Risk of Acute Compartment Syndrome in Pediatric Patients With Tibial Tubercle Avulsion Fractures: A Retrospective Review.

OBJECTIVE: Tibial tubercle avulsion fractures (TTAFs) represent 0.4% to 2.7% of pediatric physeal injuries. These injuries are thought to confer a risk of acute compartment syndrome (ACS), and these patients are often admitted for compartment monitoring and, in many cases, undergo prophylactic fasciotomy. This study sought to review our institution's experience with TTAF and associated compartment syndrome in pediatric patients. METHODS: All patients aged 8 to 18 years with TTAF at our institution from January 1, 2017 to January 1, 2023 were retrospectively reviewed. Patient demographics, injury mechanism, fracture morphology, and postinjury course were reviewed. ACS was diagnosed by clinical exam or necessitating therapeutic compartment fasciotomy. RESULTS: A total of 49 TTAFs in 47 patients were included in the final analysis. The mean age was 14.5 ± 1.2 years (range: 11 to 17), and males were significantly older than females (14.6 ± 1.1 vs 13.3 ± 1.3 y, P = 0.01). The average body mass index was 27.1 ± 7.0, and males had a significantly lower body mass index than females (26.3 ± 6.5 vs 34.1 ± 8.5, P = 0.03). Basketball was the most common mechanism of injury (49%), followed by soccer (13%), football (11%), trampoline (6%), fall (6%), jumping (4%), lacrosse (4%), running (4%), and softball (2%). The Ogden fracture types were as follows: I: 10%; II: 16%; III: 41%; IV: 24%; V: 8%. Thirty-four patients (69%) were admitted to the hospital for at least one night after presentation. Forty-six (96%) underwent surgical fixation an average of 3.5 days after injury. No patients developed ACS during their post-injury or postoperative course. Three patients underwent the removal of hardware. No other complications were observed. The average follow-up duration was 238 days. CONCLUSIONS: The results of this study suggest that the risk of ACS in pediatric patients with TTAF may be small enough to allow for same-day discharge after diagnosis or operative management in patients deemed to be sufficiently low risk by clinical judgment. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients.

INTRODUCTION: Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution. METHODS: We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships. RESULTS: Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10. CONCLUSIONS: We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Patient comprehension of hip arthroscopy: an investigation of health literacy.

Several studies have demonstrated that patients have significant impairments in understanding their injury and appropriate course of management in orthopedic surgery. The purpose of this investigation is to determine if patients are able to obtain a fundamental understanding of the requisite care associated with hip arthroscopy. Any patient who elected to have hip arthroscopy was prospectively recruited to participate in the study. All patients were told they would be asked to complete a questionnaire about their surgery and post-operative instructions. The answers to each question of the questionnaire they would receive at the first post-operative visit were verbally given to each patient during the pre-operative visit. They were also given a post-operative instruction sheet on the day of surgery that contained answers to the questionnaire. At the first post-operative visit, all patients were then asked to complete a multiple-choice questionnaire prior to seeing the surgeon. A total of 56 patients (14 males, 42 females) were enrolled. All patients reported they had read the post-operative instruction sheet. The average number of correct answers was 6.5 ± 0.6 (95% CI 6 - 7) out of 11 questions (59% correct response rate ±18% [95% CI 52 - 66%]). Although we made significant pre-operative oral and written efforts to help patients achieve an elementary level of health literacy regarding their forthcoming hip arthroscopy, many patients did not achieve satisfactory comprehension. Even with instruction and information given verbally and physically (via post-operative instruction sheet) patients did not obtain satisfactory comprehension of their surgical procedure. New ways (through video, simplified cartoons or verbal explanations) must be considered in educating patients concerning surgical procedures to increase comprehension and health literacy.

Patient Comprehension of Carpal Tunnel Surgery: An Investigation of Health Literacy.

Background: Health literacy is the ability of a patient to understand their medical condition. The purpose of this investigation is to determine whether patients are able to obtain an elementary understanding of the fundamental principles of carpal tunnel release and the postoperative instructions after going through the process of informed consent and being provided an additional standardized postoperative instruction document. Our hypothesis is that patients will lack an understanding of these principles and, therefore, will be at risk for being noncompliant in their postoperative care. Methods: Fifty patients with a diagnosis of carpal tunnel surgery who elected to undergo carpal tunnel release alone were enrolled. A standardized education process was performed. Patients completed the questionnaire at their postoperative visit. Results: The average percentage of correct answers was 75.8% (8.34 out of 11 correct). Fisher exact test analysis demonstrated that patients with a lower education level were less likely to know how long it takes for their preoperative symptoms to resolve (P = .0071), and they were less likely to correctly choose all of the important elements of postoperative care during the first week after surgery (P = .022). Conclusions: Although we made efforts to help patients achieve health literacy in carpal tunnel surgery, we found that patients continued to lack comprehension of pertinent components of carpal tunnel surgery, particularly understanding the involved anatomy.

Three-Dimensional Carpal Kinematics after Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release (CTR) has been shown to change carpal arch morphology. However, the effect of CTR on the three-dimensional kinematics of the carpal bones has not been demonstrated. PURPOSE: This study examined whether release of the transverse carpal ligament (TCL) would alter the three-dimensional kinematics of the carpus, specifically the bony attachments of the TCL. METHODS: The in vitro kinematics of the carpus was studied in five fresh-frozen cadaveric wrists before and after CTR using three-dimensional computed tomography. The specimens were evaluated in three positions: neutral, 60 degrees of flexion, and 60 degrees of extension. RESULTS: The data indicate that carpal arch width increases significantly in all positions after CTR as measured between the trapezium and hamate. Second, the trapezium-hamate distance increases in both a translational and rotational component after CTR. Additionally, the pisiform rotates away from the triquetrum after CTR. CONCLUSIONS: Carpal kinematics is significantly altered with a CTR, especially on the ulnar side of the wrist. CLINICAL RELEVANCE: Although the kinematic changes are small, they may be clinically significant and potentially responsible for pillar pain or postoperative loss of grip strength.

Orthopaedic Management of Spasticity.

Spasticity is a common manifestation of many neurological conditions including multiple sclerosis, stroke, cerebral palsy, traumatic brain injury, and spinal cord injuries. Management of spasticity seeks to reduce its burden on patients and to limit secondary complications. Non-operative interventions including stretching/splinting, postural management, physical therapy/strengthening, anti-spasticity medications, and botulinum toxin injections may help patients with spasticity. Surgical management of these conditions, however, is often necessary to improve quality of life and prevent complications. Orthopaedic surgeons manage numerous sequelae of spasticity, including joint contractures, hip dislocations, scoliosis, and deformed extremities. When combined with the efforts of rehabilitation specialists, neurologists, and physical/occupational therapists, the orthopaedic management of spasticity can help patients maintain and regain function and independence as well as reduce the risk of long-tem complications.

Femoroacetabular impingement: a review of current concepts.

Femoroacetabular impingement is becoming an increasingly more common diagnosis in the orthopaedic community for hip pain in the younger population. Variations in the femoral head and acetabulum can lead to a sequelae of changes to the cartilage that can lead to osteoarthritis. Diagnosis is made through a combination of patient history, physical examination, and diagnostic imaging. Plain radiographs are a very useful tool for evaluating the bony anatomy, while CT scan and MRI have roles for surgical planning and more definitive diagnosis. Most patients should trial physical therapy prior to consideration for any arthroscopic or open procedures. Long-term outcome studies are being performed to determine if surgical intervention has any impact on quality of life and development of osteoarthritis.

The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus.

BACKGROUND: Closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus requires operating directly next to the C-arm to hold reduction and perform fixation under direct imaging. This study was designed to compare radiation exposure from two C-arm configurations: with the image intensifier serving as the operating surface, and with a radiolucent hand table serving as the operating surface and the image intensifier positioned above the table. METHODS: We used a cadaveric specimen in this study to determine radiation exposure to the operative elbow and to the surgeon at the waist and neck levels during simulated closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus. Radiation exposure measurements were made (1) with the C-arm image intensifier serving as the operating surface, with the emitter positioned above the operative elbow; and (2) with the image intensifier positioned above a hand table, with the emitter below the table. RESULTS: When the image intensifier was used as the operating surface, we noted 16% less scatter radiation at the waist level of the surgeon but 53% more neck-level scatter radiation compared with when the hand table was used as the operating surface and the image intensifier was positioned above the table. In terms of direct radiation exposure to the operative elbow, use of the image intensifier as the operating surface resulted in 21% more radiation exposure than from use of the other configuration. The direct radiation exposure was also more than two orders of magnitude greater than the neck and waist-level scatter radiation exposure. CONCLUSIONS: Traditionally, there has been concern over increased radiation exposure when the C-arm image intensifier is used as an operating surface, with the emitter above, compared with when the image intensifier is positioned above the operating surface, with the emitter below. We determined that, although there was a statistically significant difference in radiation exposure between the two configurations, neither was safer than the other at all tested levels. CLINICAL RELEVANCE: In contrast to traditional teaching regarding radiation exposure, neither C-arm configuration-with the image intensifier serving as the operating surface or with the image intensifier positioned above a radiolucent hand table-was shown to be clearly safer for pediatric supracondylar humeral fracture fixation.

Operative treatment of type II supracondylar humerus fractures: does time to surgery affect complications?

BACKGROUND: Because of the changing referral patterns, operative pediatric supracondylar humerus fractures are increasingly being treated at tertiary referral centers. To expedite patient flow, type II fractures are sometimes pinned in a delayed manner. We sought to determine if delay in surgical treatment of modified Gartland type II supracondylar humerus fractures would affect the rate of complications following closed reduction and percutaneous pinning. METHODS: We performed a retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. Mean patient age in the type II group was 5 years (range, 1 to 15 y). A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury. RESULTS: No difference was in detected in rates of major complications between the early and delayed treatment group. Four percent of patients sustained a complication (16 patients). There were no compartment syndromes, vascular injuries, or permanent nerve injuries. Complications included nerve injury (3), physical therapy referral for stiffness (3), pin site infection (2 treated with oral antibiotics, 4 treated with debridement), refracture (2), and loss of fixation or broken hardware (2). Of the 3 patients who sustained nerve injuries, all underwent surgery within 24 hours of injury. One patient developed an ulnar motor and sensory nerve palsy after fixation with crossed K-wires. This resolved by 7 weeks postoperatively. Two patients presented with an anterior interosseous nerve palsy-1 resolved 1 week after surgery, the other by 8 weeks postoperatively. CONCLUSIONS: Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children. Further prospective work is necessary to determine if there are subtle treatment benefits from emergent treatment of type II supracondylar humerus fractures. LEVEL OF EVIDENCE: Level III-retrospective comparative series.

Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary?

BACKGROUND: Radically different conclusions exist in the pediatric orthopaedic and vascular literature regarding the management of patients with a pink hand but no palpable radial pulse in association with a supracondylar humeral fracture. METHODS: One thousand two hundred and ninety-seven consecutive, operatively treated supracondylar humeral fractures in patients presenting to a level-I pediatric trauma center from January 2003 through December 2007 were studied retrospectively. Clinical records were reviewed to determine vascular and neurological examination findings, Gartland classification, timing of surgery, and postoperative complications. RESULTS: One thousand two hundred and sixty-six patients had a documented radial pulse examination at the time of arrival in the emergency room; fifty-four (4%) of those patients lacked a palpable radial pulse. All fifty-four patients had type-3 fractures. Five (9%) of the fifty-four patients underwent open exploration of vascular structures on the basis of clinical findings of a pale hand, sluggish capillary refill, and/or weak or no pulse detected with use of Doppler ultrasound after closed reduction and percutaneous pinning. All five underwent vascular surgery to restore blood flow (two primary repairs, three saphenous vein grafts). Twenty (37%) of the fifty-four patients had a pulse documented with use of Doppler ultrasound and a pink hand after closed reduction and percutaneous pinning, but the radial pulse remained nonpalpable. These patients were observed in the hospital for signs of ischemia; one of the twenty patients required vascular repair after developing a pale hand nine hours after closed reduction and percutaneous pinning, and the other nineteen patients were also observed while they were in the hospital, and they all regained a palpable pulse either prior to discharge or by the time of the first postoperative visit. When compared with the group of patients with type-3 fractures for whom data regarding nerve examination were available, patients with type-3 fractures who lacked a palpable radial pulse had a higher rate of nerve palsy postoperatively (31% versus 9%, p < 0.0001). CONCLUSIONS: In this cohort, nearly 10% of patients who presented with a type-3 supracondylar humeral fracture and no palpable radial pulse underwent immediate vascular repair to restore blood flow following closed reduction and percutaneous pinning. However, in our series, the lack of a palpable radial pulse after closed reduction and percutaneous pinning was not an absolute indication to proceed with vascular exploration if clinical findings (i.e., Doppler signal and capillary refill) suggested that the limb was perfused. Careful inpatient monitoring of these patients postoperatively is mandatory to identify late-developing vascular compromise. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Increased severity of type III supracondylar humerus fractures in the preteen population.

BACKGROUND: Supracondylar humerus fractures are the most common operative fractures in children; however, no studies describe the older child with this injury. The purpose of this study was to compare Gartland type III supracondylar humerus fractures in children older than 8 years of age with those in younger children than age 8. We hypothesized that there would be more complications in older children, reflecting a higher-energy injury mechanism. METHODS: A retrospective chart review of supracondylar humerus fractures managed at a single level I pediatric trauma institution from 2004 to 2007 was performed. Patients with type III fractures were divided into groups based on age at presentation greater or less than 8. Baseline demographics, fracture characteristics, mechanism of injury, operative technique, and complications were analyzed. RESULTS: A consecutive series of 1297 pediatric patients with surgically treated supracondylar humerus fractures was retrospectively reviewed including 873 (67.3%) type III fractures. Of those, 160 (18.3%) patients were older than age 8 at time of injury. Older children were more likely to have fractures from high-energy mechanisms (45.1% vs. 28.7%, P<0.001) and more open fracture (3.8% vs. 1.3%, P=0.0097). There was no difference in preoperative or iatrogenic neuropraxias between groups. There was a shorter delay between presentation and surgery in older children (mean, 217 vs. 451 min, P<0.0001). Three or more pins were used more often in older patients (61.8% in older children vs. 43.6% in younger children, P<0.0001). Major complications including reoperation, loss of fixation, or compartment syndrome were rare in both groups (1.1% in younger group vs. 0.6% in older group, P=1.000). There was a trend toward more pin site infections in older children (3.75% vs. 1.56%, P=0.071). Physical therapy was required nearly 4 times more frequently in older children for management of residual stiffness (20.0% vs. 5.7%, P<0.0001). CONCLUSIONS: Children older than 8 years of age have a higher rate of open supracondylar humerus fractures, although nerve injury rates are similar. Surgeons placed more pins for fixation of fractures in older patients and elbow stiffness requiring physical therapy occurred more commonly after surgical intervention. EVIDENCE: III Retrospective cohort.

Precocious appearance of the capital femoral ossific nucleus in Larsen syndrome.

BACKGROUND: Larsen syndrome is associated with multiple complications, including spinal deformities and recalcitrant joint dislocations. We noted capital femoral ossific nuclei on ultrasonographic images that were made for two infants with Larsen syndrome who were less than two weeks of age. We sought to confirm that this finding is common in patients with Larsen syndrome and unusual in patients with normal hips or idiopathic developmental dysplasia of the hip. METHODS: We identified eight patients with Larsen syndrome who had undergone ultrasonographic or radiographic evaluation of the hips before the age of three months. We compared the findings for these eight patients with those for forty consecutive patients from a prospective study of infants with developmental dysplasia of the hip who had ultrasonographic evaluation of the hips at approximately three months of age, including twenty patients who had normal clinical and ultrasonographic findings and twenty who had clinical instability of one or both hips. RESULTS: All eight patients with Larsen syndrome had radiographic or ultrasonographic evidence of an ossific nucleus at an average age of forty days (range, six to 115 days); four of these patients had evidence of an ossific nucleus at six to ten days of age. In comparison, only two of twenty normal infants (three of forty hips) and one of twenty infants (two of forty hips) with developmental dysplasia of the hip had ultrasonographic evidence of an ossific nucleus at an average age of eighty-four days (range, seventy-six to ninety-four days) (p < 0.0001, Fisher exact test). CONCLUSIONS: In this small group of patients with clinically documented Larsen syndrome, the capital femoral ossific nucleus was evident on ultrasonography of the hip as early as six days of age and was unusual in normal patients or those with idiopathic developmental dysplasia of the hip. The detection of precocious development of a capital femoral ossific nucleus in infants being screened for skeletal anomalies may warrant further evaluation for the possibility of the presence of Larsen syndrome.

Obesity and the orthopedic trauma patient: a review of the risks and challenges in medical and surgical management.

The medical and surgical care of obese trauma patients presents a variety of unique and important challenges. Over the past 30 years, this population has increased dramatically in number, and the optimization of their care demands the attention of the medical community. The problems of caring for an obese trauma patient begin before the actual traumatic event occurs due to their substantially higher incidence of serious comorbidities, such as diabetes mellitus, hypertension, and cardiopulmonary issues. In the setting of trauma, important considerations for the obese patient include careful and expeditious preoperative medical optimization; appropriate deep vein thrombosis prophylaxis; planning for and preventing operative and postoperative challenges (eg, pulmonary and wound complications); and ensuring adequate hospital equipment and staffing resources in the acute and rehabilitative phases of care. This article outlines the scope of the obesity epidemic, reviews the medical consequences of obesity, and highlights surgical considerations specific to the care of orthopedic injuries in the obese trauma patient.

Anabolic steroid use in adolescents: identification of those at risk and strategies for prevention.

Success in sports is often defined by winning, which drives athletes to use performance-enhancing drugs (PEDs) to gain an advantage over opponents. Over the past 20 years, use of PEDs by Olympic and professional athletes has led to public discussion regarding potential negative health effects and ethical implications of their use. Unfortunately, PEDs are not isolated to professional athletes, as PED use in adolescents has increased dramatically. Many professional organizations, including the American Academy of Orthopaedic Surgeons (AAOS), have taken a stance against PED use in sports. The AAOS believes neither anabolic steroids nor their precursors should be used to enhance performance or appearance, and that these substances should be banned in all sports programs. Pediatricians and orthopedists are often the first physicians to see these young athletes. It is critical for these physicians to recognize the significance of the problem, have the knowledge to inform adolescents, dissuade them from future use, and provide viable alternatives for meeting performance goals.

Klebsiella pneumoniae-associated vertebral osteomyelitis after laparoscopic cholecystectomy.

We report a case of a patient who underwent elective laparoscopic cholecystectomy and subsequently developed Klebsiella pneumoniae-associated vertebral osteomyelitis after 2 months. Development of vertebral osteomyelitis after laparoscopic cholecystectomy has never been reported previously. Diagnosis was made via magnetic resonance imaging. The patient was successfully treated with intravenous antibiotics and had a complete recovery with no neurologic sequelae.

Brace management in adolescent idiopathic scoliosis.

UNLABELLED: Skeletally immature patients with adolescent idiopathic scoliosis are at risk for curve progression. Although numerous nonoperative methods have been attempted, including physical therapy, exercise, massage, manipulation, and electrical stimulation, only bracing is effective in preventing curve progression and the subsequent need for surgery. Brace treatment is initiated as either full-time (TLSO, Boston) or nighttime (Charleston, Providence) wear, although patient compliance with either mode of bracing has been a documented problem. We review the natural history of adolescent idiopathic scoliosis, identify the risks for curve progression, describe the types of braces available for treatment, and review the indications for and efficacy of brace treatment. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Idiopathic chondrolysis treated with etanercept.

Idiopathic chondrolysis of the hip in children has been well documented in the literature. The insidious nature of the symptoms and lack of early radiographic findings and diagnostic testing often delay diagnosis. Children often report a stiff, painful hip and have an associated limp in the absence of trauma or constitutional symptoms. Despite these symptoms it remains a poorly understood diagnosis with no identifiable cause. Some have speculated an inflammatory cause, as this disease exhibits joint space narrowing, presumably due to enzymatic activity similar to juvenile rheumatoid arthritis. Despite case reports attempting traction, physical therapy, nonsteroidal anti-inflammatories, steroids, and even operative intervention, no current treatment regimen exists that offers proven appreciable benefit. We hypothesized the powerful anti-inflammatory properties of etanercept would provide symptomatic and radiographic improvement of idiopathic chondrolysis of the hip. This article presents a case of an adolescent boy with a stiff, painful left hip that failed treatment with traction, physical therapy, naproxen, and methotrexate, prior to initiating etanercept. After 1 year of daily etanercept therapy, the patient's hip motion improved in all directions and his pain completely resolved. This novel therapeutic approach offered symptomatic relief and radiographic improvement, and may provide an effective treatment strategy for this difficult disease.

Foot and ankle fellowship training: a national survey of past, present, and prospective fellows.

BACKGROUND: Surgical specialties have become increasingly subspecialized. An expanding demand for foot and ankle care administered by trained specialists has driven the need for foot and ankle-trained orthopaedic surgeons. This survey was designed to elucidate the reasons why residents choose a career in foot and ankle surgery. METHODS: We conducted a national, anonymous, 11-question survey of past, present, and prospective foot and ankle fellows (156 mailed). The questions focused on trying to understand the decision-making process in pursuing a foot and ankle fellowship, and assessing the overall satisfaction of this career choice. Questionnaires were returned within one month of their mailing. RESULTS: We achieved a 40% overall response rate. The fellow's relationship with their residency program's foot and ankle specialist was the primary catalyst for pursuing foot and ankle as a career. Nearly all respondents were satisfied with their decision to do a foot and ankle fellowship, though some were disappointed early in practice with remuneration, practice competition, and patient dissatisfaction. American Orthopaedic Foot and Ankle Society (AOFAS) membership was nearly unanimous. CONCLUSION: The relationship established between a resident and his or her foot and ankle mentor while in training appears to have the greatest impact on pursuing foot and ankle surgery as a career. Once in practice, few trained fellows regret their decision, and few report disappointments not similarly voiced by other orthopaedic subspecialties. Based on this data, the importance of a foot and ankle rotation elective during orthopaedic residency and the impact subspecialty service attending have on resident interests and career choices seem clear.

Spinal deformity and athletics.

Exercise and athletic competition for the young individual has become increasingly more important in society. Scoliosis and Scheurmann kyphosis are spinal deformities prevalent in up to 2% to 3% and 7% of the population respectively, requiring nonoperative and occasionally operative treatment. Curve progression and patient physiologic age dictate treatment regimens. Bracing and physical therapy is the mainstay for nonoperative treatment, whereas soft tissue releases and fusion with instrumentation are used for operative correction. Athletic activity and sports participation is usually allowed for patients undergoing nonoperative treatment. Return to sport after surgical correction is variable, often decided by the treating surgeon, and based on the level of fusion and sporting activity. Although most treating surgeons promote some form of activity regardless of treatment modality chosen, caution should be taken when deciding on participation in collision activities such as football and wrestling.

Increased lengthening rate decreases expression of fibroblast growth factor 2, platelet-derived growth factor, vascular endothelial growth factor, and CD31 in a rat model of distraction osteogenesis.

BACKGROUND: The rate of lengthening has a profound impact on bone regeneration during distraction osteogenesis. Rapid distraction can delay or completely inhibit union, whereas distracting too slowly may lead to premature consolidation. However, the mechanisms responsible for retardation of healing due to rapid distraction have not been elucidated. This study explored whether rapid distraction alters the expression of certain angiogenic growth factors, in particular, fibroblast growth factor 2 (FGF-2), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF-AA), and subsequent new vessel formation as evidenced by platelet endothelial cellular adhesion marker expression (CD31), an indicator of vascular budding. METHODS: Unilateral femoral lengthenings were performed in 60 male Sprague-Dawley rats using a protocol that involved a 7-day latency period and distraction rates of either 0.5 (slow distraction) or 1.5 mm/d (fast distraction) for a total of 7.0 mm of lengthening. Animals were euthanized on postoperative days 8, 10, 12, 14, and 21 (n = 6 per time point and distraction rate). Expression of FGF-2, VEGF, PDGF-AA, and CD31 was characterized immunohistochemically. RESULTS: Cellular staining of FGF-2, PDGF-AA, VEGF, and CD31 was reduced on days 8 to 12 in the regenerate of the fast-distraction animals compared with the slow-distraction animals. Staining of all growth factors was weak on days 14 and 21 at the slow rate and absent at the fast rate. Regardless of time point, a similar spatial localization of growth factor expression was observed at the 2 rates of distraction. CONCLUSIONS: The reduced expression of angiogenic growth factors and CD31, a marker of new vessel formation, indicates that the angiogenic cascade and new vessel formation required for effective bone healing is disrupted at a distraction rate of 1.5 mm/d in a rat model of limb lengthening. CLINICAL RELEVANCE: Delayed bone healing with rapid distraction may be due in part to decreased cellular signaling required for angiogenesis. It may be possible to improve bone healing at increased distraction rates with the appropriately timed administration of growth factors.