Incidence of Urinary Retention Following Posterior Spinal Fusion for Adolescent and Pediatric Scoliosis at a Single Academic Center: Is There a Role for Prophylactic Tamsulosin?

The purpose of this study is to better characterize patient- and surgery-specific parameters associated with postoperative urinary retention (POUR) and assess the impact of prophylactic Tamsulosin following posterior spinal fusion (PSF) for the management of scoliosis in pediatric and adolescent patients. All patients who underwent PSF for surgical correction of adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS) between 2015 and 2019 were retrospectively reviewed. Patients were stratified based on whether they received prophylactic Tamsulosin. Overall, POUR was reported in 3.7% (n = 10) of all patients in the study, although Tamsulosin was associated with a lower rate of POUR, and this did not reach statistical significance. Longer fusion constructs were identified as a risk factor for POUR and could help surgeons counsel families prior to surgery. This is the first study to assess the rate of POUR on AIS and NMS patients following PSF without epidural analgesia. (Journal of Surgical Orthopaedic Advances 33(1):010-013, 2024).

Vascularized Pedicled Fibula for Pediatric Tibia Reconstruction.

SUMMARY: This video reviews the technique of a vascularized fibula flap for pediatric tibia reconstruction. A 4-year-old boy with a history of a left tibial infected nonunion status after multiple debridements presented with segmental bone loss and difficulty with ambulation. An ipsilateral vascularized fibula flap was used for reconstruction. The patient proceeded to union and was independently ambulatory with bracing.

Incidental durotomy in the pediatric spine population.

OBJECTIVESpine surgery is less common in children than adults. These surgeries, like all others, are subject to complications such as bleeding, infection, and CSF leak. The rate of incidental durotomy in the pediatric population, and its associated complications, has scarcely been reported in the literature.METHODSThis is a retrospective chart review of all pediatric patients operated on at Wake Forest Baptist Health from 2012 to 2017 who underwent spine surgeries. The authors excluded any procedures with intended durotomy, such as tethered cord release or spinal cord tumor resection.RESULTSFrom 2012 to 2017, 318 pediatric patients underwent surgery for a variety of indications, including adolescent idiopathic scoliosis (51.9%), neuromuscular scoliosis (27.4%), thoracolumbar fracture (2.83%), and other non-fusion-related indications (3.77%). Of these patients, the average age was 14.1 years, and 71.0% were female. There were 6 total incidental durotomies, resulting in an overall incidence of 1.9%. The incidence was 18.5% in revision operations, compared to 0.34% for index surgeries. Comparison of the revision cohort to the durotomy cohort revealed a trend toward increased length of stay, operative time, and blood loss; however, the trends were not statistically significant. The pedicle probe was implicated in 3 cases and the exact cause was not ascertained in the remaining 3 cases. The 3 durotomies caused by pedicle probe were treated with bone wax; 1 was treated with dry Gelfoam application and 2 were treated with primary repair. Only 1 patient had a persistent leak postoperatively that eventually required wound revision.CONCLUSIONSIncidental durotomy is an uncommon occurrence in the pediatric spinal surgery population. The majority occurred during placement of pedicle screws, and they were easily treated with bone wax at the time of surgery. Awareness of the incidence, predisposing factors, and treatment options is important in preventing complications and disability.

The use of dual growing rods to correct spinal deformity secondary to a low-grade spinal cord astrocytoma.

Pediatric intramedullary spinal cord astrocytomas are rare, and the majority are low grade, typically carrying a low risk of mortality, but a high risk of morbidity. Quality of life is, therefore, an important consideration in treating concomitant progressive kyphoscoliosis. Compared with fusion-based spinal stabilization, fusionless techniques may limit some complications related to early instrumentation of the developing spine. Another consideration is the timing of radiation therapy relative to both spinal maturity and spinal instrumentation. To date, there have been no reports of the use of a fusionless technique to treat spinal deformity secondary to an intramedullary spinal cord tumor. Herein, we report the use of fusionless spinal stabilization with dual growing rods in a boy with low-grade spinal cord astrocytoma after radiation therapy.

Classic measures of hip dysplasia do not correlate with three-dimensional computer tomographic measures and indices.

UNLABELLED: Acetabular dysplasia is a precursor to osteoarthritis of the hip, and it causes acute and degenerative injuries of soft tissue stabilizers. Traditional radiographic assessments of dysplasia are useful in moderate and severe dysplasia, but they have questionable reliability in mild dysplasia. Computed tomography (CT) reconstruction provides a method for calculation of acetabular geometry and analysis of existing radiographic methods. We performed a retrospective radiographic review of anteroposterior pelvic films and their corresponding pelvic CT scans. Using 30 skeletally mature patients, we analyzed the following five measurements for 60 hips: lateral centre edge angle of Wiberg (LCE), Tönnis angle, Sharp angle, a modified Sharp angle, and the depth to width acetabular index. We also estimated hip surface areas, volumes, and ratios from 3-D reconstructions of a CT scan taken within 60 days of the plain radiograph. The Pearson Correlation Coefficient was used to evaluate the relationship between the plain film measurements and the computed hip indices. No moderate or strong correlation was found between the measured plain film indices and the calculated hip indices. Traditional 2-D measurements used to define acetabular dysplasia have little to no ability to quantify hip volumes and surface areas. CT reconstruction provides a better screening tool in the identification of subtle acetabular hip dysplasia in adults. LEVEL OF EVIDENCE: Level III.

Use of vacuum-assisted closure in pediatric open fractures with a focus on the rate of infection.

The use of the vacuum-assisted closure device (VAC; KCI, San Antonio, Texas) has given the orthopedist a new tool for the successful management of severe traumatic wounds and open fractures. While the VAC's role in the adult population is proving itself as an improved therapy compared to "traditional wound care," it's role within pediatric orthopedics remains less well defined. Questions remain whether VAC therapy provides benefit regarding decreased infection rates as well as decreased need for extensive soft tissue coverage procedures. A review was therefore performed of a pediatric level I trauma center's experience using the VAC therapy for pediatric open fractures with a focus on the rate of superficial, deep, and chronic infection. A retrospective chart review spanning 4.5 years of all pediatric patients younger than 18 years with an open fracture initially treated with VAC therapy was conducted at a level I pediatric trauma center. This yielded 28 patients with 37 open fractures aged 2 to 17 years who were initially treated with wound VAC therapy. Subsequent chart review of these patients was performed examining in-hospital records, operative notes, and clinical follow-up visits for documented cases of superficial, deep, or chronic infection. Of 37 open pediatric fractures treated with a wound VAC, there were no cases of superficial infection and 2 cases of deep infection for an overall infection rate of 5%. Both infections resolved with surgical intervention and antibiotics without chronic infection development. When compared with historical controls, the use of VAC therapy for pediatric open fractures appears to be an equally safe and effective modality to help reduce infection in pediatric open fractures and should be considered a valuable tool in treating these injuries.

The impact of intrathecal baclofen on the natural history of scoliosis in cerebral palsy.

BACKGROUND: Intrathecal baclofen (ITB) is an effective treatment of spasticity in patients with cerebral palsy. However, several recent reports have raised concerns that the treatment may be associated with a rapid progression of scoliosis. The objective of this study was to further examine the effect of ITB treatment on the progression of scoliosis in patients with cerebral palsy. METHODS: Spastic cerebral palsy patients who were ITB candidates were followed radiographically. Baseline Cobb angles of the primary curve were measured during the period of ITB pump insertion and at the most recent follow-up visit. Each patient was matched with a control patient by the diagnosis of cerebral palsy, age, sex, topographic involvement, and initial Cobb angle. The mean rate of change in Cobb angle was compared between ITB and control patients using paired t test. A multiple linear regression model was used to examine the difference, controlling for age, sex, topographic involvement, and initial Cobb angle. RESULTS: Fifty ITB patients and 50 controls were included in the analysis. There was no statistically significant difference between the mean change in Cobb angle in ITB patients (6.6 degrees per year) compared with the matched control patients (5.0 degrees per year, P = 0.39). The results from the multiple regression analysis also failed to show a statistically significant difference (0.92 degrees per year difference between ITB patients and controls, P = 0.56). CONCLUSIONS: The progression of scoliosis in cerebral palsy patients with ITB treatment is not significantly different from those without ITB treatment. The findings suggest that patients receiving ITB experience a natural progression of scoliosis similar to the natural history reported in the literature. LEVEL OF EVIDENCE: Level III.

Collagen-platelet rich plasma hydrogel enhances primary repair of the porcine anterior cruciate ligament.

The anterior cruciate ligament (ACL) fails to heal after suture repair. One hypothesis for this failure is the premature loss of the fibrin clot, or provisional scaffolding, between the two ligament ends in the joint environment. To test this hypothesis, a substitute provisional scaffold of collagen-platelet rich plasma (PRP) hydrogel was used to fill the ACL wound site at the time of suture repair and the structural properties of the healing ACLs evaluated 4 weeks after surgery. Bilateral ACL transections were performed in five 30-kg Yorkshire pigs and treated with suture repair. In each animal, one of the repairs was augmented with placement of a collagen-PRP hydrogel at the ACL transection site, while the contralateral knee had suture repair alone. In addition, six control knees with intact ACLs from three additional animals were used as a control group. No postoperative immobilization was used. After 4 weeks the animals underwent in vivo magnetic resonance imaging to assess the size of the healing ACL, followed by biomechanical testing to determine tensile properties. The supplementation of suture repair with a collagen-PRP hydrogel resulted in significant improvements in load at yield, maximum load, and linear stiffness at 4 weeks. We conclude that use of a stabilized provisional scaffold, such as a collagen-PRP hydrogel, to supplement primary repair of the ACL can result in improved biomechanical properties at an early time point. Further studies to determine the long-term effect of primary repair enhancement are needed.

Trends in adolescent lumbar disk herniation.

The authors have retrospectively studied the trends in etiology, symptoms, and rate of recurrence for adolescents with disk herniations to determine the age at onset of symptoms, mechanism of injury, familial history, pattern of symptoms, level of herniation, method of treatment, and rate of recurrence. The review revealed a higher incidence of adolescent lumbar disk herniations in female patients and a higher percentage of patients with a family history than previously reported. Leg pain continues to be the primary presenting symptom in this group of patients and is often not recognized as the radicular pain of a herniated disk by the primary care physician. This reflects a lack of understanding of the relationship of the presenting symptoms to the pathology of the herniated nucleus pulposus, causing a delay in referral to the spine specialist.