Core Decompression and Bone Marrow Aspirate Concentrate in the Treatment of Femoral Head Avascular Necrosis in Pediatric Sickle Cell Disease: Can We Improve Natural History?

INTRODUCTION: Femoral head avascular necrosis (AVN) affects between 10% and 41% of children with sickle cell disease (SCD), resulting in the development of proximal femoral deformity and residual hip pain in the majority of patients without treatment. There have been multiple adult studies published on the outcomes of core decompression with and without the use of bone marrow aspirate concentrate (BMAC) injection both in idiopathic and SCD-related AVN with promising results, however, few studies have reported on outcomes in skeletally immature patients. PURPOSE: This study sought to report on a single surgeon's outcomes for core decompression with BMAC injection in pediatric patients with AVN of the femoral head secondary to underlying SCD. METHODS: A single-center, retrospective review was performed for pediatric patients undergoing core decompression with BMAC injection for femoral head AVN in patients with SCD with a minimum of 12-month follow-up. Demographic, radiographic, and clinical variable were collected. Patients were subdivided based upon presence of open femoral physes at the time of surgery. Successful treatment was defined as the ability to return to activities without limitations. RESULTS: A total of 13 patients (average age 14.1±2.8 y, 84.6% male, 6 skeletally immature and 7 skeletally mature) with 18 affected extremities were identified. Open physes were present in 50% of operative extremities. Skeletally immature patient demonstrated reconstitution of the femoral head in 78% of cases and 89% demonstrated regression of at least 1 Steinberg grade and none had progression. Skeletally immature patients were significantly more likely to return to activities (100% vs. 55.6%, P=0.023) and achieve a final Tonnis grade <2 (89% vs. 44%, P=0.046). CONCLUSION: Core decompression appears to alter the natural history of AVN in skeletally immature patients with SCD. Skeletal immaturity was a positive prognostic factor for the ability to return to activities without pain and achieve a lower Tonnis grade at final follow-up.

Post-operative radiculitis following one or two level anterior lumbar surgery with or without posterior instrumentation.

The purpose of this study was to define risk factors for non-compression radiculitis following anterior lumbar surgery with or without posterior instrumentation and to define a time to resolution. In this study, we followed 58 consecutive patients who had anterior lumbar surgery with or without posterior instrumentation. We identified those with and without post-operative radiculitis. There as a 36.5% rate of postoperative radiculitis. We found that there was a moderate to strong correlation with height change and radiculitis (p = 0.044). Additionally patients treated with rh-BMP2 had a higher risk of developing symptoms. In all of the patients who developed postoperative radiculitis, symptoms resolved by 3 months. In conclusion 36.5% of patients developed post operative radiculitis. This was associated with the use of rh-BMP2, as well as increasing disc height through surgery. All symptoms resolved by 3 months posoperatively.

Demographics and Distal Tibial Dimensions of Suitable Distal Tibial Allografts for Glenoid Reconstruction.

PURPOSE: To evaluate whether characteristics such as age, height, weight, sex, or body mass index affected the distal tibial dimensions and radius of curvature (ROC) of a potential donor for anterior glenoid augmentation. METHODS: A retrospective review of magnetic resonance imaging of ankles without bony trauma was performed, and the anteroposterior (AP) and medial-lateral (ML) distances and ROC of the tibial plafond articular surface were measured. Demographic characteristics, including age, sex, height, weight, and body mass index, were recorded. RESULTS: A total of 141 imaging studies were included (73 men and 68 women; average age, 38.2 ± 12.65 years). All potential specimens accommodated harvest of a 10 × 22-mm distal tibial allograft bone block. Men had greater ML (42.74 cm [95% confidence interval (CI), 42.09-43.39 cm] vs 38.01 cm [95% CI, 37.30-38.72 cm]; P < .001) and AP (38.16 cm [95% CI, 37.47-38.85 cm] vs 34.57 cm [95% CI, 33.97-35.17 cm]; P < .001) dimensions. Significant moderately positive correlations were found for AP dimensions with height (r = 0.584, P < .001) and weight (r = 0.383, P < .001) and for ML dimensions with height (r = 0.711, P < .001) and weight (r = 0.467, P < .001). ROC was positively correlated with height (r = 0.509, P < .001) and weight (r = 0.294, P < .001). Patient age was not related to either the AP or ML distal tibial dimensions or ROC. CONCLUSIONS: After magnetic resonance imaging analysis, all potential donors permitted harvest of a standard-sized distal tibial allograft irrespective of sex or common anthropometric measures, and 85.8% showed distal tibial morphology acceptable for glenoid augmentation. AP and ML graft dimensions and ROC correlated significantly with height and weight. LEVEL OF EVIDENCE: Level II, diagnostic study.

Harvesting Autogenous Cancellous Bone Graft from the Anterior Iliac Crest.

Autograft bone graft harvest is an important surgical technique in the armamentarium of the orthopaedic surgeon. The iliac crest can provide a robust amount of bone graft, but using it carries a risk of complications including neurologic injury, gait disturbance, sensory dysesthesia, and ilium fracture. We present a surgical technical involving harvest of cancellous bone graft from the anterior iliac crest that minimizes the complication profile associated with tricortical bone graft harvest. It should be noted that there are differences between the outcomes of anterior and posterior crest harvests. Anterior autograft harvest is associated with a higher complication rate, with more iliac wing fractures, postoperative hematomas, and sensory disturbances. The posterior approach, however, is associated with more postoperative pain than the anterior approach, with the patient often experiencing more pain from the harvest than from the procedure itself. The all-cancellous iliac crest bone graft harvest provides the benefit of a large quantity of autogenous bone for various procedures, ranging from spinal fusion to osseous reconstruction. The major steps of this procedure are (1) offset of the surgical incision, (2) exposure of the iliac crest while avoiding neurologic structures, (3) identifying the location of and performing a corticotomy of the iliac crest, (4) harvesting the cancellous bone graft using curets, (5) obtaining hemostasis, and (6) performing a layered closure. The postoperative course entails immediate weight-bearing as tolerated. There is a potential for complications, which are discussed at the individual points of concern during this video.