Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis.

PURPOSE: To evaluate three-dimensional (3D) vertebra and disk shape changes over 2 years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). METHODS: Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2 years postoperatively. Change in patient height was correlated with changes in the spine dimensions. RESULTS: Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4 years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8 cm by 2 years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2 mm/level versus 0.7 mm/level on the right side (p < 0.001). This differential growth was composed of 0.5 mm/vertebral level and 1.0 mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4 mm), posteriorly (- 0.3 mm) and on the right (- 0.5 mm) from FE to 2 years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes. CONCLUSIONS: Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.

Maximizing mechanical advantage: surgical technique increases stiffness in spinal instrumentation.

PURPOSE: While there has been a great improvement in the treatment of adolescent idiopathic scoliosis, sagittal deformity correction has remained challenging. Increased rod stiffness has been shown to reduce thoracic flattening. We propose that the surgical technique can increase rod stiffness. A mechanical study was created to quantify the effect this has on construct stiffness. METHODS: The sagittal bending stiffness of a constrained over contoured rod was measured using four different commonly used instrumentation systems. Pedicle screws were secured into custom printed blocks. One block was completely immobilized, while the other block was subject to four levels of constraint. This includes no constraint, mild constraint, moderate constraint, and maximal constraint with both blocks immobilized. The rod apex was loaded until 1 cm of displacement occurred. The stiffness was then calculated and compared between groups. RESULTS: All four rod types showed increased bending stiffness as the construct became more constrained. The moderately constrained and the maximally constrained groups had a significantly higher stiffness compared to the unconstrained groups in all rod types (p < 0.05). The 6.0 mm titanium circular rods showed the highest increase in stiffness between maximal and no constraint, which became 3.02 × stiffer. CONCLUSIONS: Rod stiffness is not only determined by size, shape, and metal alloy, but also by surgical technique. Constraining the spinal instrumentation by first locking the rod to the proximal and distal anchors significantly increases the sagittal bending stiffness. In a mechanical model this technique increases rod bending stiffness regardless of the material or shape.

Visual Estimation of Length by Orthopaedic Surgeons: How Accurate Are Lengths Estimated in Digital Images Compared to In-Person Estimations?

Orthopaedic surgeons are frequently required to make estimations, often without the use of measuring tools, including the lengths of wounds, incisions, bone fragments, and soft tissue defects. To evaluate the accuracy of these estimations, simulated wounds of randomized lengths were drawn on a healthy volunteer. Resident and attending physicians estimated the length of each wound via digital photograph and subsequently in person. Comparison of digital photograph versus in-person estimation was completed with paired t-test. The accuracy of estimation by experience level was assessed using Spearman rank. Accuracy was higher with in-person measurement compared with digital photographs, but overall low in both settings. There was no correlation between better accuracy and more experience in either setting. In order to properly guide treatment decisions and document physical exam findings, a ruler should be used rather than visual estimation alone. Likewise, clinical photographs used for patient care should always include a ruler. (Journal of Surgical Orthopaedic Advances 30(2):108-111, 2021).

Pediatric On-Call Challenges for the General Orthopaedic Surgeon.

Taking call as an orthopaedic surgeon is commonplace and expected at many institutions. Taking general orthopaedic call without specialized backup physicians can be challenging and daunting. Pediatric patients commonly present to emergency departments around the country with a host of pathologies, many of which are different from those of adults. It is imperative to recognize injuries and scenarios that require emergent or urgent intervention, those that can potentially become difficult, and how to triage nonurgent ones. Just as important is identifying one's ability to treat these patients (as a surgeon or an institution) and the capacity and mechanism to transfer these patients to specialized care centers. The general orthopaedic surgeon will be required to assess on-call challenges with pediatric patients.

Lumbar Discitis and Osteomyelitis After a Spinal Stem Cell Injection?: A Case Report and Literature Review.

CASE: A 32-year-old man developed lumbar discitis and osteomyelitis after receiving a cell-based injection for the treatment of degenerative disc disease. Initial cultures were negative, but he continued to worsen, and a repeat set of cultures was taken. On day 10, Cutibacterium acnes was isolated. He was then successfully treated with 12 weeks of intravenous antibiotics. CONCLUSIONS: There is minimal regulation on the preparation or administration of cell-based interventions. It is important to consider slow growing organisms such as C. acnes in patients presenting with spinal infection with insidious onset after these treatments.

Intramedullary Fixation of Both Bone Forearm Fractures in Children and Adolescents: Healing Correlates With Development of the Olecranon Apophysis.

BACKGROUND: The purpose of this study was to determine whether healing of both bone forearm (BBFA) fractures in children and adolescents is associated with the stage of the olecranon apophysis development as described by the Diméglio modification of the Sauvegrain method. METHODS: Records were reviewed from 2 children's hospitals from 1997 to 2008 to identify all patients younger than 18 years of age who had BBFA fractures treated with intramedullary nail fixation. Sixty-three patients were identified meeting inclusion and exclusion criteria. The stage of the olecranon apophysis was noted on the lateral radiograph at the time of the injury. Data were statistically analyzed to assess the olecranon stage at which the increased rate of delayed union becomes more prevalent using the receiver operating characteristic curve. Time to union, complications, and need for reoperation were recorded for each group. RESULTS: One thousand three hundred ninety-eight patient records were reviewed with 63 patients meeting the inclusion criteria. Using a receiver operating characteristic curve, a cutoff of olecranon stage > 3 (stages 4 to 7) was a significant predictor of the increased rate of delayed union time compared with olecranon stages 0 to 3 (P=0.004). Non-healing-related complication rates for each group were 2/28 (7.1%) for olecranon stages and 0 to 3 and 6/35 (17.1%) for olecranon stages 4 to 7. CONCLUSIONS: The rate of delayed union for BBFA fractures that have been treated with intramedullary nail fixation is increased in children with more mature olecranon apophyses as compared with those with younger olecranon stages. We propose the use of the stage of olecranon apophysis development when choosing the surgical approach and implant for when treating operative BBFA fractures in children. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Slipped Capital Femoral Epiphysis in an Adult Patient With Kabuki Syndrome.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is a condition which predominantly occurs in adolescents. SCFE is extremely rare in adults, and nearly all previous reported cases have been associated with an endocrine disorder. METHODS: We present a case of a 19-year-old man with Kabuki syndrome who was diagnosed with an unstable SCFE requiring surgical fixation. A literature search on PubMed and Google Scholar was done looking for all published cases of delayed-onset SCFE. All previous reported cases were reviewed to determine the likely cause of the SCFE. RESULTS: No previous cases of SCFE were described in patients with Kabuki syndrome. Literature review revealed 27 articles describing 32 cases of delayed-onset SCFE. Thirty-one of these cases were associated with endocrine disorders or pituitary tumors. Endocrine disorders associated with delayed-onset SCFE included hypothyroidism, hypogonadism, and panhypopituitarism. Pituitary adenomas and craniopharyngiomas were also associated with delayed-onset SCFE. DISCUSSION: This is the first reported case of SCFE in a patient with Kabuki syndrome. Kabuki syndrome is a genetic disorder known to cause delayed growth, resulting in delayed physeal closure, placing the patients at risk of SCFE even into adulthood. The literature search revealed that nearly all previously described delayed-onset SCFE cases were associated with endocrine disorders or pituitary tumors. We recommend that all patients diagnosed with delayed-onset SCFE be evaluated for endocrine disorders, pituitary tumors, and/or genetic disorders which can cause delayed skeletal maturation as these disorders can range from severe endocrine disorders to intracranial tumors.

Focal Periphyseal Edema: An Uncommon Cause of Adolescent Knee Pain: A Report of Three Cases.

CASE: Focal periphyseal edema (FOPE) zones have only recently been described as a cause of joint pain in adolescence. The literature is limited to a few case reports and radiologic studies describing this symptomatic physeal pathology. This series describes 3 adolescent patients with magnetic resonance imaging (MRI) confirmed FOPE zones of the distal femur. Repeat MRI of 2 of the 3 patients showed improvement yet incomplete resolution of the bone edema, corresponding with persistent knee pain. CONCLUSIONS: FOPE zones usually improve with conservative treatment, but may be a cause of persistent knee pain in adolescents.

The Rule of 57: Orthopaedic Trigonometry Made Easy.

INTRODUCTION: The Rule of 57 is an easy method for planning osteotomies and calculating translations when correcting spine and limb deformities. METHODS: The rule is based on the mathematical principle that a circle with a radius of 57 mm has a circumference of 360 mm where each 1° of the circle subtends an arc of 1 mm in length. RESULTS: Thus a 1 mm opening or closing wedge osteotomy with a width of 57 mm would result in 1° of angular correction. DISCUSSION: This basic geometric shape can be extrapolated in many ways to determine proper alignment for preoperative planning, performing osteotomies, understanding guided growth, and executing a variety of deformity corrections.

Total Knee Arthroplasty Wound Complication Treatment Algorithm: Current Soft Tissue Coverage Options.

BACKGROUND: Wound complications associated with soft tissue defects following total knee arthroplasty present challenges for the orthopedic surgeon. The scale of early complications include less morbid problems, such as quickly resolving drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft tissue coverage. METHODS: This review outlines current wound management strategies and provides an algorithm to help guide treatment and clinical decision-making. CONCLUSION: A surgeon's understanding of soft tissue coverage options is essential in protecting the knee prosthesis from a deep infection and to obtain an optimal functional outcome.

Emergency Medical Service Personnel Recognize Pediatric Concussions.

Concussions are a major cause of morbidity in pediatrics. Many concussions occur during activities with emergency medical service (EMS) providers present to determine if a higher level of care is needed. Data are limited on how capable these providers are. We assessed the ability of EMS providers to recognize pediatric concussions. Fifty-six total responses were included, 38 from EMS and 18 from our MD/RN (medical doctor/registered nurse) group. No statistical differences were found between the 2 groups when adjusted for age, gender, number of years in practice, and number of pediatric concussions managed. This first of its kind pilot study was designed to assess EMS personnel's ability to recognize and triage pediatric concussions. Our findings show EMS providers are statistically identical in their ability to recognize and triage concussions to physicians. The performance of our MD participants was lower than expected. Larger studies are needed to further investigate EMS providers' ability to recognize a concussion.