Outcomes of Elastic Stable Intramedullary Nailing for Surgical Treatment of Pediatric Tibial Shaft Fractures.

BACKGROUND: This retrospective study aimed to assess radiographic and clinical outcomes, characterize demographic, injury, and fracture characteristics, and elucidate the rate of postoperative complications and associated factors in a large cohort of children treated with elastic stable intramedullary nail for diaphyseal tibial fractures at two large pediatric referral centers. METHODS: Medical records were reviewed for demographic clinical and radiographic parameters at injury, surgery, and all subsequent clinical visits until radiographic healing was observed and/or for a minimum of 6 months postoperatively. RESULTS: A total of 146 patients (79.5% male) were included. The mean (SD) age was 11.8 (63.0) years. Radiographic union occurred by 3 months in 56.6% of patients. Nine patients had delayed union, and four had nonunion. By 3 months postoperatively, 97.2% of patients had progressed to full weight bearing and 92.5% had full range of motion of the knee and ankle. Subgroup analyses revealed that patients with open fractures were found to be more than eight times at increased risk of developing delayed union (.6 months, odds ratio = 8.71). CONCLUSION: Elastic stable intramedullary nail remains a safe and effective treatment of open and closed pediatric diaphyseal tibial fractures. A small yet notable risk of residual angular deformity, delayed union, and nonunion remains, although rates may be better than previously reported.

Subject matter predicts where top pediatric spine articles are shared: citations vs. social media.

STUDY DESIGN: Systematic review. The purpose of this study was to compare the top 25 articles on pediatric spine surgery by number of citations and Altmetric score. All published articles pertaining to pediatric spine surgery from 2010 to 2021 were assessed for: Altmetric scores, Altmetric score breakdown (e.g. Twitter, News), citation counts, and article topics. The top 25 Altmetric articles and top 25 cited articles were identified. Out of the 50 total articles, only 3 (6.0%) overlapped between the two groups. The top Altmetric articles had averages (mean ± SD) of 167 ±â€…130 Altmetric score and 66 ±â€…135 citations, while the top citation articles had averages of 22 ±â€…45 Altmetric score and 196 ±â€…114 citations. When evaluating article topics, articles on 'back pain' (36% vs. 4%; P = 0.003) and 'backpacks' (16% vs. 0%; P = 0.030) were published significantly more in the top Altmetric group, while articles on 'scoliosis' (93% vs. 36%; P < 0.001) and 'growth friendly surgery' (24% vs. 4%; P = 0.041) were published significantly more in the top citation group. The total number of citations and online mentions for both groups are presented in Table 2. The biggest differences were the top Altmetric score articles receiving greater percentages of Twitter mentions relative to overall mentions (87% vs. 57%). The most socially popular articles focused on back pain and backpacks, and the most cited articles focused on scoliosis and growth-friendly surgery. Twitter had the most mentions of all social media for both the top cited articles and the top Altmetric articles.

Modernizing Our Understanding of Total Hip Arthroplasty in the Pediatric and Young Adult Patient: A Single-center Experience.

INTRODUCTION: Pediatric hip disorders represent a broad range of pathology and remain a significant source of morbidity for children and young adults. Surgical intervention is often required for joint preservation, but when salvage is not possible, joint replacement may be indicated to eliminate pain and preserve function. Although there have been significant updates in the management of both pediatric hip disease and the field of total hip arthroplasty (THA), there is a paucity of literature reflecting advancements in the area of pediatric and young adult (PYA) arthroplasty. No study has investigated the impact of approach on outcomes after PYA THA. The purpose of this study is to describe the indications, techniques, and early outcomes of THA in the PYA population in a modern practice setting. METHODS: We performed a retrospective descriptive analysis of all patients undergoing primary THA performed at a tertiary care children's hospital from 2004 to 2019. Ninety-three hips in 76 patients were evaluated. Demographics, intraoperative variables, postoperative pain and function ratings, and complication and revision rates were collected. RESULTS: Eighty-five hips in 69 patients were included. Patients were aged 12 to 23 years old, with males and females represented equally (33 vs. 36, respectively). The most common cause of hip pain was avascular necrosis (AVN, 56/85, 66%), most commonly due to slipped capital femoral epiphysis (13/56, 23%) idiopathic AVN (12/56, 21%), and chemotherapy (12/56, 21%). Half of all hips had been previously operated before THA (43/85). Thirty-six procedures were performed via the posterolateral approach (36/85, 42%), 33 were performed via direct anterior approach (33/85, 39%), and 16 were performed via the lateral approach (LAT, 16/85, 19%). At final follow-up, 98% (83/85) of patients had complete resolution of pain, 82% (70/85) had no notable limp, and 95% (81/85) had returned to all activities. There were 6 complications and 1 early revision. Average Hip disability and Osteoarthritis Outcomes Score for Joint Replacement scores increased by 37 points from 56 to 93. The overall revision-free survival rate for PYA THA was 98.8% (at average 19-mo follow-up). CONCLUSIONS: Modern PYA THA is dissimilar in indications and surgical techniques to historic cohorts, and conclusions from prior studies should not be generalized to modern practice. In our practice, PYA patients most commonly carry a diagnosis of AVN, and THA can be performed with modern cementless fixation with large cup and head sizes and ceramic-on-cross-linked polyethylene bearings utilizing any approach. Further study is required to better characterize middle-term and long-term results and patient-reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV-retrospective case series.

Exposed Intramedullary Fixation Produces Similar Outcomes to Buried Fixation for Acute Pediatric Monteggia Fractures.

BACKGROUND: Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal. METHODS: A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion. RESULTS: Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients. CONCLUSION: Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization. LEVEL OF EVIDENCE: III.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome.

BACKGROUND: Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients. METHODS: An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification. RESULTS: A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission. CONCLUSIONS: Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Treatments and Sequelae of Pediatric Pathologic Proximal Femur Fractures Due to Benign Bone Cyst.

BACKGROUND: The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors. METHODS: A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing. RESULTS: A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14). CONCLUSIONS: In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management. LEVEL OF EVIDENCE: Level IV.

Pre-operative nutrition assessments do not improve outcomes in cerebral palsy patients undergoing varus derotational osteotomy.

ABSTRACT: Pre-operative nutritional assessments have been used as a "cornerstone" to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as "non-ambulatory" (Gross Motor Function Classification System [GMFCS] IV-V), and 45 (29%) as "ambulatory" (GMFCS I-III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative.

An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia.

INTRODUCTION: The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH. METHODS: A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum. RESULTS: A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001). CONCLUSIONS: In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum. LEVEL OF EVIDENCE: Level III.

In vivo Mouse Model of Spinal Implant Infection.

Spine implant infections portend poor outcomes as diagnosis is challenging and surgical eradication is at odds with mechanical spinal stability. The purpose of this method is to describe a novel mouse model of spinal implant infection (SII) that was created to provide an inexpensive, rapid, and accurate in vivo tool to test potential therapeutics and treatment strategies for spinal implant infections. In this method, we present a model of posterior-approach spinal surgery in which a stainless-steel k-wire is transfixed into the L4 spinous process of 12-week old C57BL/6J wild-type mice and inoculated with 1 x 103 CFU of a bioluminescent strain of Staphylococcus aureus Xen36 bacteria. Mice are then longitudinally imaged for bioluminescence in vivo on post-operative days 0, 1, 3, 5, 7, 10, 14, 18, 21, 25, 28, and 35. Bioluminescence imaging (BLI) signals from a standardized field of view are quantified to measure in vivo bacterial burden. To quantify bacteria adhering to implants and peri-implant tissue, mice are euthanized and the implant and surrounding soft tissue are harvested. Bacteria are detached from the implant by sonication, cultured overnight and then colony forming units (CFUs) are counted. The results acquired from this method include longitudinal bacterial counts as measured by in vivo S. aureus bioluminescence (mean maximum flux) and CFU counts following euthanasia. While prior animal models of instrumented spine infection have involved invasive, ex vivo tissue analysis, the mouse model of SII presented in this paper leverages noninvasive, real time in vivo optical imaging of bioluminescent bacteria to replace static tissue study. Applications of the model are broad and may include utilizing alternative bioluminescent bacterial strains, incorporating other types of genetically engineered mice to contemporaneously study host immune response, and evaluating current or investigating new diagnostic and therapeutic modalities such as antibiotics or implant coatings.

Standing in Schroth trained position significantly changes Cobb angle and leg length discrepancy: a pilot study.

STUDY DESIGN: Retrospective. OBJECTIVE: The aim of this study is to evaluate if standing in a Schroth trained position influences the radiographic assessment of Cobb angle and other radiographic parameters compared to a normal standing position. Schroth method has been associated with improved Cobb angle. This study aims to evaluate if standing in the Schroth trained position influences radiographic assessment of Cobb angle compared to a normal standing position. METHODS: This is a retrospective review of patients with adolescent idiopathic scoliosis (AIS) who were participating in Schroth therapy at the time of radiographs. Ten pairs of radiographs were included in this study. Each pair consisted of two micro-dose biplanar PA thoracolumbar spine radiographs obtained on the same day, one with the patient standing in the Schroth trained position and one in their normal standing position. Each pair of radiographs was independently evaluated by three attending pediatric spine surgeons for Cobb angle, coronal balance, shoulder balance, and leg length discrepancy, for a total of 30 paired readings (3 readings for each of the 10 pairs of radiographs). RESULTS: Major Cobb angle was a mean of 6° less (p = 0.02) and the compensatory curve was 5° less (p = 0.03) in the Schroth trained position compared to their normal standing position. Neither coronal balance (p = 0.40) nor shoulder balance (p = 0.16) was significantly different. Mean leg length discrepancy was 6.8 mm greater in the Schroth trained versus normal position (p < 0.001). CONCLUSION: Standing in a Schroth trained position for a PA spine radiograph was associated with a mean change in major Cobb angle of 6° compared to a normal standing position. If bracing was recommended for curves > 25° and surgery for curves > 45°, different treatment recommendations would have been made in 33% (10/30) of attendings' readings for the Schroth versus normally paired radiographs taken on the same day on the same patient. Studies evaluating the effect of Schroth therapy on Cobb angle must report if patients are standing in a normal or Schroth trained position during radiographs for conclusions to be valid, or differences may be due to a temporary, voluntary change in posture. LEVEL OF EVIDENCE: III.

Fever after varus derotational osteotomy is common, but not a risk factor for infection.

Postoperative fever in pediatric patients following reconstructive hip surgery is of unknown significance. This study identifies the prevalence of postoperative fever after corrective hip surgery, its relationship to infection, and whether preventative use of anti-pyretics affects patient outcomes.Overall, 222 patients who underwent a varus derotational osteotomy (VDRO) between 11/1/2004 to 8/1/2014 with minimum 6 months follow up were retrospectively identified. Variables included diagnosis, inpatient stay, daily maximum temperature, duration of fever, fever workup, and administration of scheduled anti-pyretics. Fever was defined as temperature ≥38°C.In total, 123/222 (55.4%) and 70/222 (31.5%) had postoperative fevers of ≥38°C and ≥38.5°C, respectively. Average inpatient stay was 2.7 days postoperatively. Temperature (mean = 38.0°C) was greatest on postoperative day 1 (POD1), and 43.7% of patients had T ≥38°C on POD1. Anti-pyretics did not influence the duration of fever. Anti-pyretics on the day of surgery (POD0) did not influence the incidence of fever. Acetaminophen on POD0 significantly reduced likelihood of fever on POD1 (P = .02). Average length of fevers ≥38°C and 38.5°C were 8.4 and 4.2 hours, respectively. 3/18 (16.7%) fever workups administered were positive. Postoperative fever did not predict infection. 9/222 (4/1%) patients had postoperative infection - 5/123 (4.1%) with fever ≥38°C and 4/70 (5.7%) with fever ≥38.5°C. Rates of infection in patients with and without fevers were not significantly different (P = .97 for T ≥38°C and P = .38, for T ≥38.5°C).Though common, postoperative fever does not increase risk of infection. The low prevalence of positive cultures indicates routine fever workups can safely be avoided in most patients.Level of Evidence: III, retrospective comparative study.

Suture Anchor Fixation for Fifth Metatarsal Tuberosity Avulsion Fractures: A Case Series and Review of Literature.

Fifth metatarsal tuberosity avulsion fractures are common. Despite good outcomes with nonoperative treatment, acute fractures with displacement, intra-articular involvement, comminution, or painful nonunion have been reported to benefit from early open reduction and internal fixation, especially in athletes. No consensus has been reached regarding the best surgical fixation technique. We present a case series of 4 patients with displaced fifth metatarsal tuberosity avulsion fractures and an innovative technique of fixation for the tuberosity avulsion fractures using a suture anchor.

Patient and radiographer assessment of slump sitting flexion compared to conventional standing forward bending flexion.

BACKGROUND: A comparative survey from patients and radiographers of the new slump sitting flexion posture and the conventional standing forward bending posture. This study was performed to compare the technical and logistical aspects of the slump sitting versus the forward bending posture. Slump sitting flexes the lumbar spine more than the forward bending and increases the diagnosis rate of sagittal spinal instability up to 40% depending on the diagnostic criteria used. This should not come at the expense of patient safety and comfort nor burden the radiographers. METHODS: Sixty patients were recruited from a single tertiary spine centre. Patients were block randomised into two groups with either the forward bending or the slump sitting being performed first. Feedback was obtained through self-administered questionnaires from patients regarding perceived safety, convenience and comfort, plus from radiographers regarding the imaging process, proxy measures of radiographer ability and scan difficulty. RESULTS: There was no significant difference between the baseline characteristics in both groups. Majority (63%) of patients preferred slump sitting and felt that forward bending caused pain (P=0.025). Overall, slump sitting was equivalent in comfort, perceived safety and ease to forward bending. Despite requiring more logistics (P=0.031), more effort to set up (P=0.002) and explain (P=0.012), the majority of radiographers (83%) preferred slump sitting. This method was felt to be less dangerous (P=0.015) and easier to maintain (P<0.001). CONCLUSIONS: This study showed that the superiority of slump sitting in allowing more lumbar flexion compared to the forward bending comes with patient safety or comfort. The technical demands of the learning curve can be offset with training. As such, slump sitting flexion views should be adopted as the standardized method for assessing spinal instability.