What is the Utilization and Impact of Advanced Imaging for Tibial Tubercle Fractures? An Analysis of 598 Patients From the Tibial Tubercle Study (TITUS) Group.

BACKGROUND: Given the rare nature of tibial tubercle fractures, previous studies are mostly limited to small, single-center series. This results in practice variation. Previous research has shown poor surgeon agreement on utilization of advanced imaging, but improved evidence-based indications may help balance clinical utility with resource utilization. The purpose of this study is to quantify diagnostic practices for tibial tubercle fractures in a large, multicenter cohort, with attention to the usage and impact of advanced imaging. METHODS: This is a retrospective series of pediatric tibial tubercle fractures from 7 centers between 2007 and 2022. Exclusion criteria were age above 18 years, missing demographic and pretreatment data, closed proximal tibial physis and tubercle apophysis, or a proximal tibia fracture not involving the tubercle. Demographic and injury data were collected. Fracture classifications were derived from radiographic evaluation. The utilization of advanced imaging was recorded as well as the presence of findings not identified on radiographs. Standard descriptive statistics were reported, and χ2 tests were performed (means reported±SD). RESULTS: A total of 598 patients satisfied the inclusion criteria, of which 88.6% (530/598) were male with a mean age of 13.8±1.9 years. Internal oblique x-rays were obtained in 267 patients (44.6%), computed tomography (CT) in 158 (26.4%), and magnetic resonance imaging (MRI) in 64 (10.7%). There were significant differences in the frequency at which CT (7.2% to 79.4%, P<0.001) and MRI were obtained (1.5% to 54.8%, P<0.001). CT was obtained most frequently for Ogden type IV fractures (50/99, 50.5%), and resulted in novel findings that were not visualized on radiographs in a total of 37/158 patients (23.4%). The most common finding on CT was intra-articular fracture extension (25/37). MRI was obtained most frequently for Ogden type V fractures (13/35, 37.1%), and resulted in novel findings in a total of 31/64 patients (48.4%). The most common finding was patellar tendon injury (11/64), but only 3 of these patients required tendon repair. CONCLUSIONS: Substantial variation exists in the diagnostic evaluation of tibial tubercle fractures. CT was most helpful in clarifying intra-articular involvement, while MRI can identify patellar tendon injury, periosteal sleeve avulsion, or a nondisplaced fracture. This study quantifies variation in diagnostic practices for tibial tubercle fractures, highlighting the need for evidence-based indications for advanced imaging. LEVEL OF EVIDENCE: Level III.

Treatment of Length-Unstable Pediatric Femur Fractures in Children Aged 5 to 11 years: A Focused Review.

Pediatric femur fractures in children aged 5 to 11 years are typically classified as length-stable versus length-unstable. For length-stable fracture patterns, there is frequent consensus among pediatric orthopaedic specialists regarding the appropriateness of flexible intramedullary nails, submuscular plates (SMP), or lateral-entry rigid intramedullary nails (LE-RIMN). With length-unstable fracture patterns, however, the decision is more complex. Age, weight, fracture pattern, fracture location, surgical technique, surgeon experience, several implant-specific details, and additional factors are all important when choosing between flexible intramedullary nail, SMP, and LE-RIMN. These familiar methods of fixation may all be supported by conflicting and sometimes heterogeneous data. When planning to treat length-unstable fractures in young children, surgeons should understand evidence-based details associated with each implant and how each patient-specific scenario affects perioperative decisions.

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.

Tweener Fractures in Children and Adolescents.

Tweener fractures are defined as long bone or metadiaphyseal fractures in a pediatric population for which multiple treatment options may be used. It is important to focus specifically on patients nearing skeletal maturity who present with length-unstable femoral shaft fractures, both-bone forearm fractures, distal radius metadiaphyseal fractures, and adolescent tibial shaft fractures. Although there is no gold standard of treatment for any of these fracture patterns, it is important to discuss the risks and benefits, proper application, and important technical aspects of each treatment method to allow surgeons to make an informed decision and optimize surgical outcomes in this patient population.

Treatment of Pediatric Femoral Shaft Fractures.

Diaphyseal femur fractures are common in pediatric orthopaedic settings. A patient-specific treatment plan incorporates several factors, including age, weight, fracture pattern, associated injuries, and social considerations. Nonaccidental trauma should be considered in children younger than 3 years. In general, young children are treated with noninvasive immobilization (Pavlik harness or early hip spica casting) while school-aged children are treated with internal fixation. Internal fixation options include flexible intramedullary nails, rigid locked intramedullary nails, and plate osteosynthesis. Flexible intramedullary nails have the best outcomes in children of appropriate weight, aged 5 to 11 years, with stable fracture patterns. Lateral-entry rigid intramedullary nails have been designed for use in older children. External fixation is usually reserved for complex scenarios. Regarding all treatment methods, surgeons should be aware of several technical factors necessary to optimize outcomes.

Vascular Safe Zone During Percutaneous Pinning of the Distal Femur.

PURPOSE: During percutaneous pinning of the pediatric distal femur, iatrogenic vascular damage in the medial thigh is a frequent concern. The proximity of a proximal-medial pin to these vessels has never been studied in children. This study describes a radiologic vascular safe zone that is easily visualized during surgery (wherein the superficial femoral vessels are safely posterior). METHODS: Patients ≤16 years old with magnetic resonance imaging of one or both femora between 2005 and 2020 were retrospectively reviewed. The "at-risk level" (ARL) was defined as the distal-most axial image with a femoral vessel anterior to the posterior condylar axis. A standardized retrograde lateral-to-medial pin was templated. A correlation matrix and least squares regression identified age and physeal width (PW) as ideal independent variables. A vascular safe zone above the medial femoral condyle (MFC) was modeled as a multiple of PW (i.e. x*PW) and needed to satisfy 3 age-dependent criteria: (1) at the ARL, the pin is medial to the vessels, (2) the pin exits the medial thigh before the ARL, and (3) the chosen "vascular safe zone" (x*PW) is always distal to the ARL. RESULTS: Forty-three patients averaging 7.1±3.9 (0.3-16) years old were included. Intra-Class correlation coefficients were excellent (0.92-0.98). All measurements strongly correlated with age ( r =0.76-0.92, P <0.001) and PW ( r =0.82-0.93, P <0.001). All patients satisfied criteria 1. Criteria 2 was satisfied in all patients ≥6 years old, 86% of children 4-5, and only 18% of children ≤3. In children >3 years old, the largest safe zone that satisfied criteria 3 was 2×PW. On average, the ARL was 2.5×PW (99% CI 2.3-2.7) above the MFC. The average ARL in children ≥6 years old was significantly higher than 2×PW (162 mm vs. 120 mm, P <0.001). CONCLUSION: During passage of a distal femur pin into the medial thigh, children ≥6 years old have a vascular safe zone that extends 2×PW proximal to the MFC. Surgeons should be cautious with medial pin placement in children 4-5 years old and, if possible, avoid this technique in children ≤3. LEVEL OF EVIDENCE: IV.

Preoperative MRI Reliably Predicts Pedicle Dimensions on Intraoperative CT Images in Structural Main Thoracic Curves in Patients With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: The aim of this study was to compare the length and diameter of thoracic pedicles in patients with adolescent idiopathic scoliosis (AIS) as measured on preoperative magnetic resonance imaging (pMRI) to intraoperative computed tomography (iCT) scan. SUMMARY OF BACKGROUND DATA: Optimally sized pedicle screw placement during instrumented posterior spinal fusion for AIS can maximize correction and minimize screw pullout. While iCT-guided navigation can quickly estimate screw position and size, this technology is not universally available. Many surgeons utilize pMRI, when obtained, to estimate screw sizes. Data comparing these measurements on pMRI and iCT is limited. We hypothesized that in patients with surgical magnitude AIS, pedicle length, and diameter measured on pMRI would have at least moderate reliability compared to those made on iCT images. MATERIALS AND METHODS: The pMRI and iCT for 60 patients with structural thoracic curves who underwent posterior spinal fusion for AIS at a single center between 2009 and 2017 were analyzed. Bilateral T5-T12 vertebral levels were evaluated for pedicle chord length and pedicle isthmic diameter on both pMRI and iCT. Between-study reliability and interrater reliability was evaluated for each level of the thoracic spine. RESULTS: There is good reliability for pedicle length [intraclass correlation coefficient (ICC)=0.8, 95% confidence interval (CI): 0.78-0.83] and diameter (ICC=0.86, 95% CI: 0.84-0.88) between pMRI and iCT. When assessed by level, T6 has the lowest reliability for length (ICC=0.52, 95% CI: 0.33-0.67) and diameter (ICC=0.55, 95% CI: 0.35-0.69). Interrater reliability ranged from moderate-to-good reliability for all pedicle measurements for both length and diameter on pMRI and iCT. CONCLUSION: Pedicle measurements made on pMRI may be used with reasonable reliability to predict pedicle dimensions visualized on iCT, allowing surgeons to preoperatively plan pedicle screw sizes based off magnetic resonance imaging.

Prolonged non-weightbearing treatment decreases femoral head deformity compared to symptomatic treatment in the initial stage of Legg-Calvé-Perthes disease.

The purpose of this study is to investigate the potential benefit of using prolonged non-weightbearing (PNWB) as a treatment option for early-stage Legg-Calvé-Perthes disease (LCPD). An Institutional Review Board (IRB) approved this retrospective study of patients with LCPD and ≥2-year follow-up. Patients 6-12 years of age were included if treatment began in Waldenstrom stage 1 or 2A. PNWB consisted of ≥6 months of non- or toe-touch weightbearing. PNWB was recommended if perfusion MRI demonstrated ≥40% hypoperfusion of the femoral head and parents decided against operative treatment. The control group consisted of symptomatically treated patients. Deformity index and epiphyseal quotient were measured at 2-year follow-up. Stulberg classification and sphericity deviation score (SDS) were determined at skeletal maturity or at a minimum of 5-year follow-up. When treatment was initiated in Waldenstrom stage 1, the PNWB group had significantly less femoral head deformity, including deformity index (0.21 vs. 0.52; P < 0.001), epiphyseal quotient (69% vs. 43%; P < 0.001), SDS (18 vs. 52; P = 0.004), and Stulberg (50% good vs. 0% good; P = 0.044). The PNWB group mean hypoperfusion was 68%, indicating severe hypoperfusion. Duration of recommended non-weight bearing in the PNWB group was 11.5 months (range 7-17 months). Despite severe femoral head hypoperfusion, PNWB begun during the initial stage of LCPD decreased femoral head deformity. PNWB should be considered a treatment option for patients/parents who do not wish to pursue operative intervention in early-stage LCPD with substantial hypoperfusion. Level of Evidence III - retrospective comparative study.

Paediatric lateral condyle fracture with a posterolateral elbow dislocation: an atypical injury in a preadolescent.

Paediatric lateral condyle fractures of the distal humerus are common but a concomitant elbow dislocation is rare. Typically, paediatric orthopaedic surgeons will treat lateral condyle fractures with pin or metaphyseal single-screw fixation and supplementary immobilisation for several weeks. These techniques sacrifice the early stability and mobilisation necessary to avoid stiffness after a complex elbow fracture-dislocation. We present an 11-year-old boy who sustained a traumatic posterolateral elbow dislocation with lateral condyle and coronoid fractures. Due to advanced skeletal age, both paediatric and adult treatment principles were applied to this rare injury. After initial closed reduction, open reduction and internal fixation of the distal humerus lateral condyle with divergent partially threaded compression screws was performed. Motion was initiated in 2 weeks and the patient regained almost full motion by 3 months. At 1.5-year follow-up, the affected limb carrying angle was unaffected and the patient had no functional limitations.

Ponte osteotomies in a matched series of large AIS curves increase surgical risk without improving outcomes.

PURPOSE: The routine use of Ponte osteotomies in adolescent idiopathic scoliosis (AIS) surgery is controversial with conflicting data for coronal plane correction and little analysis in the sagittal plane. The objective of this study was to analyze the efficacy of Ponte osteotomies in large curve AIS. METHODS: A single institution, prospectively-collected series of consecutive AIS patients who had Ponte osteotomies (P cohort) was directly matched to patients with no Pontes (NP cohort) by age, gender, Lenke classification, surgeon, coronal, and sagittal Cobb angles. The radiographic review included adjusted values using a 3D-derived published formula for preoperative T5-T12 kyphosis. Patient-reported outcomes (PROs) were assessed with the SRS-30 and Spinal Appearance Questionnaire (SAQ). RESULTS: There were 68 patients (34/cohort) with minimum 2-year follow-up with no differences between P and NP cohorts in age, preoperative coronal Cobb (74.5° vs 70.8°), flexibility index, measured or 3D-adjusted T5-T12 kyphosis. Rod material/diameter, fusion levels, blood loss, and operative time did not differ, but implant density was higher in the P group (1.53 vs 1.31, p < 0.001). The P group had 7.9% greater coronal Cobb correction (66.6% vs 58.7%, p < 0.003) without difference in final Cobb angles (24.7° vs. 29.1°, p = 0.052). There were no differences in measured or adjusted T5-T12 kyphosis in the sagittal plane. The P group had a 15% rate of critical intraoperative neuromonitoring changes versus 0% in the NP group (p = 0.053). At follow-up, there were no differences in scoliometer measurements or any domain of SRS-30 or SAQ scores. CONCLUSION: In this first reported matched series of AIS patients, Ponte osteotomies provide small radiographic gains in the coronal plane with no improvement in the sagittal plane and no change in truncal rotation. There was a higher risk of critical intraoperative neuromonitoring changes, and no benefits in patient-reported outcomes. This calls into question the routine use of Ponte osteotomies in AIS, even for curves averaging 70 degrees. LEVEL OF EVIDENCE: II.

Intraoperative Prone Radiographs During Scheuermann Kyphosis Correction Closely Estimate Standing Thoracic and Lumbar Parameters at 2 Years.

BACKGROUND: In patients with Scheuermann kyphosis (SK) undergoing posterior spinal fusion with instrumentation (PSFI), intraoperative lateral radiographs assess deformity correction in the prone position. The relationship between thoracic and (partially un-instrumented) lumbar parameters on prone intraoperative versus standing postoperative radiographs is unknown. METHODS: Forty-five consecutive patients with SK who underwent PSFI between 2007 and 2014 were reviewed. Thoracic kyphosis (TK), lumbar lordosis (LL), instrumented level kyphosis [upper instrumented vertebrae (UIV)-lower instrumented vertebrae (LIV)], and traditional sagittal parameters were recorded from preoperative standing, intraoperative prone, first outpatient standing, and >2-year standing radiographs and time periods were compared. Exclusion criteria included reduction modification after intraoperative radiographs and postoperative construct revision prohibiting comparison to initial intraoperative radiographs. RESULTS: Twenty-five patients averaging 16 (12 to 20) years old during surgery with 3.1 (2 to 7) years follow-up met inclusion criteria. Average surgical variables included: 13±1 fusion levels, UIV at T2, LIV at L3, 3.8±1.6 osteotomies per patient, and 43±9% correction of TK. Preoperative TK and LL measured 82 and 76 degrees, respectively. TK on intraoperative (47 degrees), 6-week (49 degrees), and >2-year (50 degrees) radiographs changed significantly only between intraoperative and >2-year radiographs (P=0.03) by just 3 degrees. LL increased 5 degrees from intraoperative prone to 6-week standing radiographs (51 to 56 degrees, P=0.01) without further significant change at >2 years (59 degrees, P=0.09). Instrumented levels (UIV-LIV) had increased kyphosis at 6 weeks (32 to 35 degrees, P=0.01) without further change at >2 years (36 degrees, P=0.06). CONCLUSIONS: TK on intraoperative prone radiographs during PSFI for SK should match the standing TK ∼6 weeks later. Intraoperative prone LL only slightly increases on early standing radiographs. Assuming a routine postoperative course, intraoperative radiographs slightly underestimate TK (by 3 degrees) and LL (by 8 degrees) on >2-year standing radiographs. These parameters (TK, LL, UIV-LIV) are visualized during surgery and should be used in future studies to predict long-term outcomes. LEVEL OF EVIDENCE: Level IV-retrospective study.

Double Versus Single Tendon Transfers to Improve Shoulder Function in Brachial Plexus Birth Palsy.

BACKGROUND: In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its combined latissimus dorsi and teres major (cLT) versus isolated teres major (iTM) tendon transfer yield different outcomes. METHODS: Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale scores were recorded. Patients with <12 months' follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within 1 year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed. RESULTS: Among 121 cLT and 34 iTM transfers, 49 cLT and 14 iTM met the inclusion criteria. Subsequent matching of cohorts yielded 28 patients (14 cLT and 14 iTM). Average age at time of transfer was 3.0±1.4 years. Follow-up averaged 4.1±3.1 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.2 to 3.5, P<0.001), whereas mMS internal rotation decreased (3.8 to 3.2, P<0.001). When comparing matched cohorts, cLT transfer produced a greater mMS external rotation improvement than iTM (2.1 vs. 1.5, respectively; P=0.025). Loss of midline function (defined as mMS external rotation <3) occurred in 5 (35.7%) cLT and 2 (14.3%) iTM patients. CONCLUSIONS: Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may yield a larger improvement in external rotation in certain patients. However, both techniques slightly decrease shoulder internal rotation. Given that more total cLT patients lost midline function among matched cohorts, iTM transfer may still be considered when limited midline function is a concern. LEVEL OF EVIDENCE: Level III.

Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients.

BACKGROUND: We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures1. Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI)2, lateral condylar fractures3, snapping medial triceps, and ulnar nerve instability4. A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications. DESCRIPTION: We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis. ALTERNATIVES: Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition5. Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut6-9, dome, 3-dimensional10, or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially)11,12. Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes13. Three-dimensional planning employs computed tomography to create expensive anatomic cutting guides that address varus, extension, and internal rotation. However, residual internal rotation is generally well tolerated, derotation is associated with loss of fixation, and the extension deformity will successfully remodel in patients who are <10 years old14. We employ 3-dimensional planning in skeletally mature patients with complex deformity and no remodeling potential. RATIONALE: The oblique lateral closing wedge is ideal for skeletally immature patients because it is simple, reproducible, and efficient. It avoids the lateral prominence without increasing complexity or complications.

Minimally Displaced Humeral Lateral Condyle Fractures: Immobilize or Operate When Stability Is Unclear?

BACKGROUND: Either casting or in situ fixation (to prevent displacement) are recommended for minimally displaced pediatric lateral condyle fractures of indeterminate stability with ≤2 mm lateral displacement and narrowed fracture extension to the epiphyseal articular cartilage. This study compares casting only, acute prophylactic in situ pinning, and surgery if casting fails due to displacement. METHODS: In total, 738 fractures at a level 1 trauma center between 2008 and 2014 were reviewed. All fractures were assigned a Song classification and Song 2 fractures followed to union were analyzed. Worsening displacement was defined as an increase in Song stage. Patients were grouped per treatment: (1) cast only; (2) in situ pinning; or (3) closed or open reduction percutaneous pinning after displacement during attempted cast treatment. RESULTS: In total, 139 fractures were included and 45 (32%) underwent surgery. Among 114 fractures intended for casting, only 20 (18%) displaced and needed surgery. This implies 82% of fractures prophylactically pinned in situ may have remained stable in a cast. On average, displaced fractures were noted 6.5 (2 to 13) days after presentation and required 1 extra clinic visit and week of immobilization without increased complications. Surgeons chose open reduction percutaneous pinning more often for displaced fractures. CONCLUSIONS: Our data estimate 82% of Song 2 fractures never meaningfully displace in a cast. Meaningful displacements occur in <2 weeks. Benefits of prophylactic pinning include 1 less x-ray and clinic visit in exchange for a clinically insignificant lateral cortex reduction and inherent surgical risks. Compliance, surgical scheduling, and a higher rate of open reduction after displacement should influence early treatment decisions. LEVEL OF EVIDENCE: Level III.

External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy.

BACKGROUND: Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. METHODS: Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. RESULTS: Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures. CONCLUSIONS: Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. LEVEL OF EVIDENCE: Level IV-therapeutic.

Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy.

PURPOSE: To identify the rate of and predictive variables for functionally limited shoulder internal rotation in postoperative patients with brachial plexus birth palsy. METHODS: Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores. RESULTS: Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM. CONCLUSIONS: Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy.

Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.

Broach Handle Design Changes Force Distribution in the Femur During Total Hip Arthroplasty.

BACKGROUND: Curved broach handles were developed to overcome limited surgical exposures during total hip arthroplasty. Some authors report increased intraoperative fracture rates during limited exposures. This study evaluates mechanical force ratios transmitted to the bone while broaching with curved vs straight handles. METHODS: An experimental model utilized a 6-axis load cell to measure force distributions produced by 4 different broach handles, each with increasing offset and curvature. Handles were separately impacted and dynamic variables assessed. Handles were then digitized using a high-resolution optical system and a finite element analysis (FEA) was performed to account for trabecular bone and vary the location of mallet impact. Off-axis forces, broaching construct moments, and stress within surrounding bone were computed. RESULTS: Using the experimental model, high-offset handles lost on average 4% more hammering force to the horizontal axis. When the FEA utilized moduli of elasticity to estimate broaching through osteoporotic trabecular bone, horizontally displaced forces (toward cortical bone) were magnified from 4% to a maximum value of 52%. Both the experimental construct and FEA confirmed that larger offset handles increase moment-to-force ratios up to 163%-235%, thus rotating the proximal and distal ends of the broach toward cortical bone. CONCLUSION: Broach handle design is an important determinant of resultant forces transmitted to the broach (and ultimately the bone) during total hip arthroplasty. Unwanted off-axis forces and enhanced rotational dynamics may play a role in intraoperative fractures during femoral canal preparation.

Relationships Between 3 Classification Systems in Brachial Plexus Birth Palsy.

BACKGROUND: The Mallet scale, Active Movement Scale (AMS), and Toronto Test are validated for use in children with brachial plexus birth palsy (BPBP). However, the inability to compare these evaluation systems has led to difficulty gauging treatment efficacy and interpreting available literature in which multiple scoring systems are reported. Given the critical importance of physical examination, we compared 3 scoring systems to clarify statistical relationships between current validated evaluation methods. METHODS: The medical records of children with BPBP treated at a single institution over a 14-year period were retrospectively reviewed. Modified Mallet, AMS, and Toronto scores were recorded throughout the entire period. Data were included if at least 2 complete scoring systems were documented during the same examination session. Spearman correlation coefficients were calculated for all composite and subscore combinations. A concordance table was constructed for select variables found to be highly correlated. RESULTS: Total single-session score combinations were as follows: 157 Mallet and AMS, 325 AMS and Toronto, and 143 Mallet and Toronto. Composite AMS and Toronto scores were found to have a strong correlation (r=0.928, P<0.001). A concordance table comparing these variables revealed that a Toronto score of 3.5 is concordant to an AMS score of 45. Modified Mallet scores had only a moderate correlation with composite AMS (r=0.512, P<0.001) and Toronto (r=0.458, P<0.001) scores. Specifically regarding the modified Mallet score, maneuvers requiring external rotation had stronger correlations with the composite modified Mallet score than maneuvers highlighting internal rotation. CONCLUSIONS: Modified Mallet scores do not correlate well with AMS or Toronto scores and should be utilized separately when managing children with BPBP. Similarly, AMS and Toronto scores are inadequate to guide clinical decisions for which the literature cites Mallet scores as outcome measures, and vice versa. Lastly, Mallet scores should incorporate an isolated internal rotation component to adequately assess midline function. LEVEL OF EVIDENCE: Diagnostic level III.

Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players.

BACKGROUND: There is limited information on the relationship between football helmet fit and concussion severity. HYPOTHESIS: Poor helmet fit may predispose football players to a more severe concussion. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 3. METHODS: Data from concussion injury reports were obtained from the National High School Sports-Related Injury Surveillance System over a 9-year period. Symptoms, duration, and helmet parameters (fit, interior padding) were analyzed for all first-time concussions. RESULTS: Data from 4580 concussions were analyzed. Patients who suffered concussions with a helmet that did not fit properly (3.22%), as determined by an athletic trainer, had higher rates of drowsiness (RR, 1.46; P = 0.005), hyperexcitability (RR, 2.38; P = 0.047), and sensitivity to noise (RR, 1.88; P < 0.001); had more symptoms (5.34 vs 4.54, P = 0.004); and had longer symptom duration (P = 0.04). Athletes with helmets lined with an air bladder had greater rates of sensitivity to light (RR, 1.13; P = 0.02), sensitivity to noise (RR, 1.25; P = 0.009), and longer symptom duration (P = 0.004) compared with foam or gel liners. CONCLUSION: An improperly fitted football helmet is a risk factor for a concussion with more symptoms and of longer duration. Concussions of longer duration are also more common in players with an air bladder-lined helmet. Current high school football rules should mandate supervision and maintenance of helmet fit throughout the season, prior to impact. CLINICAL RELEVANCE: Team physicians, athletic trainers, coaches, and high school officials should ensure proper oversight of helmet fit in high school athletes to decrease concussion severity and duration.