A Normative Baseline for the Srs-22 From Over 1000 Healthy Adolescents in India: Which Demographic Factors Affect Outcome?

STUDY DESIGN: A prospective analysis. OBJECTIVE: This study aims to 1) establish a baseline for the SRS-22 in South East Asia and 2) evaluate the influence of patient demographics on the SRS-22. SUMMARY OF BACKGROUND DATA: Previous studies have established a baseline for the SRS-22 in the US and described the impact of patient demographics. While the SRS-22 is used internationally, limited normative data are available. METHODS: After approval from the local hospital and school board, 1200 adolescents (age 10-18 years) were asked to anonymously complete the SRS-22 in English. The following demographic factors were assessed: height, weight, age, gender, household income (range <$30K to >$200K), and household status (single/dual parent income). Participants with a prior spine history or active medical problems were excluded. Statistical analysis was done with a Pearson correlation followed by an analysis of variance (ANOVA). RESULTS: One thousand nineteen unaffected adolescents completed the SRS-22 (mean age 14.4 ±â€Š1.6 years). Demographics were as follows: gender (42%F, 58%M), household status (640 single/379 dual), height (157 ±â€Š12 cm), weight (46 ±â€Š11.2 kg), body mass index (BMI; 18.5 ±â€Š3.6). SRS-22 score for all patients and by gender: Mean [4.0 ±â€Š0.4, (F)4.0 ±â€Š0.4, (M)3.9 ±â€Š0.4, P < 0.0001], Activity [3.9 ±â€Š0.4, (F)4.0 ±â€Š0.5, (M)3.9 ±â€Š0.6], Pain [4.3 ±â€Š0.6; (F)4.4 ±â€Š0.6, (M)4.2 ±â€Š0.7, P < 0.001], Image [3.9 ±â€Š0.6, (F)3.9 ±â€Š0.6, (M)3.9 ±â€Š0.6], and Mental [3.7 ±â€Š0.6, (F)3.8 ±â€Š0.6, (M)3.7 ±â€Š0.6, P < 0.001]. Male gender was associated with worse pain (-0.15), mental health (-0.11), and overall SRS-22 score (-0.11). Age was correlated with a worse image (r = -0.17, P = < 0.000), while higher BMI was associated with less pain (0.07/0.02). CONCLUSION: Younger age, female gender, and higher BMI correlated with a better SRS-22 score. Income and household status did not affect SRS-22. These findings contrast data gathered in the US but should be considered in conjunction with the minimal clinically important difference (MCID). This study establishes the first normative baseline for the SRS-22 in SE Asia and analyzed the effect of demographics on the outcome score. LEVEL OF EVIDENCE: 2.

Elastic nailing for pediatric subtrochanteric and supracondylar femur fractures.

BACKGROUND: Subtrochanteric and supracondylar femur fractures are difficult injuries to treat in children. Although elastic stable intramedullary nails are commonly used for pediatric femur shaft fractures, there is little information on their effectiveness for managing pediatric subtrochanteric and supracondylar femur fractures. QUESTIONS/PURPOSES: We (1) evaluated radiographic union rates and fracture alignment after elastic nailing of pediatric subtrochanteric and supracondylar femur fractures, (2) identified complications, and (3) determined risk factors for complications. METHODS: Between 2005 and 2011, 36 subtrochanteric fractures and eight supracondylar femur fractures were treated with elastic stable intramedullary nails and had complete followup until clinical and radiographic union. Elastic nailing was used for subtrochanteric fractures in children 5 to 12 years of age or after failed spica cast treatment in younger children and for displaced supracondylar fractures in children older than 5 years. Fracture alignment and union were measured on radiographs, and complications were identified from review of patient charts. Patients with and without complications were compared using nonparametric tests to identify risk factors. RESULTS: All fractures healed; 23 of 33 (70%) subtrochanteric femur fractures and five of seven (71%) supracondylar femur fractures healed with anterior angulation of about 5°. For subtrochanteric fractures, complications included repositioning/removal of nails before radiographic union (n = 4), malunion (n = 2), fracture (n = 1), irritation (n = 1) at nail insertion site, and limb length discrepancy (n = 1); despite these complications, there were 22 (61%) excellent, 12 (33%) satisfactory, and only two (6%) poor outcomes. For supracondylar fractures, complications included infection after nail removal (n = 1) and nail site irritation (n = 2); there were three (38%) excellent, five (62%) satisfactory, and no poor outcomes. Complications were more likely after subtrochanteric fracture during motor vehicle accident (p = 0.045). CONCLUSIONS: Although complication rates are high with elastic nailing for pediatric subtrochanteric (22%) and supracondylar (38%) femur fractures, elastic nailing represents an important option for difficult-to-manage femur fractures. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Genu recurvatum after tibial tuberosity fracture.

Fractures of the tibial tuberosity are infrequent injuries that occur during adolescence. Displaced tibial tuberosity fractures are typically treated with open reduction and internal fixation. Since these fractures occur at or near skeletal maturity, growth disturbances are not seen. This paper presents a case, the first report to our knowledge, of genu recurvatum deformity after open reduction and internal fixation of a tibial tuberosity fracture. A successful treatment plan of tibial tuberosity osteotomy with proximal tibial opening wedge osteotomy was used for the correction of genu recurvatum deformity and to maintain appropriate patellar height. At eighteen-month followup, the deformity remains corrected with satisfactory functional results. This case highlights the importance of recognition of potential complications of fracture management in adolescence.

Complications of medial patellofemoral ligament reconstruction in young patients.

BACKGROUND: The medial patellofemoral ligament (MPFL) has been recognized as the primary restraint to lateral subluxation of the patella. Reconstruction of the MPFL for patellar instability has demonstrated early clinical success, but postoperative complications have rarely been reported, especially in young patients. PURPOSE: To assess early complications (<3 years) of MPFL reconstruction in young patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The charts and radiographs of all patients who underwent MPFL reconstruction between 2005 and 2011 were retrospectively reviewed to identify postoperative complications. A complication was considered major if the patient required hospitalization or further surgery. Each complication was analyzed to identify the technical factors related to it. RESULTS: A total of 179 knees underwent MPFL reconstruction during the study period. There were 38 complications in 29 knees (16.2%), with 34 major and 4 minor. Major complications included recurrent lateral patellar instability (8 patients), knee motion stiffness with flexion deficits (8 patients), patellar fractures (6 patients), and patellofemoral arthrosis/pain (5 patients). Eighteen of 38 (47%) complications were secondary to technical factors and were considered preventable. Female sex and bilateral MPFL reconstructions were risk factors associated with postoperative complications. CONCLUSION: Complications occurred in 16.2% of MPFL reconstruction surgeries for patellar instability in young patients, with almost half resulting from technical problems. Patients should be counseled preoperatively on the risk of potential complications.

Transient cortical blindness as a complication of posterior spinal surgery in a pediatric patient.

Postoperative vision loss after spinal surgery is a well-known but devastating complication that may result from direct ocular ischemia, embolism to the central retinal artery, ischemic optic neuropathy, or occipital cortical ischemia. The occipital cortex is situated in the posterior border zone of the middle and posterior cerebral arteries and is susceptible to ischemic damage. Transient cortical blindness as a cause of postoperative vision loss has never been reported after spine surgery in a child. We report an 11-year-old female patient with muscular dystrophy who underwent posterior spinal fusion and instrumentation under hypotensive anesthesia for scoliosis who developed transient cortical blindness.

Mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion: a meta-analysis.

STUDY DESIGN: Meta-analysis on mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion. OBJECTIVE: To compare mid- to long-term outcomes and complications of the most commonly used instrumentation systems in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: A meta-analysis of mid- to long-term results of different methods of instrumentation, including the most currently used all-pedicle screw construct, is lacking. METHODS: A structured literature review was conducted for studies concerning management of patients with adolescent idiopathic scoliosis with instrumented posterior fusion. Pooled means, standard deviations, and sample sizes were either identified or calculated on the basis of the results of each study. RESULTS: Meta-analyses were performed on outcomes from 27 studies. Overall, 1613 patients who had been treated with Harrington rods, 361 patients who had undergone Cotrel-Dubousset instrumentation, and 298 patients who managed with all-pedicle screw constructs were reviewed. The mean follow-up was 14.9 years. Cotrel-Dubousset and pedicle screw instrumentations achieved a significantly greater degree of correction of the thoracic curve than Harrington rods (40.3° vs. 14.7°; P < 0.001 and 21.9° vs. 14.7°; P = 0.005, respectively). Cotrel-Dubousset technique achieved a significantly higher degree of correction than all-pedicle screw construct in both the thoracic (40.3° vs. 21.9°, respectively; P < 0.001) and lumbar curves (37.2° vs. 16°, respectively; P < 0.001). Similarly, Cotrel-Dubousset construct achieved a greater correction of both thoracic kyphosis (33.5° vs. 23°, respectively; P < 0.001) and lumbar lordosis (46° vs. 50.7°, respectively; P = 0.002) than pedicle screws. All-pedicle screw fixation was associated with the lower risk of pseudarthrosis, infection, neurological deficit, and reoperation. CONCLUSION: This study confirms the negative effect of Harrington rods on sagittal alignment. We further found that the degree of correction in the coronal and sagittal planes was higher after Cotrel-Dubousset instrumentation than all-pedicle screw fixation. All-pedicle screw constructs offered the lower risk of mid- to long-term complications and revision surgery.

Osteoarticular allograft reconstruction for hill-sachs lesion in an adolescent.

Glenoid and humeral head bone loss is the most common cause of failure after surgical shoulder instability stabilization. Large Hill-Sachs lesions involving >30% of the articular surface of the humeral head typically occur after neglected or locked shoulder dislocations. Such large lesions may require osteochondral allograft reconstruction or prosthetic replacement to regain shoulder stability and function.Previous reports of osteochondral allograft reconstruction have focused on adults. This article describes a case of a 16-year-old autistic boy who sustained an anterior dislocation of the right shoulder following a seizure episode. The dislocation was diagnosed 12 days later as a progressive deformity, and his parents noticed his inability to use his upper extremity. The patient had a large (30%) humeral head Hill-Sachs lesion and persistent anterior shoulder instability after initial closed reduction. He underwent an open osteochondral allograft reconstruction for the restoration of the humeral head articular surface. The sizing of the defect, matching harvest of the allograft, and perfect fit of the allograft to the defect are critical steps to ensure congruent restoration of the humeral head. The allograft was stabilized in the defect of the humeral head using cancellous screws placed from below the articular surface. Radiographs 20 months postoperatively showed complete incorporation of the osteochondral allograft. At 30 months postoperatively, his shoulder was stable and functional.

The spectrum of traumatic Schmorl's nodes: identification and treatment options in 3 patients.

Schmorl's nodes may be present as a simple endplate intravertebral herniation following trauma or as a large cystic lesion of the vertebral body. In this article, we report on 3 patients with severe back pain following trauma resulting in traumatic Schmorl's nodes and pathologic fracture of the vertebral body. All 3 cases had antecedent trauma. Radiographs showed a cystic lesion in the vertebral body through the endplate with surrounding bony edema, indicative of fracture. In 2 cases, the integrity of the vertebral body was severely compromised, requiring vertebrectomy and fusion. The wide spectrum of presentation and treatment options of traumatic Schmorl's nodes are presented, ranging from symptoms that are responsive to treatment to pathologic fracture of the vertebral body leading to significant collapse and the need for major surgical stabilization.

All-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients: a surgical technique using a split tibial tunnel.

Many techniques have been described for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, including extra-articular, complete or partial transphyseal, and physeal-sparing techniques. An all-epiphyseal technique places the tendon and its tunnels and fixation all within the child's epiphysis, leaving the growth plates untouched. We describe an all-epiphyseal quadruple-hamstring ACL reconstruction using a split tibial tunnel. The split tibial tunnels drop the tunnel size down to 4.5 to 5.5 mm from 7 to 8 mm because only half the total graft diameter passes through each of the split tunnels. This increases the safety margin for keeping the tunnel within the tibial epiphysis, in addition to avoiding damage into the growth plate. The bone bridge between the 2 tunnels serves as a solid low-profile fixation post. Femoral graft fixation is achieved with an interference screw, which allows precise tensioning and low-profile fixation entirely within the femoral tunnel. By placing the graft at the native ACL's anatomic attachment points without spanning or violating the growth plates at any step of the procedure, an all-epiphyseal ACL reconstruction with a split tibial tunnel theoretically minimizes the risk of growth disturbance in an ACL-deficient child.

Lumbar paraspinal compartment syndrome.

The purpose of this study was to systematically review the available evidence on lumbar paraspinal compartment syndrome with specific reference to patient demographics, aetiology, types, diagnosis, clinical features, and treatment. This was an Institutional Review Board-exempt study performed at a Level 1 trauma center. A PubMed search was conducted with the title query: lumbar paraspinal compartment syndrome. Eleven articles met our search criteria. Three of the patients with acute paraspinal compartmental syndrome treated with fasciotomy had a full recovery and were able to resume skiing after four months. The aetiology of the onset of lumbar paraspinal compartment syndrome is broadly divided into acute and chronic. Lumbar paraspinal compartment syndrome is one of the causes of back pain with diagnostic clinical features which should be considered in the differential diagnosis of a patient with low back pain. Prospective multicentre trials may provide the surgeon with more insight into the diagnosis and management of lumbar paraspinal compartment syndrome.

The anterolateral incision for pilon fracture surgery: an anatomic study of cutaneous blood supply.

The purpose of this study was to examine the blood supply to the adjacent skin and its vulnerability to anterolateral tibial plating performed with fibular plating through a single surgical incision. Ten lightly embalmed cadaver legs without a history of lower extremity trauma or surgery with a mean age of 71 years (range, 57 to 87 years) were used for this investigation. Each specimen was injected with a commercially available silicone compound through the popliteal artery. The left leg was plated through a modified extensile Böhler approach and the right leg served as the control. Each leg was anatomically dissected. All measurements were taken using a digital caliper by a single investigator. A mean of 93 (range, 4 to 17) perforating arteries were present and in the proximity of the fibula plate. Our findings suggest the potential for iatrogenic soft tissue breakdown along the posterior border of the anterolateral surgical incision in this procedure as a result of compromised blood supply to the skin.

A rare case of anterior thoracic myelomeningocele with scoliosis--case report and review of the literature.

BACKGROUND CONTEXT: Spinal deformities associated with spinal dysraphism are a challenging problem. Myelomeningocele has been reported in the lumbar spine. However, it is rare in the thoracic spine. PURPOSE: The purpose of the report was to heighten the awareness of the rare presentation of the myelomeningocele in the thoracic spine and the ability to correct the scoliosis without debulking the lesion. STUDY DESIGN: This is a clinical case report and literature review. METHODS: We report a 13-year-old girl presented with complaints of back pain, difficulty in breathing, and easy fatigability. On examination, she had a thoracolumbar scoliosis, weakness of the right ankle dorsiflexors, and impaired sensation over the L5 dermatome of the right lower limb. Radiographic examination revealed a 128° thoracolumbar scoliosis with congenital hemivertebra at T6-T9, block vertebrae of T4 and T5, and intrathoracic myelomeningocele. She underwent an anterior closing wedge osteotomy and posterior correction of scoliosis without removal of the sac. RESULTS: Four-year postoperative follow-up is uneventful. To date, our patient is the first patient who had scoliosis correction surgery for the rare presentation of a myelomeningocele in the thoracic spine without removal of the sac. CONCLUSIONS: To the best of our knowledge, this is the only case of anterior thoracic myelomeningocele with scoliosis in the literature who had undergone a surgical correction of the scoliosis with osteotomy without removal of the sac. Although rare, these curves are well amenable to surgical correction of scoliosis, thereby improving endurance and functional lung capacity.

The management of nonunion and delayed union of patella fractures: a systematic review of the literature.

Nonunion and delayed union of patella fractures are rare conditions that are fraught with challenges. There exists limited evidence in the literature to guide the clinician in the management of these complications. Therefore, the purpose of this study was to perform a systematic review of the available evidence on the management of nonunion and delayed union of patella fractures. A total of five publications which met our criteria were identified and formed the basis of this study. The decision making in the treatment of this condition is based on the functional demands of the patient, the factors that led to the development of the nonunion, the potential impact of the biomechanical effects of a total patellectomy, and the presence of an intact extensor mechanism of the knee for a later reconstructive procedure. Patients with low functional demands may be managed with nonoperative methods; however, those who perform heavy physical work or participate in sports usually require open reduction and internal fixation. Tension band wiring is the treatment of choice for patients suitable for a reconstructive procedure. Partial or total patellectomy is also an option for small distal fragments or an inability to satisfactorily perform internal fixation.