Rotation and Asymmetry of the Axial Plane Pelvis in Cerebral Palsy: A CT-Based Study.

Spinopelvic malignment is commonly seen with non-ambulatory cerebral palsy (CP). Axial plane deformation is not well described in the literature. The purpose of this study was to describe and quantify the axial plane deformity in CP using CT scans and compare it to normal controls. We retrospectively collected data using CT scans of the abdomen and pelvis of 40 patients with GMFCS IV/V CP and neuromuscular scoliosis (CPP) and normal controls (NP) matched by age and sex. Pre-operative Cobb angle was recorded for the CP patients. Pelvic anatomy was evaluated at the supra-acetabular region of bone using two angles-iliac wing angle and sacral ala angle, measured for each hemipelvis. The larger of each hemipelvis angle was considered externally rotated while the smaller angle was considered internally rotated, termed as follows-iliac wing external (IWE) and internal (IWI); sacral ala external (SAE), and internal (SAI). Differences were noted using an independent t-test while correlations with Cobb angle were performed using Pearson's correlation. Iliac wing measurements showed the externally rotated hemipelvis showed a significantly greater magnitude compared with normal controls at 47.3 ± 18.1 degrees vs. 26.4 ± 3.7 degrees in NP (p < 0.001) while no internal rotation was observed (p > 0.05). Sacral ala measurements showed greater magnitude in both external and internal rotation. SAE was 119.5 ± 9.5 degrees in CPP vs. 111.2 ± 7.7 degrees in NP (p < 0.001) while SAI was 114.1 ± 8.5 degrees in CPP vs. 107.9 ± 7.5 degrees in NP (p = 0.001). In the CP cohort, the mean Cobb angle was 61.54 degrees (n = 37/40). Cobb angle correlated with the degree of external iliac wing rotation-IWE (r = 0.457, p = 0.004) and degree of absolute difference in the rotation of the iliac wing (r = 0.506, p = 0.001). The pelvis in a patient with CP scoliosis is asymmetrically oriented exhibiting a greater external rotation of one hemipelvis relative to normal controls. The severity of neuromuscular scoliosis is related to the pelvic axial rotation in CP patients. Axial plane deformity exists in the CP pelvis and this deformity warrants consideration when considering spinopelvic instrumentation strategies and outcomes of supra-pelvic and infra-pelvic pathologies.

Symptomatic flatfoot in cerebral palsy.

PURPOSE OF REVIEW: The purpose of this review is to evaluate the current literature and best practices in the evaluation and treatment of symptomatic flatfoot in cerebral palsy. RECENT FINDINGS: While techniques to reconstruct the neuromuscular flatfoot and reestablish bony levers have remained similar over time, the concept of surgical dosing has helped guide appropriate interventions based on the magnitude of disease and functional level of the child. Moreover, the utilization of multisegment foot modeling in motion analysis has allowed quantitative description of such deformities and their impact on gait. SUMMARY: Future research should focus on refining operative indications and interventions with larger, multicenter, prospective cohorts to provide more robust evidence in surgical decision making. Long-term data are needed to confirm and compare efficacy of procedures. Radiographic data alone are not sufficient for describing functional foot position. Gait analysis with foot modeling and pedobarography along with patient-centered subjective outcomes will be needed in such investigations to make conclusive recommendations.

Does Skeletal Maturity Predict the Pattern of Tibial Tubercle Avulsion Fracture?

BACKGROUND: Proximal tibial physeal development and closure is thought to relate to tibial tubercle avulsion fracture (TTAF) patterns. Prior work has yet to formally evaluate the relationship between skeletal maturity and fracture pattern.  Using 2 knee radiograph-derived skeletal maturity assessments [growth remaining percentage (GRP) and epiphyseal union stage], we examined their association with TTAF injury patterns using the Ogden and Pandya fracture classifications. We hypothesized that different TTAF injuries would occur during unique periods of skeletal development. METHODS: Pediatric patients sustaining TTAFs treated at a single institution (2008-2022) were identified using diagnostic and procedural coding. Demographics and injury characteristics were collected. Radiographs were reviewed to assign epiphyseal union stage, Ogden and Pandya classifications and for measurements to calculate GRP. Univariate analyses examined the relationship between injury subgroups, patient demographics, and skeletal maturity assessments. RESULTS: Inclusion criteria identified 173 patients with a mean age of 14.76 (SD: 1.78) and 2.95% (SD: 4.46%) of growth remaining. The majority of injuries were classified Ogden III/Pandya C. Most (54.9%) were the result of the axial loading mechanism. Ogden groups showed no significant differences across all patient characteristics studied including age and GRP. With the exception of Pandya A fractures, we did not identify a direct relationship between GRP, age, and Pandya groups. Epiphyseal union stage differed for Pandya A and D groups. CONCLUSIONS: A predictable pattern in TTAF characteristics across skeletal (GRP), epiphyseal union, or chronologic age was not identified in this study. Distal apophyseal avulsions (Ogden I/II and Pandya A/D) occurred across a broad chronologic and skeletal age range. No differences were identified in epiphyseal or posterior extension (Ogden III/IV and Pandya B/C) injuries. Although differences in age and GRP were identified among Pandya As, this is thought to be due to the degree of skeletal immaturity that is a prerequisite for differentiation from Pandya Ds. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Implicit Racial Bias in Pediatric Orthopaedic Surgery.

INTRODUCTION: Racial and ethnic minority patients continue to experience disparities in health care. It is important to understand provider-level factors that may contribute to these inequities. This study aims to evaluate the presence of implicit racial bias among pediatric orthopaedic surgeons and determine the relationship between bias and clinical decision making. METHODS: A web-based survey was distributed to 415 pediatric orthopaedic surgeons. One section measured for potential implicit racial bias using a child-race implicit association test (IAT). IAT scores were compared with US physicians and the US general population using publicly available data. Another section consisted of clinical vignettes with associated questions. For each vignette, surgeons were randomly assigned a single race-version, White or Black. Vignette questions were grouped into an opioid recommendation, management decision, or patient perception category for analysis based on subject tested. Vignette answers from surgeons with IAT scores that were concordant with their randomized vignette race-version (ie, surgeon with pro-White score assigned White vignette version) were compared with those that were discordant. RESULTS: IAT results were obtained from 119 surveyed surgeons (29% response rate). Overall, respondents showed a minor pro-White implicit bias ( P <0.001). Implicit bias of any strength toward either race was present among 103/119 (87%) surgeons. The proportion of pediatric orthopaedic surgeons with a strong pro-White implicit bias (29%) was greater than that of US physicians overall (21%, P =0.032) and the US general population (19%, P =0.004). No differences were found in overall opioid recommendations, management decisions, or patient perceptions between concordant and discordant groups. CONCLUSION: Most of the pediatric orthopaedic surgeons surveyed demonstrated implicit racial bias on IAT testing, with a large proportion demonstrating strong pro-White bias. Despite an association between implicit bias and clinical decision making in the literature, this study observed no evidence that implicit racial bias affected the management of pediatric fractures. LEVEL OF EVIDENCE: Level IV.

Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience.

OBJECTIVE: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries. DESIGN: Retrospective observational. SETTING: Urban, tertiary care, academic orthopedic hospital. PATIENTS: Pediatric, sports knee surgery, 23-month period. INTERVENTIONS: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries. MAIN OUTCOME MEASURE: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. RESULTS: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p < 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient. CONCLUSIONS: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

Limb Lengthening in Russell-Silver Syndrome: An Update Confirming Safe and Speedy Healing.

INTRODUCTION: Russell-Silver syndrome (RSS) is a unique cause of syndromic, and often severe, limb length discrepancy (LLD). RSS causes growth retardation both in utero and postnatally, with asymmetry in limb length more noticeable as growth progresses throughout childhood and adolescent. We aim to present the largest cohort in the literature on limb lengthening in patients with RSS and to validate previous literature supporting faster bony consolidation in these patients with more robust data. We further aim to establish differences in healing within this cohort based on age, sex, segment lengthened, or type of lengthening procedure performed, to help refine patient expectations and guide practitioners in treating this population. METHODS: This was a retrospective study of patients with a diagnosis of RSS who underwent a limb lengthening procedure for the purpose of limb equalization. They were compared with a historic control group of patients who underwent limb lengthening for LLD of a non-RSS etiology. The primary outcome measure was bone healing index (BHI). RESULTS: The RSS group consisted of 24 patients with 29 segments lengthened, and was compared with a historic control group consisting of 20 patients with 22 segments lengthened (Goldman). Patients with RSS had a significantly lower BHI, and therefore faster healing of their lengthening site, than their non-RSS peers (P=0.02). Within the RSS cohort, we did not detect a difference in BHI based on intervention type or sex, but we did find a trend toward faster healing in femurs over tibiae (P=0.08), and established that younger patients tended toward lower BHIs (P<0.01). CONCLUSIONS: Our results confirmed with more robust data the prior finding that patients with RSS may undergo limb lengthening procedures at least as safely as their non-RSS counterparts, and with even faster bony consolidation, especially in younger patients. We hypothesize that concurrent treatment with growth hormone supplementation may contribute to this finding, although further study is necessary. This is the largest cohort of RSS patients treated with limb lengthening for LLD reported in the literature, and these findings will help to guide surgeon decision-making when treating this unique population. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Correction to: At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes.

[This corrects the article DOI: 10.1007/s11420-020-09765-5.].

Use Caution When Assessing Preoperative Leg-Length Discrepancy in Pediatric Patients With Anterior Cruciate Ligament Injuries.

BACKGROUND: Pre- and postoperative standing hip-to-ankle radiographs are critical for monitoring potential postoperative growth arrest and resultant deformities after pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine the prevalence of apparent preoperative leg-length discrepancies (LLDs) that resolve at the first postoperative radiographic examination in patients undergoing ACL reconstruction in order to understand what proportion of the noted preoperative deformities may have been inaccurate. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of prospectively collected preoperative and first postoperative full-length hip-to-ankle radiographs was performed in a cohort of skeletally immature patients who had an acute ACL injury and underwent subsequent surgical reconstruction. Leg length measurements for both the injured and the uninjured legs were obtained for comparison. RESULTS: A total of 112 patients (mean age, 12.7 ± 1.7 years) were included (79 boys and 33 girls). Leg-length measurement interrater reliability among 3 raters for 25 randomly chosen images was nearly perfect (intraclass correlation coefficient, 0.996; 95% CI, 0.994-0.998). At baseline, there was no apparent preoperative LLD (<5 mm) in 48% (n = 54) of participants, while 37% (n = 41) displayed a small apparent LLD (5 to <10 mm), 12% (n = 13) displayed a moderate apparent LLD (10 to <15 mm), and 4% (n = 4) displayed a large apparent LLD (≥15 mm). Of the patients with an apparent preoperative LLD, 66% (n = 38) of them tore their ACL on the leg measuring shorter. At first postoperative radiographs, 48% (n = 28) of patients with an apparent preoperative LLD showed resolution to no LLD: 46% (n = 19) of patients with a small apparent preoperative LLD, 54% (n = 7) of patients with a moderate apparent LLD, and 50% (n = 2) of patients with a large apparent LLD. CONCLUSION: A high percentage of patients (48%) with apparent preoperative LLDs showed resolution to no LLDs by their first postoperative imaging, indicating that preoperative hip-to-ankle radiographs display some false LLDs in patients with recent ACL tears who are unable to fully extend their injured leg and bear weight.

Risk Factors for Contralateral Slipped Capital Femoral Epiphysis: A Meta-analysis of Cohort and Case-control Studies.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is an important cause of hip pain and disability in pediatric patients. SCFE occurs bilaterally in 12% to 80% of cases, and the risk of contralateral SCFE is noted to be 2335 times higher than the index SCFE. Several studies have reported risk factors for contralateral SCFE; however, these studies have not been systematically analyzed. The purpose of this systematic review and meta-analysis was to review and analyze risk factors for subsequent contralateral SCFE and identify the strongest risk factors for a subsequent slip. METHODS: A systematic review was performed of all observational studies focusing on risk factors for subsequent contralateral SCFE indexed in Medline, Embase, and Cochrane databases. Data extraction was performed and summarized using descriptive statistics. Meta-analysis was performed for risk factors with sufficient constituent study data. Quality assessment was performed using the Newcastle-Ottawa Scale, and funnel plots were generated to assess publication bias. RESULTS: The initial search strategy identified 226 references, and after exclusions, 20 studies were included in this analysis. Demographic risk factors included age, sex, weight, body mass index, ethnicity, and urban/rural residence; clinical risk factors included endocrine abnormality, duration of symptoms, slip stability, and slip chronicity; and radiographic risk factors included slip angle, triradiate cartilage, alpha angle, posterior sloping angle (PSA), physeal sloping angle, modified Oxford score, and bone age. Younger patient age, body mass index≥95th percentile, presence of an endocrine abnormality, higher PSA of the unaffected hip, and lower modified Oxford score have been noted to be significant risk factors for contralateral SCFE. Meta-analysis showed that younger age (-0.9; confidence interval, -1.1, -0.6), and higher PSA (4.7 degrees; 95% confidence interval, 3.3-6.2 degrees) of the unaffected hip were predictive of subsequent contralateral SCFE. The majority of studies were of good quality. CONCLUSION: There are several risk factors for subsequent contralateral SCFE. On the basis of the available data, younger patients with a high PSA of the unaffected hip would most likely benefit from prophylactic fixation of the unaffected hip. LEVEL OF EVIDENCE: Level II.

Evaluating the use of an electronic inclinometer in correcting rotational disorders of the hip in children.

BACKGROUND: Femoral derotation osteotomies are commonly performed to correct rotational disorders of the hip in children. Surgical correction is typically assessed visually with the use of a goniometer or osteotomy template, but these methods have been shown to be inaccurate. In this study, we aimed to determine the accuracy of an electronic inclinometer in performing derotation osteotomies of 2 different magnitudes in comparison to commonly used visual techniques. METHODS: We performed derotation osteotomies of 15°and 30° in a synthetic femur model using a goniometer, triangle osteotomy template, and electronic inclinometer. The degree of derotation was assessed by computed tomography (CT) and measured by a musculoskeletal radiologist. Statistical analyses included descriptive statistics, as well as t-test, analysis of variance (ANOVA), and Fisher's exact test to determine differences between osteotomy techniques. RESULTS: We performed 40 proximal femoral derotation osteotomies. The mean difference from the planned derotation was 5.9° for the goniometer technique, 3.8° for the osteotomy triangle technique, and 3.2° for the electronic inclinometer technique (p-value = 0.048). There was no difference between the techniques for 15° derotation osteotomies (p-value = 0.28); however, there was a trend towards significance for 30° derotation osteotomies (p-value = 0.07). Fewer osteotomies had a difference greater than 3° from the planned derotation using the electronic inclinometer technique (p-value = 0.04). CONCLUSIONS: The accuracy of derotation osteotomies can be improved with the use of an electronic inclinometer. This technology has the potential to improve surgical technique, minimize surgical error, and possibly improve patient outcomes.

A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever.

PURPOSE: Tibial spine fractures (TSFs) are graded according to the Meyers and McKever (MM) classification system, which is based on a qualitative evaluation of plain radiographs. However, although MRI images can provide important information about these fractures, there is no MRI-based classification system. This study aims to (1) establish the intra- and inter-rater reliability of the MM system for use with radiographs, (2) propose a quantitative, MRI-based system and compare its reliability to the MM system, and (3) assess how often using the MRI-based system changes the classification and potential treatment plan as previously determined using MM. METHODS: The MRI-based system was designed with three grades based on quantitative displacement patterns of the fractured fragment and tissue entrapment. Four raters from a tertiary care center evaluated 20 fractures according to the MM and MRI-based systems. Observers graded images at two time points at least 2 weeks apart, after which we compared the intra- and inter-rater reliability of each system (using Fleiss' kappa and weighted kappa, respectively) and assessed how often using the MRI-based system changed the fracture grade. RESULTS: Both the MM and MRI-based systems exhibit fair to moderate intra- and inter-rater reliability (average kappa values ranged from 0.38 to 0.66). Use of the MRI-based system changed the fracture grade and as a result modified the treatment recommendations in 32.5% of cases: 6.9% were previously unnoticed fractures, 13.1% underwent a raise in grade, and 12.5% were graded as lower than before. CONCLUSION: The MRI-based system is as reliable as the MM system and provides specific, quantitative criteria for classifying fractures according to fragment displacement and tissue entrapment. The new MRI-based system potentially clarifies treatment indications for TSFs. LEVEL OF EVIDENCE: Diagnostic Study, Level II.

Reliability and Reproducibility of Subject Positioning with EOS Low-Dose Biplanar X-ray.

BACKGROUND: EOS low-dose biplanar X-ray used with tantalum bead implantation is an appealing imaging modality to evaluate limb length and physeal growth due its relatively low radiation exposure, excellent inter- and intra-observer reliability, and minimal magnification/shrinkage error. QUESTIONS/PURPOSES: The purpose of this study was to establish the error in total length and inter-bead distances using EOS and tantalum beads due to variable positioning in the EOS gantry, by assessing variation in measurements made on the same subject repeatedly positioning by one positioner (intra-positioner measurement error) and variation in measurements made on the same subject with positioning by multiple positioners (inter-positioner measurement error). METHODS: Tantalum bead markers were placed about the distal femoral physis of a cadaveric lamb femur. Three investigators positioned the femur in the EOS gantry 10 times, totaling 30 EOS scans. Total limb length and inter-bead distances were measured on AP and lateral views; mean and standard error were calculated. A random effects analysis of variance for nested data was used to determine the proportion of variation due to differences between positioners and differences between positioning by the same positioner. RESULTS: Intra-positioner measurement error ranged from 0.01 to 0.06 mm. Inter-positioner measurement error ranged from 0.00 to 0.09 mm. CONCLUSIONS: EOS has relatively low radiation and allows standing assessment of limb length and alignment. In this study, length measurements and inter-bead distances demonstrated minimal error due to positioning in the EOS gantry, documenting that there is minimal error from positioning, minimal magnification/shrinkage error, and exceptional inter and intra-rater reliability. EOS is the preferred method for length and angular measurements, and with tantalum beads, is ideal for measuring growth about the physis.

Presentation of Adolescent Idiopathic Scoliosis: The Bigger the Kid, the Bigger the Curve.

BACKGROUND: It is our clinical suspicion that children with higher body mass index (BMIs) who are diagnosed with scoliosis tend to have larger curves on presentation. The purpose of this study was to determine the effect of BMI on severity of curve at initial presentation of adolescent idiopathic scoliosis. METHODS: This is a retrospective, descriptive cohort study of consecutive patients age 10 or greater referred to a single large tertiary care center with concern for spinal asymmetry. Patients were separated into 3 BMI categories as measured on the presenting visit: normal weight-≥5th and <85th percentile, overweight-≥85th and <95th percentile, and obese-≥95th percentile. In addition to demographic information, data collected included BMI, curve magnitude, curve location, Risser stage, and where or by whom spinal asymmetry was noted. RESULTS: A total of 150 patients, 50 in each the normal weight, overweight, and obese categories, were included in this study. Average curve at presentation for normal weight patients was 18.1 degrees, for overweight patients 23.9 degrees (P=0.02), and for obese patients 24.5 degrees (P=0.02). As compared with the normal weight group, odds ratio of presenting with a curve of 40 degrees or above was 10.8 for the overweight group (95% confidence interval, 1.3-88.5, P=0.03) and 12.2 for the obese group (95% confidence interval, 1.5-99.8, P=0.02). Assuming a cut-off of 45 degrees as surgical range, no normal weight patients presented in surgical range (0%), but 7/50 (14%, P=0.01) overweight and 8/50 (16%, P<0.01) obese patients did. Moreover, higher BMI patients were significantly more likely to present at a higher degree of skeletally maturity, with an average Risser of 1.8 for normal weight patients, 2.7 (P=0.01) for overweight patients, and 2.9 (P=0.01) for obese patients. CONCLUSIONS: Overweight and obese patients with adolescent idiopathic scoliosis present at significantly larger curve magnitudes and significantly higher degrees of skeletal maturity. Moreover, these patients were significantly more likely to present with very large curves and, in our study, all patients presenting with a surgical range curve were either overweight or obese. LEVEL OF EVIDENCE: Level III-Retrospective case-control.

Closing the growth plate: a review of indications and surgical options.

PURPOSE OF REVIEW: The purpose is to review the indications for epiphysiodesis in the treatment of pediatric limb length discrepancies; provide an update on current diagnostic, planning, and surgical techniques; and to introduce possible future alternatives. RECENT FINDINGS: Retrospective comparative studies have failed to demonstrate superiority of one epiphysiodesis technique over the others. EOS low-dose biplanar X-ray and smartphone growth prediction applications are improving our ability to diagnose and plan treatment for leg length discrepancy. Arthroscopically guided percutaneous epiphysiodesis and radiofrequency ablation are newer techniques that are still under investigation. SUMMARY: Epiphysiodesis is the treatment of choice for children with predicted leg length discrepancies between 2-5 cm, provided that the physes are open with sufficient growth remaining. The most common epiphysiodesis techniques are performed percutaneously and either ablate the physis with drills/curettes or use metal implants to tether the physis and prevent further growth. Surgical treatment is typically ambulatory in nature, and allows for early return to weight bearing. In modern series, complication rates are less than 10%, with the majority being minor complications. Further high-quality prospective research is needed to determine the optimal epiphysiodesis surgical technique.

It's not just the big kids: both high and low BMI impact bracing success for adolescent idiopathic scoliosis.

PURPOSE: Bracing is a common treatment for patients with adolescent idiopathic scoliosis (AIS) and is recommended for most skeletally immature patients with a curve of 25-45° in order to prevent or delay curve progression. The aim of this study was to determine at which body habitus orthotic management for AIS becomes less effective. We hypothesize that overweight children are more likely to fail brace treatment. METHODS: This was a retrospective cohort study involving consecutive patients with AIS treated with a thoracolumbosacral orthosis at a large pediatric tertiary care center. Patients were divided into three groups based on BMI: (1) high-BMI group (BMI >85th percentile); (2) low-BMI group (BMI <20th percentile); (3) mid-BMI group (BMI 20th-85th percentile). Successful orthotic treatment was defined as an increase in the primary curve of <5°, prevention of progression past 45°, and avoidance of surgery. RESULTS: The study cohort comprised 182 patients with a mean age of 12.5 years at brace prescription and a mean follow-up of 2 years. Compared to the mid-BMI group, high- and low-BMI patients were significantly more likely to fail orthotic management. The association between high-BMI and orthotic failure disappeared when compliance and in-brace correction were taken into account, but the association between low-BMI and each poor outcome remained significant. CONCLUSIONS: Based on our results, children on either end of the BMI spectrum are more likely to fail brace treatment for scoliosis than their mid-BMI counterparts. In high-BMI patients, this appears to be in large part attributable to an inadequacy of in-brace curve correction as well as to poorer brace compliance, while a low BMI appears to be an independent risk factor for brace failure.

Titanium Elastic Nailing for Pediatric Tibia Fractures: Do Older, Heavier Kids Do Worse?

BACKGROUND: Elastic nailing is a common method of fixation for tibial shaft fractures in skeletally immature individuals. Poor outcomes of titanium elastic nails for femoral shaft fractures have been associated with increasing patient age and weight, especially patients weighing >50 kg. Our objective is to determine if there is an upper weight or age limit to the safe and effective use of titanium elastic nails for tibial shaft fractures in the pediatric population. METHODS: This is a retrospective cohort study of patients who underwent stabilization of a tibial shaft fracture with titanium elastic nails at a large tertiary-care pediatric trauma center. Data collected included patient demographics, injury characteristics, and radiographic data. Weight groups were stratified as ≥ or <50 kg, and age groups as 14 years or older or less than 14 years old. Malunion was defined as 10 degrees of angulation in either the sagittal or coronal plane. Union was defined as bridging of ≥3 cortices on orthogonal radiographs. A significant difference in time to union was considered to be 3 weeks. RESULTS: Ninety-five patients were included with a mean age of 12.1 years (range, 6 to 16 y) and a mean weight of 50.2 kg (range, 21 to 122 kg). Malunion rate was similar between weight cohorts: 13.3% (6/45) in the ≥50-kg group and 10% (5/50) in the <50-kg group (P=0.61). Malunion rate was similarly comparable between age groups: 17.6% (6/34) in the 14 years and older group and 8.2% (5/61) in the less than 14-year-old group (P=0.17). There was no statistically significant difference in time to union between weight or age cohorts. In sum, we did not find a significant difference in the rate of malunion or time to healing between younger and older patients or between lighter and heavier patients. CONCLUSION: The use of titanium elastic nails for tibial shaft fractures, unlike for other long bone fractures, seems not to be precluded in older and heavier patients. LEVEL OF EVIDENCE: Level III.

Ifosfamide dose-intensification for patients with metastatic Ewing sarcoma.

BACKGROUND: Outcomes for patients with metastatic Ewing sarcoma (ES) remain poor. We investigated whether the intensification of ifosfamide improved survival for patients with metastatic ES. PROCEDURE: We conducted a retrospective chart review of 30 patients with metastatic ES treated with the MSKCC "EFT regimen." The regimen included an intensification of ifosfamide dosing from 1,800 mg/m(2) /day × 5 days per cycle to 2,800 mg/m(2) /day × 5 days per cycle. RESULTS: Twenty six of the 30 patients completed planned chemotherapy. Two patients experienced disease progression during therapy. There were no toxic deaths. One patient developed secondary leukemia. The 4-year event free survival (EFS) was 27% and the overall survival (OS) was 39%. CONCLUSIONS: Intensification of ifosfamide was tolerated and did not increase toxicity in patients with metastatic ES. The intensification did not improve outcomes for these patients with metastatic disease.

Supracondylar humeral fractures with isolated anterior interosseous nerve injuries: is urgent treatment necessary?

BACKGROUND: It is unclear if pediatric patients with a supracondylar humeral fracture and isolated anterior interossous nerve injury require urgent treatment. METHODS: A retrospective, multicenter study of 4409 patients with operatively treated supracondylar humeral fractures was conducted. Exclusion criteria were additional nerve injuries other than the anterior interosseous nerve, any sensory changes, pulselessness, ipsilateral forearm fractures, open fractures, less than two months of follow-up, or pathological fractures. RESULTS: Thirty-five of 4409 patients met inclusion criteria. The average time to surgery was 14.6 hours (range, two to thirty-six hours). No patient developed compartment syndrome. There was no significant difference in time to return of anterior interosseous nerve function relative to the time to surgical reduction and fixation (p = 0.668). A complete return of anterior interosseous nerve function occurred in all patients with an average time of forty-nine days (range, two to 224 days). Ninety percent of patients recovered anterior interosseous nerve function by 149 days. CONCLUSIONS: To our knowledge, this is the largest series to date of supracondylar humeral fractures with anterior interosseous nerve injuries. There is no evidence that a supracondylar humeral fracture with an isolated anterior interosseous nerve injury requires urgent treatment. A delay in treatment up to twenty-four hours was not associated with an increased time of nerve recovery or other complications. This series excluded patients with sensory nerve injuries, pulselessness, and ipsilateral forearm fractures, which all may require urgent surgery. Barring other clinical indications for urgent treatment of a supracondylar humeral fracture, an isolated anterior interosseous nerve injury (no sensory changes) may not by itself be an indication for urgent surgery. The anterior interosseous nerve injuries in this series showed complete recovery at a mean time of forty-nine days.