Assessment of rib hump deformity correction in adolescent idiopathic scoliosis with or without costoplasty using the double rib contour sign.

STUDY DESIGN: Level III-therapeutic study. OBJECTIVE: The purpose of this study was to determine whether the addition of costoplasty in adolescent idiopathic scoliosis surgery improved correction of the rib hump deformity. BACKGROUND: Trunk deformity is comprised of vertebral rotation, posterior vertebral element, and rib deformities. Surgical correction of the rotational deformity has been performed by segmental spinal instrumentation with vertebral derotation, but complete correction of the rib hump by derotation is rarely achieved. METHODS: A multicenter registry database for adolescent idiopathic scoliosis was reviewed with the inclusion criteria of Lenke type I curves treated with posterior spinal fusion with or without costoplasty, instrumented with pedicle screws or hybrid constructs, with a minimum follow-up of 2 years. The first group (group I) was treated with pedicle screws, direct vertebral rotation, and no costoplasty, whereas the second group (group II) was treated with pedicle screws, vertebral rotation, and costoplasty. The rib index (RI), calculated from the double rib contour sign, and Cobb angle were measured radiographically and compared between groups. RESULTS: The groups comprised 36 subjects in group I and 40 subjects in group II. The mean preoperative Cobb angles for groups I and II were 49.7 and 49.8 degrees, respectively, whereas the mean postoperative Cobb angles were 10.2 and 10.9 degrees, respectively. There was no difference in preoperative and postoperative values when comparing both groups (P=0.48 and 0.96, respectively). Before spine surgery, RI for groups I and II was 1.61 and 1.80, respectively. Postoperatively, the rib indices were 1.39 for group I and 1.29 for group II. These differences were found to be statistically significant (P=0.002 and 0.006, respectively). The amounts of correction of RI were 0.23 and 0.51 for groups I and II, respectively. This difference was found to be statistically significant (P<0.0001). The correction percentages were 13.7% and 28.3%, respectively. This difference was also found to be statistically significant (P<0.0001). CONCLUSIONS: Costoplasty combined with pedicle screws and vertebral derotation may significantly improve rib hump deformity as opposed to pedicle screws and vertebral derotation alone.

Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures.

BACKGROUND: In vitro mechanical studies have demonstrated equal or superior fixation of pediatric femoral fractures with use of titanium elastic nails as compared with stainless steel elastic nails, and the biomechanical properties of titanium are often considered to be superior to those of stainless steel for intramedullary fracture fixation. We are not aware of any clinical studies in the literature that have directly compared stainless steel and titanium elastic nails for the fixation of pediatric femoral fractures. The purpose of the present study was to compare the complications associated with the use of similarly designed titanium and stainless steel elastic nails for the fixation of pediatric femoral fractures. METHODS: A group of fifty-six children with femoral fractures that were treated with titanium elastic nails was compared with another group of forty-eight children with femoral fractures that were treated with stainless steel elastic nails. Both nail types were of similar design, and a similar retrograde insertion technique was used. The groups were compared with regard to complications as well as insertion and extraction time. Major complications were defined as malunion with sagittal angulation of >15 degrees and coronal angulation of >10 degrees, nail irritation requiring revision surgery, infection, delayed union, and rod breakage. Minor complications were defined as nail irritation or superficial infection not requiring surgery. RESULTS: The malunion rate was nearly four times higher in association with the titanium nails (23.2%; thirteen of fifty-six) as compared with the stainless steel nails (6.3%; three of forty-eight) (p = 0.017, chi-square test; odds ratio = 4.535 [95% confidence interval, 1.208 to 17.029]). The rate of major complications was 35.7% (twenty of fifty-six) for titanium nails and 16.7% (eight of forty-eight) for stainless steel nails. The rates of minor complications were similar for the two groups, as were the insertion times and extraction times. The supplier price of one titanium nail ranges from $259 to $328, depending on size, whereas the price of one stainless steel nail would be $78 in current United States dollars. CONCLUSIONS: Our results indicate that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion.

Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis.

The inherent ability of pediatric metaphyseal radius fractures to heal and remodel made us question the need for immediate anatomic reduction under conscious sedation. We believe that isolated closed distal radius fractures with 15 degrees of angulation and 1 cm of shortening will heal well and remodel completely without clinical or functional sequelae. Time and expense can be decreased by splinting and follow-up without the need for immediate anatomic reduction in the emergency room. In order to answer this question, we retrospectively evaluated 34 pediatric metaphyseal wrist fractures that lost position after attempted reduction and healed in their angulated or shortened position. We looked at the time to healing, time to remodeling and any residual clinical or functional deficits. We then did a comparison cost analysis with time matched patients who had complete but minimally displaced fractures of the distal radius that were treated by immediate splinting with orthopaedic follow-up. Our results showed that skeletally immature patients with open physes, isolated injuries, dorsovolar and radioulnar angulations less than 15 degrees and less than 1 cm of shortening will heal and be out of cast within an average of 6 weeks and completely remodel within an average of 7.5 months. The average time in the emergency room was 2 h less with no reduction. The cost of the emergency room visit with attempted reduction was 50% more than splinting with early referral (US dollars 536 versus US dollars 270). None of our patients had significant clinical deformities or residual functional deficits.

Femoral shaft fractures in children: traction and casting versus elastic stable intramedullary nailing.

BACKGROUND: Treatment of pediatric femoral fractures by 90/90 traction and spica casting (TXN/CST) has begun to be replaced by elastic stable intramedullary nailing (ESIN). The purpose of our study was to perform a cost analysis of TXN/CST versus ESIN in addition to comparing clinical/functional parameters. METHODS: We reviewed all children admitted with femoral shaft fractures between January 1995 and April 1998. Overall cost and clinical/radiographic outcome measures were analyzed, and 60% of patients' parents completed a follow-up telephone interview. Sixty-eight patients representing 71 femoral shaft fractures that had complete data and 1-year follow-up were included. RESULTS: No difference existed between the two groups for standard clinical/functional criteria. ESIN was associated with a lower overall cost than TXN/CST. ESIN also resulted in better scar acceptance, and higher overall parent satisfaction. CONCLUSION: Less cost and comparable clinical outcome make ESIN a better option than traditional TXN/CST for femoral fracture care in the skeletally immature patient.