Biomechanical investigation of two long bone growth modulation techniques by finite element simulations.

Implants used to correct pathological varus-valgus deformities (VVD) and leg length discrepancies (LLD) may not be optimized for the specific treatment, as suggested by their off-label use. Detailed analysis of this issue has been limited by the poorly understood mechanical behavior of the growing physis and ignorance of the loads acting on the implants. The aim of this study was to predict and compare the loading conditions of a growth modulation implant in VVD and LLD treatments. Idealized finite element (FE) models of the juvenile distal femur treated with the Eight-Plate implant were developed for VVD and LLD. Bone growth was simulated using thermal strains. The axial force in the plate was compared between the two treatments. Case-specific plate forces were predicted by virtually reproducing the screw deformation visible on radiographs of LLD (N = 4) and VVD (N = 4) clinical cases. The simple FE models reproduced the clinical implant deformations well. The resulting forces ranged from 129 to 580 N for the VVD patients. For LLD, this range was from 295 to 1002 N per plate, that is, 590-2004 N for the entire physis. The higher forces in LLD could be explained by restricted screw divergence in the double-sided implant application. For the first time, the loading conditions of a growth modulation implant were investigated and compared between two treatments by FE analyses, and the range of case-specific loads was predicted. These simulation tools may be utilized for guiding appropriate usage and for efficient development of implants. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1398-1405, 2018.

An evaluation of supracondylar humerus fractures: is there a correlation between postponing treatment and the need for open surgical intervention?

PURPOSE: The goal of this study was to evaluate the treatment and recovery of patients treated for Gartland type III supracondylar humerus fractures in order to determine if postponing treatment leads to a higher rate of open surgical treatment or complications. METHODS: A retrospective study was conducted examining the medical records of children with Gartland type III supracondylar humerus fractures at our institution for a two-year period. The patients included in the study were treated with closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF). RESULTS: After exclusions, 134 patients were included in the study, with an average age of 5.6 years. The patients were grouped according to whether their treatment was postponed (39.6 %) or immediate (60.4 %). The majority of all patients were treated using CRPP: 46 (86.8 %) of the postponed patients and 75 (92.6 %) of the immediate patients. Very few postsurgical complications occurred in the patients; there was only one (1.6 %) case of iatrogenic nerve injury in a postponed patient as well as four (3.8 %) cases of loss of carrying angle: one (2.3 %) in postponed patients and three (4.8 %) in immediate patients. CONCLUSIONS: Postponing treatment of type III supracondylar humerus fractures in children did not lead to an increase in open surgical treatment; nor did it lead to an increase in complications.

Postoperative pain management after spinal fusion surgery: an analysis of the efficacy of continuous infusion of local anesthetics.

Spinal fusion surgery is a major surgery that results in severe postoperative pain, therefore pain reduction is a primary concern. New strategies for pain management are currently under investigation and include multimodal treatment. A 3-year retrospective analysis of patients with idiopathic scoliosis undergoing spinal fusion surgery was performed at our hospital, assessing patient pain scores, opioid use, and recovery. We evaluated the effect of adding continuous infusion of local anesthetics (CILA) to a postoperative pain management protocol that includes intraoperative intrathecal morphine, as well as postoperative patient-controlled analgesia and oral opioid/acetaminophen combination. The study compared 25 patients treated according to the standard protocol, with 62 patients treated with CILA in addition to the pain management protocol. Patients in the CILA group used nearly 0.5 mg/kg less opioid analgesics during the first 24 hours after surgery.

Ultrasound evaluation of ulnar nerve anatomy in the pediatric population.

BACKGROUND: Ulnar nerve instability has been reported in up to 17% of children. Accurate assessment is important to achieve because of potential nerve complications that can arise from treatment of common pediatric fractures, including supracondylar humerus fractures. The objective of our study was to evaluate our ability to use ultrasonography to determine the extent of ulnar nerve dislocation in the normal pediatric population and to determine if there is a relationship between ulnar nerve instability and ligamentous laxity. METHODS: We conducted a prospective ultrasound evaluation of 51 children, examining the excursion of the ulnar nerve through full range of motion. On the basis of its movement during flexion, the ulnar nerve was categorized as stable, subluxating, or dislocating. In addition, we assessed all subjects for ligamentous laxity using the Wynne-Davies signs of joint laxity. The subjects were then divided into groups based on age or ligamentous laxity, and statistical analysis was performed. RESULTS: Most of the elbows evaluated had stable ulnar nerves (64/102, 62.7%), 27.5% (28/102) had subluxating nerves, and 9.8% (10/102) had dislocating nerves. Patients aged between 6 and 10 showed the highest rate of dislocating or subluxating nerves, with 50%, and also the highest average laxity score, 2.0. When grouped according to ligamentous laxity, patients who had multiple signs of ligamentous laxity had statistically higher numbers of subluxating and dislocating nerves (91.6%, 11/12) than those with lower laxity scores (25.6%, 10/39). CONCLUSIONS: There are a substantial number of subluxating or dislocating ulnar nerves in children, and the incidence is often bilateral. Patients with ligamentous laxity are more likely to possess unstable ulnar nerves. Ultrasound evaluation and assessment of ligamentous laxity are additional tools that can be used to assess elbow anatomy and identify children at risk for iatrogenic nerve injury. LEVEL OF EVIDENCE: Level III, diagnostic study.

Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results.

PURPOSE: A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN. METHODS: Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10-17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients. RESULTS: Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications. CONCLUSIONS: Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.

Concept of treatment in supracondylar humeral fractures.

This opinion of treatment for children's supracondylar humeral fractures discusses techniques of fracture reduction and stabilization. A useful method of external visualization of the fracture is reviewed. The article discusses the treatment of 95 fractures in children using crossed and two lateral pin techniques.

The delay in diagnosis of slipped capital femoral epiphysis: a review of 102 patients.

OBJECTIVES: The aim of this study were (1) to evaluate the incidence of apparent missed diagnosis of slipped capital femoral epiphysis (SCFE) by the primary care system and (2) to identify possible factors leading to a delay in diagnosis of this disorder. SETTING AND DESIGN: A retrospective review of emergency department records, outside medical charts, and preoperative and postoperative radiographs of children treated surgically for SCFE at the Children's Hospital of Los Angeles (CHLA) from 1989 to 1997 was done to assess the delay in diagnosis for SCFE. The primary care system included outside emergency department visits, urgent care clinic visits, and private office visits. RESULTS: Of 102 patients (69 men, 33 women; mean age at surgery, 11.9 years), 68% were above the 95th percentile mean weight for age. Pain in the hip and/or groin was documented in 60%. The mean duration of symptoms experienced before being seen at CHLA was 140 days (hours to 1.5 years) and the mean delay after the first primary care visit till being seen at CHLA was 76 days (hours to 1 year). Fifty-two percent of primary care visits for hip, groin, knee, or thigh pain in obese children did not lead to either a diagnosis of SCFE or a referral for orthopedic evaluation. CONCLUSIONS: This study documents a 2 1/2-month delay and a 52% incidence of apparent missed diagnosis for SCFE by the primary care system. There seems to be a need for increased orthopedic education for primary care providers.

Lymphangiomatosis of the spine: two cases requiring surgical intervention.

STUDY DESIGN: Two cases of lymphangiomatosis of the spine are presented. OBJECTIVES: To report two cases of lymphangiomatosis of the spine requiring surgical intervention and to review the literature. SUMMARY OF BACKGROUND INFORMATION: Lymphangiomatosis is a rare childhood disease characterized by abnormal lymph tissue at multiple sites. Skeletal and visceral involvement are both common. Prognosis depends on the extent of extraskeletal disease. METHODS: Two cases of lymphangiomatosis causing neural compression and instability at the cervicothoracic junction are presented. Both patients underwent surgical decompression and stabilization. RESULTS: One patient died, whereas the other regained full function and activity. CONCLUSIONS: Surgery is indicated when lymphangiomatosis causes neural compression and instability of the spine. Surgical outcome is strongly influenced by extraskeletal involvement.

Thoracoscopic anterior spinal release and fusion: evolution of a faster, improved approach.

PURPOSE: The aim of this study was to compare the perioperative parameters and outcomes of video-assisted thoracoscopic surgery (VATS) with open thoracotomy for anterior release and fusion in the treatment of pediatric spinal deformities. METHODS: Twenty-six patients treated with VATS anterior spinal release and posterior spinal fusion by the authors were reviewed retrospectively. Fourteen age- and disease-matched patients who underwent open thoracotomy for anterior spinal release and posterior spinal fusion by the same group of surgeons during the same time period were evaluated for comparison. Patients whose anterior level of exposure extended below the diaphragm were excluded. RESULTS: Blood loss, operative transfusion, and length of postoperative chest tube use all were decreased in the VATS patients compared with thoracotomy patients (P < or =.05). The average operating time for VATS was less than that for thoracotomy but did not reach statistical significance. However, operating time was significantly shorter in the second 13 VATS patients compared with the first 13 patients. No complications specifically related to the VATS approach were identified. CONCLUSIONS: The VATS technique is a safe and comparable alternative to open thoracotomy. Although there is a learning curve for VATS, greater experience could show an advantage in this approach to the anterior spine for the treatment of pediatric spinal deformity.