Thread Delamination in 4.5 mm AO Cannulated Screws: A Small Case Series in the Pediatric Trauma Population.

BACKGROUND: Thread delamination associated with cannulated screws have been reported but likely represent an under-recognized complication in the orthopaedic literature. The purpose of this study is to report the occurrence of repeated hardware failures through thread delamination in the setting of a commonly used orthopaedic cannulated screw implant in a small cohort involving pediatric fracture care at a single academic level I trauma center. METHODS: Between August 2015 and December 2020, 9 cases of hardware failure associated with 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated stainless-steel screws were identified within a pediatric orthopaedic division at a single academic level I trauma center. Three cases were excluded, and 6 cases of thread delamination were retrospectively reviewed. RESULTS: Six cases of thread delamination comprised a cohort of patients with a mean age of 13.7 years (range: 12 to 15 y). All cases involved 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated screws, including 5 partially threaded and 1 fully threaded screw. Five cases involved open reduction and internal fixation of incarcerated medial humeral epicondylar fragments and the other case was an open reduction and internal fixation of a displaced medial malleolar fracture. Five of these occurred within a recent 18-month period of time. There were 4 cases of partial, distal thread delamination, 1 case of partial proximal thread delamination and another case of complete thread delamination which had unwound into the tibiotalar joint and required an anterior ankle arthrotomy to retrieve the thread. None of the 5 patients in this series who currently harbor a retained thread have experienced symptoms because of this issue. CONCLUSIONS: Thread delamination associated with cannulated screw implantation likely represents an under-reported phenomenon in orthopaedic surgery. In cases where retained, delaminated threads exist, these do not appear to cause short-term concern. LEVEL OF EVIDENCE: Level IV-case series.

Anatomic all-epiphyseal ACL reconstruction with "inside-out" femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction.

PURPOSE: To understand if anatomic physeal-sparing ACL reconstruction in the immature host preserves range of motion, permits a return to sports, and avoids limb length discrepancy and accelerated intra-articular degeneration with a cross-sectional radiographic, physical examination and patient-reported outcomes analysis. METHODS: A cross-sectional recall study included 38 patients aged 7-15 who underwent all-epiphyseal ACL reconstruction with hamstring allograft performed by a single surgeon at a large academic medical center. All-epiphyseal reconstructions were performed using a modified Anderson physeal-sparing technique, with the femoral tunnel placed using an "inside-out" technique. Assessments consisted of a physical exam, long leg cassette radiographs, KT-1000 measurements, subjective patient metrics, and magnetic resonance imaging. RESULTS: Thirty-eight (56.7%) of 66 eligible patients returned for in-person clinical and radiographic exams. Patients were 11.4 ± 1.8 years at the time of surgery. Five patients were females (13.2%). Mean follow-up was 5.5 ± 2.4 years. ACL re-injuries occurred in four patients (10.5%), all of whom underwent revision reconstructions. Thirty-three of the remaining 34 (97.1%) patients returned to sports following their reconstruction, and 24 (70.6%) returned to their baseline level of competition. Mean limb length discrepancy (LLD) was 0.2 ± 1.4 cm. Nine patients had an LLD of > 1 cm (26.5%), which occurred at an equivalent age as those with < 1 cm LLD (10.8 ± 2.0 vs. 11.7 ± 1.7, n.s.). Pre-operative Marx scores (13.1 ± 3.5) were not significantly different from post-operative values (12.3 ± 5.1, n.s.). Patients who required ACL revisions had significantly lower Marx scores than those with intact primary grafts (8.3 ± 7.1 vs. 13.4 ± 4.5, p = 0.047). Cohort mean International Knee Documentation Committee (IKDC) score was 89.7 ± 12.7. CONCLUSION: Anatomic all-epiphyseal anatomic ACL reconstruction appears to be useful in patients with significant projected remaining growth, with good return-to-sport outcomes and minimal risk of clinically significant physeal complications. However, given the limited patient recall possible in the present study, further large sample size, high-quality works are necessary to validate our findings. LEVEL OF EVIDENCE: Level IV.

Bilateral absence of the cruciate ligaments with meniscal dysplasia: Unexpected diagnosis in a child with juvenile idiopathic arthritis.

Bilateral agenesis of the cruciate ligaments is a rare congenital anomaly. We report a unique case of a young girl who had congenital short femur and diagnosed with polyarticular juvenile idiopathic arthritis (JIA) and later discovered to have congenital absence of both anterior and posterior cruciate ligaments and meniscal dysplasia in both the knees when MRI was performed at 11 years of age. The MRI was performed to evaluate knee laxity and persistent symptoms despite medical management and multiple steroid injections for arthritis treatment. This patient is one of the youngest with congenital absence of both the cruciate ligaments to be treated with ACL reconstruction. We highlight the unique radiographic imaging manifestations of congenital cruciate ligament agenesis and emphasize the role of MRI to confirm and depict additional intraarticular abnormalities.

Does a Weekly Didactic Conference Improve Resident Performance on the Pediatric Domain of the Orthopaedic In-Training Examination?

BACKGROUND: Performance on the Orthopaedic In-training Examination (OITE) has been correlated with performance on the written portion of the American Board of Orthopaedic Surgery examination. Herein we sought to discover whether adding a regular pediatric didactic lecture improved residents' performance on the OITE's pediatric domain. METHODS: In 2012, a didactic lecture series was started in the University of Pittsburgh Medical Center (UPMC) Hamot Orthopaedic Residency Program (Hamot). This includes all topics in pediatric orthopaedic surgery and has teaching faculty present, and occurs weekly with all residents attending. A neighboring program [UMPC Pittsburgh (Pitt)] shares in these conferences, but only during their pediatric rotation. We sought to determine the effectiveness of the conference by comparing the historic scores from each program on the pediatric domain of the OITE examination to scores after the institution of the conference, and by comparing the 2 programs' scores. RESULTS: Both programs demonstrated improvement in OITE scores. In 2008, the mean examination score was 19.6±4.3 (11.0 to 30.0), and the mean percentile was 57.7±12.6 (32.0 to 88.0); in 2014, the mean examination score was 23.5±4.2 (14.0 to 33.0) and the mean percentile was 67.1±12.1 (40.0 to 94.0). OITE scores and percentiles improved with post graduate year (P<0.0001). Compared with the preconference years, Hamot residents answered 3.99 more questions correctly (P<0.0001) and Pitt residents answered 2.93 more questions correctly (P<0.0001). Before the conference, site was not a predictor of OITE score (P=0.06) or percentile (P=0.08); there was no significant difference found between the mean scores per program. However, in the postconference years, site did predict OITE scores. Controlling for year in training, Hamot residents scored higher on the OITE (2.3 points higher, P=0.003) and had higher percentiles (0.07 higher, P=0.004) than Pitt residents during the postconference years. CONCLUSIONS: This study suggests that adding a didactic pediatric lecture improved residents' scores on the OITE and indirectly suggests that more frequent attendance is associated with better scores. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Regional Anesthesia Is Cost-Effective in Preventing Unanticipated Hospital Admission in Pediatric Patients Having Anterior Cruciate Ligament Reconstruction.

BACKGROUND AND OBJECTIVES: Published studies have shown a benefit of regional anesthesia (RA) in preventing unplanned hospital admissions (UHAs) and decreasing hospital costs after orthopedic surgeries in adults but not pediatric patients. We performed a retrospective analysis to assess the effect of converting from an opioid to RA-based approach to pain management after pediatric anterior cruciate ligament (ACL) reconstruction. METHODS: The records of patients having ACL reconstruction were reviewed. Two groups, those with (n = 115) and without (n = 39) nerve blocks, were identified. Single-shot blocks or indwelling catheters were performed in the operating room (OR) or a block room. Time to discharge readiness, postoperative opiate and antiemetic consumption, hospital admission or discharge, and complications were recorded. The cost of providing RA, the change in UHA and postanesthesia care unit utilization, and subsequent financial impact were calculated. RESULTS: Regional anesthesia-based pain management was associated with a lower rate of UHA (P = 0.045), less time in postanesthesia care unit phase II (P = 0.013), and a reduction in opioid consumption (P < 0.001). Use of a dedicated RA team with a dedicated block room resulted in cost savings or neutrality, whereas RA catheters placed in the OR were associated with increased direct hospital costs. CONCLUSIONS: Regional anesthesia for pain after ACL repair in pediatric patients facilitated reliable same-day surgery discharge and significantly reduced UHAs. Single-shot blocks and blocks performed outside the OR were the most cost-effective. In addition, nerve block patients required less opioids and were ready for discharge sooner.

Subscapular Abscess in a Nine-Year-Old Female Patient: A Case Report.

CASE: The subscapular space is a clinically concealed anatomic space where soft-tissue abscesses can form. To our knowledge, five cases of a subscapular abscess have been reported in the past thirty-four years, so there is little evidence available to guide treatment. We present a unique case of a spontaneous, subscapular abscess due to methicillin-resistant Staphylococcus aureus in a pediatric host, and we describe a surgical approach for adequate debridement. CONCLUSION: The effective treatment of a subscapular abscess depends on an accurate, rapid diagnosis and effective surgical debridement. A modified Judet approach provides adequate access to the subscapular space for debridement.

The effectiveness of ambulatory continuous peripheral nerve blocks for postoperative pain management in children and adolescents.

BACKGROUND: Ambulatory continuous peripheral nerve blocks (CPNBs) are feasible for pediatric patients. We sought to evaluate the efficacy of CPNBs in a pediatric population. METHODS: This retrospective report of 33-month prospectively collected data investigates patient, parent, and nurse pain control satisfaction score (PCSS), the incidence and severity of pain, daily analgesic consumption following discharge home with various CPNBs and On-Q pumps, and any complications and side effects related to CPNBs. RESULTS: Four hundred and three patients (403; aged 5-22) were discharged home with 410 CPNBs (brachial and lumbar plexus, femoral, sciatic, and paravertebral); 76.7% on the day of surgery. The median/interquartile range (IQR) ropivacaine continuous infusion via On-Q pump was 0.24 (0.20-0.30) mg·kg(-1)·hr(-1), and the median/IQR duration was 72 (48-72) h. The median/IQR home PCSS was 10 (9-10). Median Postoperative Ambulatory Care Unit (PACU)/IQR pain control satisfaction scores were 10 (8-10) for the patient, 10 (9-10) for the parent, and 10 (9-10) for the nurse. Thirty-three (10.0%) patients did not report any pain at home, and median maximum home/IQR pain score was 4 (2-6). In the PACU, 126 (31.3%) patients did not report any pain and median/IQR pain score was 1 (0-3). No opioids were administered at home for 12 (4.3%) patients and in the PACU for 150 (37.4%). Sixty-three (14.4%) complications and side effects for 58 patients were reported. We report 93.1% ambulatory efficacy of CPNBs. CONCLUSION: Our patients and their caregivers were very satisfied with ambulatory CPNBs. When combined with oral analgesics, CPNBs provided effective home postoperative analgesia.

Closed reduction with CT-guided screw fixation for unstable sacroiliac joint fracture-dislocation.

BACKGROUND: Unstable posterior pelvic ring fractures and dislocations are uncommon but potentially life-threatening injuries in children. Early definitive management reduces risk of immediate complications as well as chronic pain and gait dysfunction. Conventional operative therapy carries substantial risk of extensive blood loss and iatrogenic neurological and vascular injury. Minimally invasive image-guided intervention may further reduce immediate risk and improve long-term outcome. OBJECTIVE: To describe CT-guided closed reduction and internal fixation (CRIF) and review outcomes of unstable fracture-dislocation of the sacroiliac (SI) joint in children. MATERIALS AND METHODS: Between 2000 and 2003, three children (two girls, one boy) age 8-14 years were referred to interventional radiology for treatment of unstable SI joint fracture-dislocation not adequately treated with anterior external fixation alone. RESULTS: The three affected SI joints (two left, one right) were treated in a combined approach by pediatric interventional radiologists and orthopedic surgeons, using a percutaneous approach under CT guidance. Over a threaded guiding pin, 7.3 mm cannulated screws were used to achieve stable reduction of the affected SI joints. One screw was removed after slight (2 mm) migration. No neurovascular or other complications occurred. All patients had satisfactory healing with near-anatomic reduction, although recovery of the youngest was delayed by associated spinal injury. CONCLUSIONS: Compared to open surgical alternatives, CRIF under CT guidance reduces operating time, decreases blood loss, and allows early definitive fixation and immediate non-weight-bearing mobilization with a low rate of complication for unstable posterior pelvic ring fractures. In addition, CT-guided placement of the guide pin may allow safer screw positioning and may minimize the total number of screws needed to achieve pelvic stability.

Acute synovitis of the knee resulting from intra-articular knee penetration as a complication of flexible intramedullary nailing of pediatric femur fractures: report of two cases.

Management of pediatric femur fractures using flexible intramedullary nail fixation is widely accepted. Few complications have been reported in the literature; these include primarily malunions and nonunions. The authors present two cases of a previously unreported complication-acute synovitis of the knee following intra-articular penetration of the knee joint by migration of a flexible nail.