. LEVEL OF EVIDENCE: Level IV, systematic review of low-quality studies.

Early Results of Drilling and/or Microfracture for Grade IV Osteochondritis Dissecans of the Capitellum.

BACKGROUND: Surgical treatment is recommended for patients with unstable osteochondritis dissecans (OCD) of the elbow. However, little information is available comparing the anticipated results from the host of techniques. In this investigation, clinical and radiographic resolution as well as return to sports rates were assessed in adolescent patients following loose body (LB) removal and drilling/microfracture of grade IV lesions. METHODS: We reviewed 21 adolescents treated with LB removal and drilling/microfracture for grade IV elbow OCD. Patients with additional elbow pathology, prior elbow surgery, or <1 year follow-up were excluded. Clinical resolution was defined as resolution of tenderness and radiographic resolution as resolution of edema on magnetic resonance imaging (MRI). Return to sport rates and Timmerman scores were assessed. Mean clinical and MRI follow-up times were 2.2±1.19 and 2.4±1.54 years, respectively. Clinical and radiographic parameters associated with clinical and/or radiographic resolution or return to sports were determined using penalized likelihood logistic regression. Wilcoxon signed-rank tests were used to evaluate the change in range of motion and in Timmerman scores. RESULTS: Fifteen (71.4%) patients had either clinical or radiographic resolution at most recent follow-up. Nine (50%) had complete resolution on MRI, whereas 13 (61.9%) were nontender at their follow-up. Four patients with recurrent LBs underwent revision surgery. There were no complications in the 21 index procedures. Eighteen (85.7%) patients returned to any sport, whereas 14 (66. 7%) returned to their primary sport. Elbow flexion and extension improved by medians of 12 and 21 degrees, respectively (P=0.002, 0.01). Timmerman scores improved by a median of 30 (P=0.001). Shorter duration of symptoms correlated with smaller OCD lesions (P=0.03) and with improved clinical or radiographic resolution and return to sport rates. CONCLUSIONS: The majority of patients with grade IV elbow OCD achieves clinical and/or radiographic resolution and return to sports 2 years after LB removal and drilling/microfracture. Recurrence may be seen, however, and further investigation is needed to assess the efficacy of this technique compared with other treatment strategies. LEVEL OF EVIDENCE: Level IV.

Management of pediatric trigger thumb and trigger finger.

Pediatric trigger thumb and trigger finger represent distinct conditions and should not be treated like adult acquired trigger finger. Over the last two decades, our understanding of the natural history of pediatric trigger thumb and the etiology and surgical management of pediatric trigger finger has improved. Pediatric trigger thumb may spontaneously resolve, although resolution may take several years. Open surgical release of the A1 pulley of the thumb is an alternative option that nearly uniformly restores thumb interphalangeal joint motion. Surgical management of pediatric trigger finger with isolated release of the A1 pulley has been associated with high recurrence rates. Awareness of the anatomic factors that may contribute to triggering in the pediatric finger and willingness to explore and address other involved components of the flexor mechanism can prevent surgical failure.

Ponseti Clubfoot Casting: Factors That Affect Trainee Competency (Retrospective Observational Study).

INTRODUCTION: This study investigates how previous simulation training and clinical experience affects trainee performance when manipulating a foot, applying a Ponseti clubfoot cast, and performing an Achilles tenotomy on a clubfoot simulator. METHODS: Sixty-four Accreditation Council for Graduate Medical Education orthopaedic trainees participated in the 2017 to 2018 Top Gun (TG) skills competition at the International Pediatric Orthopaedic Symposium. Trainees were judged by expert pediatric orthopaedic surgeons on how they manipulated a clubfoot model, applied a cast, and performed a simulated tendoachilles tenotomy (TAT). An analysis was done to correlate the test variables with a contestant's TG Ponseti score. RESULTS: Twenty-one contestants with previous residency training using synthetic clubfoot models scored higher (P = 0.007) than those trainees without training. Trainees who had applied >10 clubfoot casts and who participated in >10 TATs in training also scored higher (P = 0.038 and P = 0.01, respectively). Thirteen contestants who had previously attended an International Pediatric Orthopaedic Symposium meeting and seven contestants who attended a American Academy of Orthopaedic Surgery clubfoot workshop scored higher (P = 0.012 and P = 0.017 respectively). DISCUSSION: Clinical and previous simulation experience related to the Ponseti method correlated with improved performance on our Ponseti simulation. Trainees who had previous experience with >10 clubfoot casts and >10 TATs scored higher during TG than less experienced trainees.

Scaphoid fractures in children and adolescents: contemporary injury patterns and factors influencing time to union.

BACKGROUND: Historically, scaphoid fractures in children and adolescents have predominantly involved the distal pole, requiring neither surgical care nor extended follow-up. Changing patient characteristics, however, appear to be altering fracture epidemiology and treatment. The purpose of this investigation was to characterize contemporary fracture patterns in children and adolescents and to identify factors influencing time to healing following both nonoperative and operative treatment. METHODS: A retrospective analysis of 351 scaphoid fractures that had been treated from 1995 to 2010 was performed to characterize fracture patterns. The mean patient age was 14.6 years (range, seven to eighteen years). Complete clinical and radiographic follow-up data were available for 312 fractures (89%), with 222 fractures presenting acutely and ninety not acutely. Union rates following casting or surgical treatment were determined, and Cox regression analysis was utilized to identify factors influencing both the union rate and the time to union. RESULTS: Overall, 248 fractures (71%) occurred at the scaphoid waist, eighty-one (23%) occurred at the distal pole, and twenty-two (6%) occurred at the proximal pole. Male sex, high-energy mechanisms of injury, closed physes, and high body-mass index were associated with fractures of the waist or proximal pole. Treatment of acute fractures with casting alone resulted in a 90% union rate. Lower union rates were seen in association with the use of casting alone for the treatment of chronic fractures, displaced fractures, and proximal fractures. Longer time to union was seen in association with older fractures, displaced fractures, proximal fractures, and fractures in patients with osteonecrosis. The union rate following surgery was 96.5% (109 of 113). Increased time to union was seen in association with open physes, fracture displacement, proximal fracture, the type of screw used for surgical fixation, and the use of bone graft at the time of surgery. DISCUSSION: With changes in patient characteristics and activities, scaphoid fracture patterns in children and adolescents are now similar to the published patterns in adults. While 90% of acute nondisplaced fractures heal with nonoperative treatment, three months of cast immobilization or more may be required for more proximal injuries. Almost one-third of pediatric patients with scaphoid fractures will present late with chronic nonunions; in these instances, surgical reduction and internal fixation should be considered the primary treatment option.