The Association Between the Utilization of Traction and Postoperative Complications Following Growing Rod Instrumentation for Early-onset Scoliosis.

BACKGROUND: Preoperative and/or intraoperative traction have been proposed as adjunctive methods to limit complications associated with growth-friendly instrumentation for early-onset scoliosis (EOS). By gradually correcting the deformity before instrumentation, traction can, theoretically, allow for better overall correction without the complications associated with the immediate intraoperative correction. The purpose of this multicenter study was to investigate the association between preoperative/intraoperative traction and complications following growth-friendly instrumentation for EOS. METHODS: Patients with EOS who underwent growth rod instrumentation before 2017 were identified from 2 registries. Patients were divided into 2 groups: preoperative traction group versus no preoperative traction group. A subgroup analysis was done to compare intraoperative traction only versus no traction. Data was collected on any postoperative complication from implantation to up to 2 years postimplantation. RESULTS: Of 381 patients identified, 57 (15%) and 69 (18%) patients received preoperative and intraoperative traction, respectively. After adjusting for etiology and degree of kyphosis, there was no evidence to suggest that preoperative halo traction reduced the risk of any complication following surgical intervention. Although not statistically significant, a subgroup analysis of patients with severe curves demonstrated a trend toward a markedly reduced hardware failure rate in patients undergoing preoperative halo traction [preoperative traction: 1 (3.1%) vs. no preoperative traction: 11 (14.7%), P=0.083]. Nonidiopathic, hyperkyphotic patients treated with intraoperative traction were 61% less likely to experience any postoperative complication (P=0.067) and were 74% (P=0.091) less likely to experience an unplanned return to the operating room when compared with patients treated without traction. CONCLUSIONS: This multicenter study with a large sample size provides the best evidence to date of the association between the use of traction and postoperative complications. Our results justify the need for future Level I studies aimed at characterizing the complete benefit and risk profile for the use of traction in surgical intervention for EOS. LEVEL OF EVIDENCE: Level III.

The Use of Halo Gravity Traction in the Treatment of Severe Early Onset Spinal Deformity.

STUDY DESIGN: Retrospective Review of Prospective cohort. OBJECTIVE: To describe the feasibility of preoperative halo gravity traction (HGT) with subsequent growing rod/guided growth (GR/GG) placement in early onset spinal deformity (EOSD). SUMMARY OF BACKGROUND DATA: In children with severe EOSD, primary implantation of GR/GG constructs is not always possible. We describe a staged protocol with preoperative HGT followed by GR/GG implantation. METHODS: EOSD patients treated with HGT prior to GR/GG implantation were included. HGT used traction up to 50% body weight for 4 to 29 weeks. Pulmonary function tests (PFTs) were performed before and after HGT. Coronal Cobb (CC) and Sagittal Cobb (SC) angles were measured on the Pre-HGT, Post-HGT and 6 week postop x-rays. RESULTS: Thirty patients were included. Average age at GR/GG implantation was 9 years. Most cases (n = 24, 80%) were idiopathic. Most pts had kyphoscoliosis (n = 16, 53.3%). Pre-HGT CC averaged 112 ±â€Š22° and SC averaged 106 ±â€Š26°. CC and SC improved 29% after HGT. There was a significant improvement in body mass index following HGT. CC improved further to 70 ±â€Š14° (36% vs. pre-HGT) and SC to 63 ±â€Š21° (41%) with GR/GG placement. HGT-related complications occurred in nine patients (30%); eight pin site infections, one cranial abscess. Most HGT complications were managed with local pin care and oral antibiotics. Halo revision was required in two pts (6.7%). There was no change in PFTs with HGT (P > 0.05). Averagely, 14 levels were spanned during GR/GG implantation; two patients required vertebral column resection. Surgical complications occurred in nine (30%) patients. At average 16 month follow-up, seven patients (23.3%) required reoperation. CONCLUSION: Preoperative HGT can make severe EOSD curves amenable to GR/GG implantation. HGT results in ∼30% correction with improvement to ∼35-40% following GR/GG. HGT has a 30% complication rate but most are pin-site infections managed with pin-site care and oral antibiotics; 6.7% of patients require revision. LEVEL OF EVIDENCE: 4.

Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks.

AIMS: The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS: National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS: A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION: This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.

Desenvolvimento e avaliação de equipamento de tração, para redução de fraturas de ossos longos de cães / Development and evaluation of a traction device for reducing long bone fractures in dogs

Fraturas costumam ocorrer com encavalgamento das extremidades ósseas, dificultando, assim, sua redução. Esta pesquisa teve como objetivo desenvolver um equipamento de tração esquelética a ser utilizado em caninos acometidos de fraturas de ossos longos. Foram utilizados 21 cães de raças variadas, pesando entre dois e 27kg, com idade entre dois meses e 11 anos, com fraturas diafisárias ou metafisárias ocorridas entre três e 24 dias. Enquanto a fixação do corpo do paciente à mesa foi efetuada com cintas de náilon, a força de tração aplicada ao longo do eixo ósseo do membro fraturado foi realizada mediante cintas de náilon ou pinos transfixados e estribos (sendo os pinos implantados na epífise distal do osso fraturado), com a força de tração medida por um dinamômetro, não sendo aplicada carga maior que 25kg. Em todos os casos, a força de tração iniciava com o valor de cinco quilogramas, exceto em animais com peso inferior a esta, a qual começava com carga equivalente a esse peso; e em todos, se necessário, era aumentada a cada cinco minutos para se manter tração igual ao peso ou aos valores que oscilavam do seu peso até cinco quilogramas, dependendo do tamanho do animal, até se atingir a tração necessária para se proceder à redução. Para essa progressão de distensão, o equipamento possuía haste rosqueada de 25mm de diâmetro, uma porca com sistema timão e cilindro deslizante por fora da haste, este conectado ao animal por uma corrente, e o dinamômetro. Todos os animais tiveram as fraturas reduzidas sem haver perda óssea, o que evidencia que o aparelho se mostrou eficiente tanto na redução como na manutenção da redução da fratura, e eles não apresentaram, no pós-operatório, sinais de prejuízos neurológicos, vasculares, cutâneos e articulares. O distensor ósseo aqui desenvolvido tem como características: ser de simples confecção, ter baixo custo, não gerar danos ao paciente e facilitar a redução dos fragmentos tanto em fraturas recentes quanto em antigas.(AU)

Fractures usually occur with overriding of bone fragments, thus hindering fracture reduction. The aim of this research was to develop and test a skeletal traction device for use in dogs with long bone fractures. Twenty-one dogs were included, regardless of breed or gender, weighing between two and 27kg, and between two months and 11 years of age, with metaphyseal or diaphyseal fractures that had occurred between three and 24 days prior to intervention. While fixation of the patient's body to the table was performed using nylon straps, the traction force applied along the bone axis of the fractured limb was performed using nylon straps or transfixed pins and stirrups (with the pins implanted in the distal epiphysis of the fractured bone). Tensile strength was measured by a dynamometer, and the maximum load applied was no greater than 25kg. In all cases, the distraction force began at five kilograms except in dogs below this weight, where the starting load was equivalent to the weight of the animal. If necessary, in all dogs, force was increased every five minutes to maintain equal traction to the dog's weight or values which ranged from the dog's weight to five kilograms depending on the size of the animal, until the necessary traction for reduction was obtained. For this progression of distension, the equipment had a 25-milimeter-diameter threaded rod, a nut with a rudder system and sliding cylinder outside the rod, which connected to the dog via a chain and the dynamometer. Fracture reduction was achieved in all dogs without bone loss, and the device was shown to be efficient in both allowing and maintaining fracture reduction, with no neurologic, vascular, cutaneous, or articular damage. The developed bone distractor has the following characteristics: simple to construct, low cost, does not harm the patient, and facilitates reduction of the fragments in recent and old fractures.(AU)

Staged Growing Rods With Preimplantation of Spinal Anchors for Complex Early Onset Scoliosis.

BACKGROUND: Treatment of early onset scoliosis (EOS) with growing rods (GR) can be challenging in patients with significant deformity, hyperkyphosis, or poor bone quality, due to risks of neurological deficit and hardware pull-out. The objective of this study is to report a series of EOS patients managed with a 2-stage GR technique used to minimize these complications. METHODS: Two-stage GR technique was performed in 8 patients at mean age of 5.4 (range, 3.4 to 7.9) years. At stage 1, proximal and distal anchors were implanted with local fusion. At stage 2, the distraction rods were inserted. There were at least 3 months between stages 1 and 2, and halo-gravity traction was used before stage 2 unless contraindicated. Demographic, clinical, and surgical data were retrospectively reviewed with mean 4.9 (range, 2.0 to 9.4) years of follow-up. Radiographic measurements including Cobb and kyphosis angles were evaluated before stage 1, after halo-gravity traction, after stage 2, and at last follow-up. Indications for staging, anchor healing time, and complications were collected and analyzed. RESULTS: Indications for 2-stage surgery were poor bone quality in 5 patients and neurological changes during initial attempt at GR placement in 3 patients. The mean time between stage 1 and 2 was 23 (15 to 45) weeks. Patients have undergone mean 7 (3 to 16) lengthenings. Three patients have been converted to magnetically controlled GR. The major coronal Cobb angle improved from mean 81 degrees (range, 61 to 97) preoperatively to 40 degrees (24 to 50) after stage 2 and remained at 40 degrees (27 to 53) at last follow-up. Kyphosis remained controlled from 45 degrees (10 to 76) preoperatively to 38 degrees (9 to 61) after stage 2 to 41 degrees (17 to 65) at last follow-up. Complications included superficial wound problems (4 patients), broken rods (2 patients), proximal migration (2 patients), and implant prominence (1 patient). At minimum 2-year follow-up, no patients had lingering neurological complications or instrumentation-bone failure of the GR construct. CONCLUSIONS: Two-stage GR technique can effectively be utilized in EOS patients with poor bone quality or in the event of intraoperative neurological changes. Satisfactory deformity correction can be obtained and routine serial lengthenings can take place with minimal complications. LEVEL OF EVIDENCE: Level IV- case series.

Correlation of obesity with patient-reported outcomes and complications after hip arthroscopy.

PURPOSE: This study aimed to evaluate patient-reported outcomes and complications after hip arthroscopy in an obese population compared with a matched nonobese control group with a minimum 2-year follow-up, using the Modified Harris Hip Score (MHHS) and Nonarthritic Hip Score (NAHS). METHODS: Data were analyzed from 21 consecutive obese patients (body mass index [BMI] ≥ 30) and 18 nonobese patients (BMI < 25) who underwent hip arthroscopy between 2009 and 2012 with a minimum follow-up of 2 years. Data collected included MHHS, NAHS, traction and intraoperative times, and postoperative complications. RESULTS: Traction times were similar between obese and nonobese patients at 48 and 45 minutes (P = .51), respectively. Operative times were also similar at 54 and 51 minutes (P = .79), respectively. Each group had a statistically significant improvement in MHHS from baseline to final follow-up: 45 to 79 (P < .001) in the obese group and 49 to 81 (P < .001) in the nonobese cohort. Similarly, the NAHS showed significant improvement in each group from baseline to final follow-up: 43 to 75 (P < .001) in the obese cohort and 45 to 83 (P < .001) in the nonobese group. There was no difference between groups in MHHS or NAHS data. There were 8 complications in the obese group, most commonly deep vein thrombosis (DVT) and worsened pain, whereas the nonobese cohort had one complication (an instance of heterotopic ossification [HO]). Overall, obese patients had 11.1 times the risk of a complication developing than did nonobese patients (95% confidence interval, 1.2 to 99.7). CONCLUSIONS: Hip arthroscopy in the obese patient population leads to improved short- to mid-term patient-reported outcomes similar to those seen in nonobese patients. Obese patients, however, are at a significantly increased risk of postoperative complications such as DVTs and worsened hip pain. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Outcome of patients with Legg-Calvé-Perthes onset before 6 years of age.

BACKGROUND: The prognosis of Legg-Calvé-Perthes disease (LCPD) in young patients has been accepted as favorable. The purpose of this study was to clarify the outcome of LCPD patients with onset before 6 years of age. METHODS: From 1989 to 2007, of 332 LCPD patients, 114 hips (in 100 patients) were diagnosed before 6 years of age (mean age, 4.5 y old) with subsequent repair of the epiphysis in all cases. Waldenström classification at presentation was initial stage in 76 hips and fragmentation stage in 38 hips. Lateral pillar classification was group A in 17 hips, group B in 22 hips, group B/C in 24 hips, and group C in 51 hips. Treatment methods were observation with restriction of activity alone in 42 hips and several containment treatments in 72 hips. RESULTS: At the mean age of 14, Stulberg classification was class I in 26 hips, II in 46 hips, III in 28 hips, and IV in 14 hips. These data show an acceptable outcome in 72 of 114 hips (63%). Logistic regression analysis revealed that lateral pillar classification (odds ratio, 3.6) and good range of abduction without treatment (odds ratio, 4.0) were prognostic factors. CONCLUSIONS: Poor outcome was observed even in patients before 6 years of age with large necrotic area. Lateral pillar classification and good range of abduction were prognostic factors. LEVEL OF EVIDENCE: Level IV. Therapeutic studies-investigating the results of treatment. Case series.

A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale.

BACKGROUND: Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery. A period of non-surgical management is recommended for most patients, but there is little evidence to guide non-surgical decision-making. We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The results suggested this approach may be effective, particularly in a more specific sub-group of patients. The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation, and within the pre-defined sub-group. METHODS/DESIGN: The study will recruit 120 patients with low back pain and signs of nerve root irritation. Patients will be randomized to receive an extension-oriented treatment approach, with or without the addition of mechanical traction. Randomization will be stratified based on the presence of the pre-defined sub-grouping criteria. All patients will receive 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments will occur after 6 weeks, 6 months, and 1 year. The primary outcome will be disability measured with a modified Oswestry questionnaire. Secondary outcomes will include self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups, and examine the interaction between treatment and sub-grouping status. DISCUSSION: This trial will provide a methodologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation, and will examine the validity of a pre-defined sub-grouping hypothesis. The results will provide evidence to inform non-surgical decision-making for these patients. TRIAL REGISTRATION: This trial has been registered with http://ClinicalTrials.gov: NCT00942227.

Overhead traction in the treatment of congenital dislocation of the hip.

Long-term results of traction treatment for congenital hip dislocation (CDH) performed between 1984 and 1990 are presented. The new traction scheme consists of 4 distinctive phases. It is based on gradually changed direction of traction--first, from the longitudinal direction to flexion and abduction against the hypomochilion. The traction is applied by means of non irritable adhesive tape using 1/4-1/5 of the child's body weight. The period of active traction is followed by retention period in Hanausek's biomechanical device. The success rate of the scheme, in terms of reduction, was 90 per cent. In 31 per cent the Salter innominate osteotomy was performed because of residual deformity. In 10 per cent of the cases open reduction was necessary.

Current practice in use of prereduction traction for congenital dislocation of the hip.

To define the current application of preliminary traction for congenital dislocation of the hip (CDH), 335 members of the Pediatric Orthopaedic Society were surveyed, with an 87% response rate. Most respondents believe that traction reduces the incidence of avascular necrosis (AVN) and enables easier reduction. Only 5% of those surveyed do not use traction, but it is used more frequently in the Northeastern United States. Home traction, favored by 31% of the respondents, is used longer than hospital traction. Although traction is commonly used, a consensus to use preliminary traction has not been achieved. Practice patterns should not be used to determine effectiveness of a treatment.