The role of subcutaneous fat and BMI in predicting surgical outcomes and patient reported outcomes in robotic-assisted total hip arthroplasty.

Background: The purpose of this study was to assess if subcutaneous fat (SCF) or BMI is a predictor of surgical complications and patient reported outcomes in patients undergoing robotic-assisted total hip arthroplasty (THA). Methods: Patients who underwent robotic-assisted primary THAs at one institution between 2018 and 2020 were included in this retrospective cohort study. Prior to surgery, computed tomography (CT) was used to measure SCF in the posterolateral quadrant of the hip. SCF was measured 3 centimeters (cm) proximal to the greater trochanter (PGT) and 3 cm inferior to the distal tip of the greater trochanter (DGT).Measurements were normalized to the size of the patient's bony anatomy by dividing the subcutaneous fat area measurement by the transverse diameter of the femur 10 cm inferior to the tip of the greater trochanter. Patients were divided into quintiles determined by SCF distribution around the mean (groups 1-5) and BMI (BMI<25, BMI 25-29.9, BMI 30-34.9, BMI 35-39.9, and >40). Ninety day outcomes and PROMIS (Patient Reported Outcome Measures Information System) scores were acquired from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database preoperatively, at 14-112 days post-operative and at the latest follow up. Results: There were 175 patients identified with a mean age of 63.83 years (range 27-89) and a mean BMI of 30.73kg/m2 (range 18.2-48.4). Interclass correlation coefficient was greater than 0.9 in all PGT, DGT, and GT measurements. Analysis of Variance (ANOVA) found there was a significantly shorter time from incision to closure in quintiles 1 and 3 when compared to the SCF quintile 5 (p<0.05) and that there was a significantly shorter time from incision to closure in BMI categories 1, 2, and 3 when compared to BMI category 5 (BMI > 40). There were no differences between SCF and BMI as predictive of length of stay, transfusion status, infection, or PROMIS scores. Conclusion: It can be concluded that hip SCF on axial CT images can reliably measure SCF and is predictive of time from incision to closure, but it does not show a significant difference in predicting the length of stay, infection, or PROMIS scores when compared to BMI.

The Correlations Between Concussions and Chronic Traumatic Encephalopathy (CTE) in the National Football League: Why Does Society Keep Promoting Sports With High CTE Rates?

The National Football League (NFL) is a highly popular sport in the United States, attracting numerous aspiring athletes due to its lucrative pay and fame. However, the pursuit of a career in the NFL comes with significant health risks, particularly concussions and their long-term effects. Repeated head traumas in the NFL can lead to chronic traumatic encephalopathy (CTE), a neurodegenerative disease that is characterized by a spectrum ranging from cognitive and behavioral aberrations and has been linked to conditions such as Parkinson's and Alzheimer's diseases. Despite growing evidence, NFL officials have historically downplayed the connection between concussions and CTE, attributing symptoms to other factors such as performance-enhancing drugs. To address the concussion crisis, the NFL has implemented rule changes and partnered with engineers to develop safer helmets. However, the most effective approach to combating CTE involves early detection through MRI brain scans, which are a potential method for identifying the disease in living patients and subsequently facilitating early intervention. While other contact sports such as boxing have been shown to increase the risk of traumatic brain injury as well as CTE, the impact the NFL has on CTE is the most prominent in today's society. This editorial emphasizes the need for the NFL to acknowledge the clear link between concussions and CTE and to invest in comprehensive diagnostic and therapeutic strategies such as new monoclonal antibody therapies. Despite ethical and technical challenges, such as the use of embryonic stem cells and the risks associated with radioactive scans, advancing these methods could save lives and improve the long-term health outcomes of current and former NFL players. Enhanced understanding and proactive management of CTE are crucial for mitigating the severe impact of concussions in professional football.

Operative Management of Pediatric Physeal Bar Development and Genu Valgum.

Background: Pediatric orthopedic conditions present unique challenges due to ongoing skeletal growth and development. Managing these cases requires addressing both structural anomalies and functional deficits. Care presentation: This case report discusses a 13-year-old male with recurrent left knee pain exacerbated by physical activity. The patient's history of a left knee infection at 1.5 years of age, possibly septic arthritis or osteomyelitis, underscores the long-term consequences of early pathology on skeletal growth and alignment. Imaging studies revealed a distal lateral femur physis bar and genu valgum, necessitating surgical intervention. Management and Outcomes: The surgery involved medial distal femur hemiepiphysiodesis and lateral distal femur bar excision to correct anatomical deformities and restore optimal limb alignment and function. Postoperative rehabilitation, including targeted exercises to improve quadriceps strength, was crucial for functional recovery and reducing the risk of complications such as medial patellofemoral pain. Conclusion: This case highlights the importance of a multidisciplinary approach in managing complex pediatric orthopedic cases.

Nutrient and Hormonal Effects on Long Bone Growth in Healthy and Obese Children: A Literature Review.

Longitudinal bone growth is mediated through several mechanisms including macro- and micronutrients, and endocrine and paracrine hormones. These mechanisms can be affected by childhood obesity as excess adiposity may affect signaling pathways, place undue stress on the body, and affect normal physiology. This review describes the physiology of the epiphyseal growth plate, its regulation under healthy weight and obesity parameters, and bone pathology following obesity. A literature review was performed utilizing PubMed, PMC, NIH, and the Cochrane Database of Systematic Reviews pertinent to hormonal and nutritional effects on bone development, child obesity, and pathologic bone development related to weight. The review indicates a complex network of nutrients, hormones, and multi-system interactions mediates long bone growth. As growth of long bones occurs during childhood and the pubertal growth spurt, pediatric bones require adequate levels of minerals, vitamins, amino acids, and a base caloric supply for energy. Recommendations should focus on a nutrient-dense dietary approach rather than restrictive caloric diets to maintain optimal health. In conclusion, childhood obesity has profound multifaceted effects on the developing musculoskeletal system, ultimately causing poor nutritional status during development. Weight loss, under medical supervision, with proper nutritional guidelines, can help counteract the ill effects of childhood obesity.

Comparing the Outcomes of Titanium and Stainless Steel Flexible Nails in Repairing Pediatric Long Bone Fractures.

Background: Traditionally, pediatric femoral fracture treatment favored conservative methods, relying on casting and the inherent bone remodeling ability in immature bones. Surgical intervention was deferred until age 6, as nonoperative approaches often resulted in complications. Titanium elastic nailing (TENS) emerged as an effective treatment for diaphyseal femoral fractures in ages 6 to 16. However, the choice between TENS and stainless steel elastic nailing (SSENS) remains debated due to inconsistent findings. Objective: This study aimed to evaluate the effectiveness of both nailing systems in pediatric long bone fractures. Methods: A retrospective chart review at William Beaumont Hospital Royal Oak included 83 patients aged 6 to 16 treated with TENS or SSENS between January 2011 and January 2021. Data collected encompassed nail related issues, time to fracture union, full weight bearing, and nail removal. Results: In the TENS group (n=29), the average age was 8.8±2.4 years, and the average BMI was 17.2±3.4. The SSENS group (n=54) had an average age of 9.3±2.7 and an average BMI of 19.7±8.4. Time to fracture union for TENS was 93.8±60.5 days, while SSENS was 82.2±40.0 days. Conclusion: This study found no statistically significant differences in nail-related complications, time to fracture union, full weight bearing, or nail removal between TENS and SSENS in pediatric long bone fractures. The choice between these systems should be based on individual circumstances. Limitations include a small sample size and the study's retrospective nature.

#lowbackpain on TikTok: A New Frontier for Orthopaedic Medical Education.

INTRODUCTION: Low back pain has become a substantial health problem in all developed countries. Many healthcare professionals and content creators have begun sharing their treatment methods and opinions through social media, especially the video-based platform TikTok. TikTok has been downloaded more than 2.6 billion times with over a billion daily users. Its influence on public health makes it imperative that information be accurate and safe. This study aims to analyze TikTok's most popular content on lower back pain and how orthopaedic surgeons contribute on this growing platform. OBJECTIVES: To analyze TikTok's most popular content on lower back pain and how orthopaedic surgeons are and can contribute on this growing platform. METHODS: A TikTok search conducted on April 22, 2023, using the terms '#lowerbackpain'and '#lowbackpainrelief,' resulted in numerous videos, 100 of which met inclusion criteria. Videos were included if they were related to the content, had more than 1000 views, were in English, and were not duplicates. Video characteristics were recorded and evaluated for quality by two reviewers using DISCERN. A two-sample t-test was used to assess differences. RESULTS: Overall, the top videos on lower back pain had an average of 2,061,396 views, with a mean DISCERN score of 34. The mean total DISCERN score was 36 and 34 for physicians and nonphysicians, respectively, while the video by the orthopaedic surgeon (n = 1) scored 31. The most recommended treatments included at-home exercises (n = 75) and visiting a chiropractor (n = 4). CONCLUSION: We find that the information presented by nonphysicians offered quick, at-home fixes to medical problems without offering any research or proven data to support their claims. We cannot overlook Tiktok's immense influence in the realm of orthopaedic health as it has become a sphere of information dissemination and education. Thus, we suggest that there is not necessarily a need for a greater number of surgeons and/or resident physicians to involve themselves on the platform, but rather the involvement of governing bodies and spine societies to put out position statements for our patients.

Pediatric Patients with Osteomyelitis and/or Septic Joint Undergoing Surgical Debridement Have Equivalent Short-Term Outcomes with or without Preoperative MRI.

The purpose of this study was to determine if short-term outcomes differed for pediatric patients with suspected musculoskeletal infection with or without a preoperative MRI. This was a multicenter, retrospective review of patients aged 0-16 years who presented with atraumatic extremity pain, underwent irrigation and debridement (I&D), and received at least one preoperative or postoperative MRI over a 10-year period. Primary outcomes were time to OR, total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Secondary outcomes entailed the rate at which concurrent osteomyelitis was identified in patients with septic arthritis and the extent of the resulting surgical debridement. Of the 104 patients, 72.1% had a preoperative MRI. Patients with a preoperative MRI were significantly less likely to have surgery on the day of admission. No difference was found between groups regarding total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Of the 57 patients diagnosed with septic arthritis, those with a preoperative MRI were significantly more likely to have concurrent osteomyelitis identified and to undergo bony debridement in addition to arthrotomy of the joint. In conclusion, patient outcomes are not adversely affected by obtaining a preoperative MRI despite the delay in time to OR. Although preoperative MRI can be beneficial in ruling out other pathologies and identifying the extent of concurrent osteomyelitis, the decision to obtain a preoperative MRI and timing of surgery should be left to the discretion of the treating surgeon.

3D printed capsule shells for personalized dosing of cyclosporine-loaded SNEDDS.

Cyclosporine (CsA) is a potent immunosuppressant agent that has been used since 1980 for the treatment of various autoimmune diseases and is extensively used to enhance the survival rate of patients and grafts following organ transplant surgeries. CsA is a poorly soluble drug with a narrow therapeutic window and inter-subject variability, which can lead to graft rejection, nephrotoxicity and other severe adverse effects. This study explores a novel method that combines solubility enhancement of CsA using SNEDDS formulation and personalized dosage delivery using 3D printing technology. The oil phase was chosen as a combination of caproyl 90 and octanoic acid while the Smix phase was chosen as a combination of cremophore El and PEG 400. The optimized liquid SNEDDS was solidified using PEG 6000. An FDM printer was used to print a capsular shell with an oval base that ascends to form a dome with an opening at the top. This opening is used to fill the molten CsA-loaded SNEDDS formulation using a pipette or syringe. The CsA-loaded SNEDDS formulation was characterized by FTIR, DSC and SEM/EDX. The in-vitro release of CsA showed complete release within sixty minutes and followed Korsmeyer-Peppas release kinetics. The drug release was not affected by either the shell opening size or the amount of the loaded formulation. This novel method is simple and straightforward for personalized dosage delivery of drug-loaded SNEDDS formulations.

The Duration of Symptoms Influences Outcomes After Lumbar Microdiscectomies: A Michigan Spine Surgery Improvement Collaborative.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: We investigate whether duration of symptoms a patient experiences prior to lumbar microdiscectomy affects pain, lifestyle, and return to work metrics after surgery. METHODS: A retrospective review of patients with a diagnosis of lumbar radiculopathy undergoing microdiscectomy was conducted using a statewide registry. Patients were grouped based on self-reported duration of symptoms prior to surgical intervention (Group 1: symptoms less than 3 months; Group 2: symptoms between 3 months and 1 year; and Group 3: symptoms greater than 1 year). Radicular pain scores, PROMIS PF Physical Function measure (PROMIS PF), EQ-5D scores, and return to work rates at 90 days, 1 year, and 2 years after surgery were compared using univariate and multivariate analysis. RESULTS: There were 2408 patients who underwent microdiscectomy for lumbar disc herniation for radiculopathy with 532, 910, and 955 in Groups 1, 2, and 3, respectively. Postoperative leg pain was lower for Group 1 at 90 days, 1 year, and 2 years compared to Groups 2 and 3 (P < .05). Postoperative PROMIS PF and EQ-5D scores were higher for Group 1 at 90 days, 1 year, and 2 years compared to Groups 2 and 3 (P < .05). CONCLUSION: Patients with prolonged symptoms prior to surgical intervention experience smaller improvements in postoperative leg pain, PROMIS PF, and EQ-5D than those who undergo surgery earlier. Patients undergoing surgery within 3 months of symptom onset have the highest rates of return to work at 1 year after surgery.

Efficacy and Outcome Measurement of iFactor/ABM/P-15 in Lumbar Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVES: To determine the efficacy and overall outcomes of iFactor/ABM/P-15 following lumbar spine surgery. METHODS: We performed a search of the Cochrane Library, Medline Ovid, PubMed, and SCOPUS databases from inception until August 2023. Eligible studies included outcomes of patients receiving iFactor following lumbar spine surgery. The primary outcomes of interest were fusion rates and iFactor efficacy after lumbar surgery in patients who received iFactor. Secondary outcomes included patient-reported outcomes and complication rates. RESULTS: A total of 766 titles were initially screened. After inclusion criteria were applied, 5 studies (388 patients) were included, which measured overall outcomes of iFactor/ABM/P-15 following lumbar spine surgery. These studies showed acceptable reliability for inclusion based on the Methodical Index for Non-Randomized studies and Critical Appraisal Skills Programme assessment tools. iFactor/ABM/P-15 facilitated significantly faster bone development in various procedures while maintaining favorable clinical outcomes compared to traditional grafts. CONCLUSIONS: This systematic review found that iFactor/ABM/P-15 use for lumbar spine surgery maintains similar managing patient-reported outcomes relative to other grafting methods. In regard to rates of fusion, iFactor/ABM/P-15 showed a significantly faster rate of fusion when compared to traditional grafts including allograft, autograft, demineralized bone matrix (DBM), and recombinant human bone morphogenetic protein-2 (rhBMP-2). Future multicenter randomized control trials with larger sample sizes are recommended to further assess iFactor/ABM/P-15 efficacy in lumbar spine surgery.

Virtual and Augmented Reality in Spine Surgery: An Era of Immersive Healthcare.

In the dynamic realm of spinal surgery, the integration of virtual reality (VR) and augmented reality (AR) technologies is heralding a transformative era. These cutting-edge tools are not only reshaping the training landscape for surgical trainees, offering immersive and interactive experiences but are also enhancing the surgical precision of seasoned professionals in the operating room. While the potential of VR and AR is vast, their adoption is tempered by significant costs and challenges in seamless integration. As the spinal surgery community looks ahead, it becomes imperative to emphasize the validation, reliability, and thorough cost-benefit analysis of these technologies. This article delves into the current applications, benefits, challenges, and future trajectories of VR and AR in spinal surgery, underscoring their pivotal role in the evolution of immersive healthcare.

Transforming Orthopedic Joint Surgeries: The Role of Artificial Intelligence (AI) and Robotics.

The landscape of orthopedic joint surgeries, specifically total hip arthroplasty (THA) and total knee arthroplasty (TKA), is rapidly changing, and artificial intelligence (AI) along with robotics is at the helm of this transformation. These technologies, working synergistically, have introduced unprecedented levels of precision and personalization to surgical procedures, thereby significantly enhancing patient outcomes. In this editorial, we explore the changing perspectives of orthopedic surgeons toward AI and robotics and dissect the incorporation of these technologies in surgeries, their associated advantages, their inherent limitations, and potential future prospects. We draw from a host of recent studies to provide a comprehensive understanding of how these transformative technologies can augment surgical performance and patient care.

Pediatric Distal Tibia Physeal Injury Presenting with Acute In-toeing: A Case Report and Literature Review.

Ankle fractures are among the most common fractures sustained in the pediatric population. Given the frequency of physeal involvement of the distal fragment, complications including growth arrest, overgrowth, and rotational deformities are not uncommon. This case report describes a 12-year-old adolescent boy who presented after an acute right ankle injury sustained while playing. He noted right ankle pain, swelling, and in-toeing of his foot. Radiographs of the ankle demonstrated a distal tibia Salter-Harris type II fracture that appeared nondisplaced. However, a CT scan of the ankle demonstrated a 60° difference in the rotational profile between the injured and noninjured tibias. The patient's acute rotational deformity was corrected with closed reduction and percutaneous pinning. Pediatric distal tibia physis fractures presenting with in-toeing are rare and difficult to diagnose accurately with radiographs alone. Accordingly, a detailed history, physical examination, comparison radiographs, and CT scans are imperative in making the correct diagnosis and determining the appropriate treatment.

Subsidence of All-Polyethylene Tibial Components Used in Unicondylar Knee Arthroplasty: A Cohort Study.

INTRODUCTION: Unicompartmental designs and techniques have been developed to preserve bone stock and minimize soft tissue trauma. Early modern designs and techniques have been introduced with little support in the peer-reviewed literature. MATERIAL AND METHODS: From October 2002 to May 2004, 64 consecutive DePuy Preservation unicondylar knee arthroplasties (UKAs) were performed in 56 patients. Two patients died of unrelated consequences, leaving 62 UKAs for review (55 medial, 7 lateral). All procedures were performed through a quadriceps-sparing approach. All components were cemented, including an all polyethylene tibial component. Clinical and radiographic follow-up data were reviewed and analyzed. RESULTS: At an average follow-up of 2.5 years, six (11%) of the medial tibial components have subsided. Of these, four had moderate-to-severe pain, one did require a revision to a total knee arthroplasty (TKA), and another did stabilize. An additional two patients continued to have knee pain (one requiring conversion to TKA), leaving a total of 55 UKAs (89%) functioning well at early follow-up. Additional complications have included four deep vein thromboses, three cardiac issues following the index procedure, one surgical site infection, one intraoperative medial femoral condyle fracture, and one reoperation for loose cement fragments. CONCLUSION: This study demonstrates a high rate of subsidence for all-polyethylene tibial components used in UKA, resulting in pain and failure of the arthroplasty. Despite the less invasive approach, we found complications that are usually associated with TKA surgery as well as those unique to UKA.

Soft Tissue Benign Hand Masses in the First Web Space: A Retrospective Case Series.

INTRODUCTION: Hand masses are fairly common. While most of these masses are either ganglion cysts or benign tumors, masses in the first web space are not rare, and they may in fact represent a variety of lesions. These include both benign and malignant tumors, metastases, or congenital and anomalous structures, and may involve nerves, vascular structures, connective tissue, and joints. METHODS: In this retrospective case series, data on 12 cases of first dorsal web space hand mass treated at our center over a period of five years were collected and analyzed. RESULTS:  Twelve consecutive patients presenting with a first dorsal web space hand mass over a period of five years were reviewed. This represented a group of nine females and three males, with a mean age of 53 years (range = 16-70 years). Seven patients had a mass on the right side and five on the left side. The surgical approach to resect the mass in all 12 patients was dorsal. The most common diagnosis was ganglion cyst (50%), followed by lipoma (25%) and aneurysm (16.6%). There was one case of eccrine spiradenoma. CONCLUSION: First dorsal web space hand masses can encompass multiple different pathologies, and the first web space has an intricate anatomy. Both of these factors mandate a careful approach that includes meticulous preoperative planning with appropriate advanced imaging studies, which helps to make the surgical procedure more efficient and accurate.

A Tibial Tubercle Fracture Masquerading as an Inferior Pole of the Patella Fracture.

Pediatric tibial tubercle fractures are uncommon injuries that most often occur in adolescent men. Patients will typically present with anterior knee pain with or without patella alta. This case report describes a tibial tubercle fracture in a 13-year-old man misidentified as an inferior pole patella sleeve fracture on physical examination and preoperative radiographs. The tubercle reduction was secured with cannulated screws while injury to the patellar tendon periosteal sleeve was repaired with suture anchors. This case highlights the utility of advanced imaging when the etiology of extensor mechanism disruption is unclear. Furthermore, it is imperative to set expectations with parents and guardians that the full extent of the injury may only be confirmed under direct visualization in the operating room because of the complexity of such injuries.

Pediatric Humeral Shaft Fracture Nonunion: A Case Report.

Humeral shaft fractures in the pediatric population are a commonly encountered injury in everyday practice. Most patients with these injuries are treated without surgery and go on to have an uneventful recovery. Nonunion of these injuries in the pediatric population has been reported only once in the literature. This case report follows a 13-year-old female after a seemingly standard transverse humeral shaft fracture. The patient was treated with a fracture brace initially. No signs of healing were noted at the eight-week post-injury follow-up. The family elected for continued conservative management until the patient returned at four months post-injury with persistent gross motion at the fracture site and no healing on radiographs. Laboratory testing did show that she has mild-to-moderate vitamin D deficiency, which was addressed. The patient underwent nonunion treatment with open reduction, internal fixation, and bone grafting. She went on to full union with an uncomplicated postoperative course. This case presents an interesting and unique case presentation. This report shows that, while rare, it is a potential outcome of humeral shaft fractures in the pediatric population. This case also demonstrates that using the standard adult operative technique for nonunion treatment with rigid internal fixation and bone grafting in a pediatric patient will lead to full-bone healing.

Pediatric Upper Cervical Spine Trauma: A 10-Year Retrospective Review at a Pediatric Trauma Center.

Background Traumatic upper cervical spine injuries (tUCSI) are generally caused by high-impact injuries to the C1-C2 vertebral level. The current literature is limited with regards to comparing epidemiological trends, treatment options, and overall outcomes for tUCSI within the pediatric cohort. The purpose of this study was to analyze pediatric tUCSI epidemiological data, potential variations in treatment and patient outcomes, and to evaluate any specific trends that may be clinically relevant. Methodology We conducted a retrospective cohort study on pediatric patients ages 1 day to 16 years old, admitted for tUCSI over the past 10 years (1/2011 to 1/2021) at a Midwest level 1 trauma center. Retrospective data was queried using ICD-9 and ICD-10 diagnosis codes for tUCSI. Children were stratified into three age groups: Group 1 - Infants and Toddlers (children under three years of age); Group 2 - Young Children (children between three and seven years of age); Group 3 - Juveniles and Adolescents (children between the ages of seven and 16). Numerical data and categorical variables were summarized and the normality of the distribution of data was evaluated using the Anderson-Darling normality test. Differences between the age groups were examined using either an unpaired, independent Two-Sample t-test or Unpaired Mann-Whitney U test. Pearson's chi-squared or Fisher's exact tests were used to compare categorical data between groups. Results Forty total patients were included in the final analysis, 23 female (57.5%) and 17 male (42.5%). The mean age was 11 ± 4 (range 2-16). Overall, the most common mechanism of injury was a motor vehicle collision (n=16, 40%), followed by sports injury (n=13, 32.5%), falls (n=6, 15%), and unknown mechanism (n=5, 12.5%). The most common mechanism of injury in young children was a fall (n=4, 57.5%, p<0.001). Adolescents and Juveniles significantly suffer from sports injuries compared to young children (n=13, 39.4%, p=0.043). Mechanisms of injuries presented with unique associated concomitant injuries. The most common associated sites of injuries were lower cervical spine (n=31, 77.5%), and skull injury (n=4, 10%). The vast majority of these cases were managed nonoperatively (pain medication and non-operative cervical orthosis) (n=36, 90%). Mortality and morbidity rates from tUCSI were rare in our cohort (n=1, 2.5%). Conclusion This study found that the majority of pediatric tUCSI patients can be managed nonoperatively, with dislocations and spinal instability being the most common indications for operative management. Commonly used non-operative external fixation methods include cervical collars and Minerva jackets. Our cohort showed very low mortality and morbidity rates, however, these preliminary results will require validation by future prospective multicenter studies.

Operative Fixation of Pediatric Forearm Fractures: Does the Fracture Location Matter?

BACKGROUND: Flexible intramedullary nails (FNs) are successfully used to treat pediatric forearm fractures, especially midshaft fractures. Distal forearm fractures have been described as "difficult to manage" with FN insertion. The purpose of this study was to report the clinical and radiographic outcomes of using flexible nails in pediatric forearm fractures and the impact of fracture location on the outcome of the procedure. METHODS: This is a retrospective review of pediatric patients who presented with forearm fractures that were surgically treated with flexible nails between 2009 and 2018. Patient demographics, fracture location, and classification were reported. Intraoperative and postoperative complications were reported. The primary outcomes were fracture radiographic union, intraop and postop complications, and the need for additional surgical procedures. RESULTS: Fifty-nine patients were included, with a mean age of 11 years. All fractures healed with patients regaining full range of motion. The authors were able to use flexible nails successfully in 48/59 (81%) patients. In eleven cases (19%), FN fixation was not able to provide adequate fixation to maintain reduction. The method of fixation was changed from FN insertion to another method in nine cases. In two cases, FN fixation was augmented with another fixation method. Fractures within 3 inches of the distal articular surface were at a higher risk of intraoperative change/augmentation of the fixation method (29%) compared with fractures that occurred more than 3 inches from the distal articular surface (11%). CONCLUSION: The majority of pediatric forearm fractures can be treated successfully with flexible nails. Surgeons involved in treating these fractures should pay attention to distal third fractures. Stabilizing the distally located fractures using FN fixation can be challenging. Surgeons should be prepared to use an alternative fixation method when needed.

The Diagnosis and Management of Pediatric Spine Infections.

The management of pediatric spine infections requires a multidisciplinary approach that includes orthopedic surgeons, infectious disease specialists, interventional radiologists, and others. The prevalence of the disease has increased in frequency, virulence, and degree of soft tissue involvement over the past several years; there has also been a resurgence of some types of infections, such as tuberculosis, fungal, and viral pathogens. The diagnosis can often be reached with a detailed history, physical examination, laboratory tests, and imaging studies. Pathologies mimicking infection require a more invasive approach for diagnosis, including core or open biopsy. The treatment of discitis, spondylodiscitis, vertebral osteomyelitis, spinal epidural, and intramedullary abscesses in children is at times complex, and although many infections can be treated non-surgically with antibiotic therapy, some more extensive infections require surgical management. A timely diagnosis is important as it allows the initiation of the appropriate antimicrobial therapy and would decrease the complexity of the subsequent surgical intervention.