Magnetically Driven Intramedullary Limb Lengthening in Patients with Pre-existing Implanted Programmable Devices: A Case Series.

Aim: The aim of the study is to demonstrate the safety and efficacy of the use of magnetically controlled intramedullary nails in patient with programmable implantable devices. Background: Magnetically driven intramedullary limb lengthening devices have revolutionised the field of limb reconstruction. Because the system is powered by strong magnets, there are warnings to avoid the use of the device in patients with implanted programmable devices, such as cardiac pacemakers. Materials and methods: Four patients with three different types of programmable implanted devices presented to two centres for limb lengthening and limb reconstruction. Each patient had a limb length discrepancy and desired correction using an intramedullary lengthening device. After thorough counselling about the potential risks and benefits of the procedure as well as discussions with each patient's medical team, the decision to proceed with surgery was made. Results: All four patients underwent osteoplasty with insertion of a magnetically driven intramedullary lengthening nail. Goal length was achieved with successful consolidation and subsequent nail removal in all patients. There were no malfunctions of the implantable devices during the distraction phase in any of the patients. Conclusion: With proper precautions, intramedullary lengthening can be performed safely and successfully using a magnetically driven nail in patients with previously implanted programmable devices. Clinical significance: This initial experience suggests use of magnetically controlled intramedullary nails in patient with programmable implantable devices can be undertaken safely within constraints of precautions. How to cite this article: Iobst CA, Hatfield DN, Forro SD, et al. Magnetically Driven Intramedullary Limb Lengthening in Patients with Pre-existing Implanted Programmable Devices: A Case Series. Strategies Trauma Limb Reconstr 2023;18(2):111-116.

Pediatric Limb Lengthening and Reconstruction Surgical Coding Survey Results.

BACKGROUND: In surgical specialties like orthopaedics, documenting the surgery performed involves applying the appropriate current procedural terminology (CPT) code(s). For limb reconstruction surgeons, the wide-ranging types of surgeries and rapid evolution of the field create a variety of factors making it difficult to code the procedures. We sought to (1) assess whether appropriate limb reconstruction codes currently exist and (2) determine whether there is agreement among experienced pediatric orthopaedic surgeons when applying these codes to similar cases. METHODS: A REDCAP survey comprised of 10 common pediatric limb reconstruction cases was sent to experienced pediatric limb reconstruction surgeons in the United States. Based on the description of each case, the surgeons were asked to code the cases as they usually would in their practice. There were no limitations regarding the number or the types of codes each surgeon could choose to apply to the case. Nine additional demographic and general coding questions were asked to gauge the responding surgeon's coding experience. RESULTS: Survey participants used various codes for each case, ranging from only 1 code to a maximum of 9 codes to describe a single case. The average number of codes per case ranged from 1.2 to 3.6, with an average of 2.5 among all 10 cases. The total number of unique codes provided by the respondents for each case ranged from 5 to 20. Only 3 of the 10 cases had an agreement >75% for any single code, and only 2 of the 10 cases had >50% agreement on any combination of 2 codes. CONCLUSIONS: There are dramatic variations in coding methods among pediatric orthopaedic limb reconstruction surgeons. This information highlights the need to improve the current CPT coding landscape. Possible solutions include developing new codes that better represent the work done, developing standardized guidelines with the existing codes to decrease variation, and improving CPT coding education by developing limb reconstruction coding "champions." LEVEL OF EVIDENCE: Level V.

Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient.

Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.

Early Weight-bearing Accelerates Regenerate Bone Mineralisation: A Pilot Study Comparing Two Post-operative Weight-bearing Protocols Following Intramedullary Limb Lengthening Using the Pixel Value Ratio.

Introduction: Limb lengthening is increasingly accomplished by internal lengthening nails. Previous versions of the magnetic lengthening nails made from titanium alloy allowed limited weight-bearing. In contrast, the newer nails made of stainless steel allow increased weight-bearing. An objective comparison of the rate of healing of the regenerate bone based on the weight-bearing capabilities of these two types of lengthening nails has not been evaluated. The hypothesis for the study is that earlier commencement of full weight-bearing in patients treated with the stainless steel STRYDE® nail will lead to faster healing of the regenerate bone during intramedullary limb lengthening compared with those treated with the titanium PRECICE® nail. Materials and methods: Thirty patients, divided into two groups of 15 each, underwent antegrade intramedullary lengthening of the femur using a magnetic lengthening nail between May 2017 and November 2020. The pixel value ratio (PVR) obtained from serial digital radiographs was used to quantitatively determine the regenerate bone's mineralisation rate. We compared the rate of healing of the regenerate bone in both groups of patients using the PVR. Results: Patients treated with the STRYDE® nail achieved unassisted full weight-bearing significantly earlier than patients treated with the PRECICE® nail (12 weeks vs 17 weeks for STRYDE® and PRECICE® nail-lengthened patients, respectively, p = 0.003). There was no difference in the PVR between both groups of patients at the time of full weight-bearing (p = 0.0857). However, patients treated with the STRYDE® nail attained a PVR of 1 significantly earlier than those treated with the PRECICE® nail (0.0317). Conclusion: The STRYDE® nail provides an earlier return of function and full weight-bearing compared with the PRECICE® lengthening nail. Earlier commencement of weight-bearing ambulation leads to more rapid mineralisation of the regenerate bone in patients undergoing intramedullary limb lengthening. How to cite this article: Bafor A, Duncan ME, Iobst CA, et al. Early Weight-bearing Accelerates Regenerate Bone Mineralisation: A Pilot Study Comparing Two Post-operative Weight-bearing Protocols Following Intramedullary Limb Lengthening Using the Pixel Value Ratio. Strategies Trauma Limb Reconstr 2022;17(3):148-152.

Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE).

BACKGROUND: Intramedullary lengthening nails have shown excellent short-term results. The FITBONE and the PRECICE nail are the two most commonly used intramedullary lengthening nails. The manufacturer of each nail recommends the removal of the implant after the completion of the treatment. Despite the need for removal of each nail, the authors are not aware of any prior publications documenting the results of standard intramedullary lengthening nail removal. Therefore, the aim of this study was to examine the intraoperative and postoperative complications of elective intramedullary lengthening nail removals. MATERIALS AND METHODS: We performed a retrospective chart review of patients operated with intramedullary lengthening nails at two limb reconstruction centres (one in the United States, and the second in Denmark). Data retrieved from the patient charts included patient demographics, nail information and any complications occurring at or after nail removal. Only lower limb lengthening with FITBONE and PRECICE or STRYDE nails that had an elective nail removal was included. RESULT: A total of 271 elective nail removals were included in the study. Complications occurred during 3% of the nail removals and in 13% after nail removal. There were 18 reported cases with postoperative knee pain. All these patients had nail removal through the knee joint, representing 8% of the retrograde femur nail removals and 7% of the tibia nail removals. Four postoperative fractures occurred, of which two needed surgery. Eleven percent of femur removals and 26% of tibial removals sustained a complication. CONCLUSION AND CLINICAL SIGNIFICANCE: This study emphasises the importance of adequate follow-up of the bone lengthening patient even after the nail has been removed. It also shows that the recommended removal of the intramedullary nail (IMN) lengthening nails must be included in studies reporting on the overall risks of complications using bone lengthening nails. HOW TO CITE THIS ARTICLE: Frost MW, Kold S, Rahbek O, et al. Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE). Strategies Trauma Limb Reconstr 2021;16(2):110-115.

Radiographs of 366 removed limb-lengthening nails reveal differences in bone abnormalities between different nail types.

AIMS: Limb-lengthening nails have largely replaced external fixation in limb-lengthening and reconstructive surgery. However, the adverse events and high prevalence of radiological changes recently noted with the STRYDE lengthening nail have raised concerns about the use of internal lengthening nails. The aim of this study was to compare the prevalence of radiological bone abnormalities between STRYDE, PRECICE, and FITBONE nails prior to nail removal. METHODS: This was a retrospective case series from three centres. Patients were included if they had either of the three limb-lengthening nails (STYDE, PRECICE, or FITBONE) removed. Standard orthogonal radiographs immediately prior to nail removal were examined for bone abnormalities at the junction of the telescoping nail parts. RESULTS: In total, 306 patients (168 male, 138 female) had 366 limb-lengthening nails removed. The mean time from nail insertion to radiological evaluation was 434 days (36 to 3,015). Overall, 77% of STRYDE nails (20/26) had bone abnormalities at the interface compared with only 2% of FITBONE (4/242) and 1% of PRECICE nails (1/98; p < 0.001). Focal osteolysis in conjunction with periosteal reaction at the telescoping interface was only observed in STRYDE nails. CONCLUSION: Bone abnormalities at the interface of telescoping nail parts were seen in the majority of STRYDE nails, but only very rarely with FITBONE or PRECICE nails. We conclude that the low prevalence of radiological changes at the junctional interface of 242 FITBONE and 98 PRECICE nails at the time of nail removal does not warrant clinical concerns. Cite this article: Bone Joint J 2021;103-B(11):1731-1735.

Retrograde Extramedullary Lengthening of the Femur Using the PRECICE Nail: Technique and Results.

BACKGROUND: Lengthening of long bones by distraction osteogenesis is now possible using intramedullary lengthening nails. Constraints of bone size, medullary canal obstruction, and the presence of an open physis are contraindications in skeletally immature patients. We present a technique describing the "off-label" use of a magnetic lengthening nail placed extramedullary and in retrograde manner, for lengthening of the femur in skeletally immature patients. METHODS: A retrospective review of 5 skeletally immature patients with significant length discrepancy of the femur are presented along with a description of the surgical technique. Data collected included age, sex, date of surgery, diagnosis, presence of associated deformities, the magnitude of length discrepancy, the amount of length gained, the amount of time to achieve full weight-bearing, the time to hardware removal, and any complications. RESULTS: There were 5 patients (3 females). The mean age was 7.2±2.7 years (4 to 10 y). The mean limb length discrepancy was 6.5±3.7 cm (3.5 to 11 cm). A mean length of 3.46±0.4 cm (3.1 to 4 cm) was achieved which represents 12.9±1.8% (10.32 to 13.47%) of the bone length. The time taken to achieve full weight-bearing ambulation was 89.2±19.3 days (60 to 109 d) or 12.7 weeks. All hardware was removed 247.6±215.6 days (99 to 628 d) after surgery. Patients were followed up for a mean duration of 19.2 months (11 to 30 mo). No supplemental fixation was required and no complications were noted. Acute deformity correction was also performed at the time of surgery in 2 patients who had distal femur valgus deformity. CONCLUSIONS: Retrograde extramedullary lengthening of the femur is an option that should be considered for limb length equalization in skeletally immature patients. It avoids the inconvenience of external fixation and can be used to simultaneously correct deformities of the distal femur. Although the total amount of length gained is modest, we believe it is a promising limb lengthening technique that merits further investigation. LEVEL OF EVIDENCE: Level III.

The Gait Outcomes Assessment List for Children With Lower Limb Difference (GOAL-LD): Assessment of Reliability and Validity.

BACKGROUND: The Gait Outcomes Assessment List for children with Lower Limb Difference (GOAL-LD) is a patient and parent-reported outcome measure that incorporates the framework of the International Classification of Functioning, Disability, and Health. This prospective multicenter cohort study evaluates the validity and reliability of the GOAL-LD and the differences between parent and adolescent report. METHOD: One hundred thirty-seven pediatric patients aged over 5 years attending limb reconstruction clinics at the participating sites were assessed at baseline, and a self-selected cohort also completed an assessment 2 to 6 weeks later. Construct and criterion validity were assessed by comparing GOAL-LD scores with a measure of limb deformity complexity (LLRS-AIM) and the Pediatric Outcomes Data Collection Instrument, using Spearman correlation coefficients. Face and content validity were determined through ratings of item importance. Test-retest reliability was reported as an intraclass correlation coefficient and internal consistency using Cronbach α. Adolescent reports were compared with their parents using paired t tests. RESULTS: The GOAL-LD demonstrated a moderate negative correlation with the LLRS-AIM (r=-0.40, P<0.001) and was able to discriminate between deformity complexity groups as defined by the LLRS-AIM (χ2=11.43, P=0.022). Internal consistency was high across all domains (α≥0.68 to 0.97). Like domains of the Pediatric Outcomes Data Collection Instrument and the GOAL-LD were well correlated. Parents reported a lower total GOAL-LD score when compared with adolescents (mean difference 3.04; SE 1.06; 95% confidence interval, 0.92-5.16; P<0.01); however this difference was only significant for body image and self-esteem (Domain F) and gait appearance (Domain D). Test-retest reliability remained high over the study period (intraclass correlation coefficient 0.85; SE 0.03; 95% confidence interval, 0.77-0.91). CONCLUSIONS: The GOAL-LD is a valid and reliable self and parent-reported outcome measure for children with lower limb difference. Parents report a lower level of function and attribute a higher importance to items when compared with their children. The GOAL-LD helps to communicate parent and child perspectives on their function and priorities and therefore has the capacity to facilitate family centered treatment planning and care. LEVEL OF EVIDENCE: Level II-diagnostic. Prospective cross-sectional and a longitudinal cohort design.

Evolving Surgical Management for Early-Onset Scoliosis in Spinal Muscular Atrophy Type 1 Given Improvements in Survival.

CASE: We present a case of an 18-month-old child with early-onset scoliosis in the setting of spinal muscular atrophy (SMA) type 1 whose rapidly progressive scoliosis is successfully managed with magnetic growing rods, the youngest age of implantation in a patient with SMA we are currently aware of. Technical challenges, complications, and outcome are described in this case presentation. CONCLUSION: Patients with SMA type 1 and early-onset scoliosis can be managed with growing-rod constructs given dramatic improvements in medical care that have expanded life expectancy.

A novel way to dynamize a spatial frame and optimize fracture healing.

BACKGROUND: Fracture site motion creates mechanical strains on the healing tissues which influences bone formation. Axial micro-motion maximizes dilatational strains, whereas shearing motions maximize deviatoric strains on the healing tissues. Dilatational strains optimize bone healing, deviatoric strains retard bone healing. Dynamization of external fixation using either an Ilizarov or Spatial Frame platform is used to increase loading on the limb which increases the mechanical stress and strain on the tissues to improve healing. The scientific literature does not address how dynamization of the spatial frame effects fracture site motion. The purpose of this study is to assess the effect of modified shoulder bolts incorporated into a spatial frame during dynamic loading. METHODS: Five identical two-ring spatial frame constructed were mounted on Sawbones tibias with an osteotomy performed distal to the tibial tubercle. Sinusoidal load was applied at a rate of 0.25 Hz. Axial force and displacement, in addition to motion of the proximal and distal tibia segments were recorded. Eight constructs were tested: 1) All struts of the Spatial Frame rigid, 2) Strut #1 loose, 3) Struts #1 and #3 loose, 4) Struts #1, #3 and #5 loose, 5) All struts loose, 6) All struts rigid with dynamization bolts on the proximal end, 7) All struts rigid with dynamization bolts on alternating sides, 8) Threaded rods between the rings with two millimeters of dynamization. RESULTS: No difference in vertical displacement was observed between the Ilizarov and all struts locked. No significant difference in shear values between all struts locked and modified shoulder bolt struts was observed. Increase in vertical movement with the modified shoulder bolts was an average of 1.83 mm. Significant shear forces at the fracture site were observed with unlocking single or multiple struts of the spatial frame. CONCLUSION: Modified shoulder bolts can be used for spatial frame dynamization without increasing shear motion.

Probability analysis of sequential SCFE (PASS score).

PURPOSE: The study aimed to develop a scoring system based on clinical and radiological findings to predict the risk of a sequential slipped capital femoral epiphysis (SCFE). METHODS: Paediatric patients with unilateral SCFE and at least two years of radiographic follow-up were screened for inclusion. Medical records were reviewed for multiple variables including age, gender, body mass index (BMI), stability of SCFE, and time to sequential presentation. Radiographic analysis included triradiate physeal status, Risser staging, superior epiphyseal extension ratio (EER), posterior epiphyseal angle (PEA), posterior sloping angle (PSA) and slip severity. RESULTS: In total, 163 patients (88 male, 54%, 75 female, 46%) met inclusion criteria. Of those, 65 (40%) with a mean age of 11.9 ± 1.3 years developed sequential SCFE at a mean of 9.8 ± 6.4 months after the initial slip. Eight independent variables were statistically different (p < 0.05) between unilateral and sequential groups. Following multivariate analysis, Risser stage and triradiate status were no longer significant and did not influence the strength of the final model (overall area under the curve (AUC) = 0.954) and were consequently excluded. We developed the PASS score using three radiographic parameters using chosen cut-off values that were close to their maximized value and weighted the point value assigned to each parameter based on the strength of predictor. CONCLUSION: A PASS score of three or higher predicts a high probability of sequential SCFE with 95% confidence and may warrant prophylactic screw fixation. PASS score calculation can be used to predict a sequential SCFE and provide an objective method to determine the utility prophylactic screw fixation. LEVEL OF EVIDENCE: II.

Opioid prescription patterns for pediatric orthopaedic fracture patients.

BACKGROUND: While hospitalizations attributed to opioid poisonings are increasing in the pediatric population, the patterns of prescribing behaviors of health care providers remains unclear. The aims of this study were to identify the opioid prescribing patterns of an orthopaedic team for post-surgical pediatric orthopaedic fracture patients, and to examine whether patient demographics, injury type, and type of providers were associated with the opioid prescribing patterns at discharge. METHODS: A retrospective chart review was performed among all patients aged 0-18 years undergoing surgery for elbow, forearm, wrist, femur, tibia and ankle fractures between 2014 and 2016 at a large children's hospital. Inclusion criteria were patients with isolated operative fractures involving the elbow, forearm, wrist, femur, tibia or ankle who received an opioid prescription at discharge prescribed by a member of the orthopaedic team. Exclusion criteria included patients discharged without opioids or patients discharged with opioid prescriptions from another medical team. RESPONSE: 1000 unique patients (546 male) were identified, with average age of 7.9 years. The most common fracture was elbow (67.2%), followed by femur (12.4%), ankle (9.4%), forearm (5.8%), wrist (4.6%), and tibia (1.6%). Average dose of opioids prescribed was 28.4 (SD = 11.5) per patient. All prescriptions followed recommended guidelines for each medication. Patients who were older (p < 0.0001) or heavier (p < 0.0001) were prescribed a significantly greater average number of opioid doses. Nurse practitioners wrote 57.0% of the discharge prescriptions, followed by residents (23.0%) and physician assistants (14.5%). Attending surgeons accounted for only 5.5% of prescriptions. Residents and physician assistants prescribed significantly higher average doses than nurse practitioners and attending surgeons (p < 0.0001). Patients receiving liquid opioids received a statistically significant (p < 0.001) smaller number of doses than patients receiving tablets. CONCLUSIONS: Pediatric orthopaedic trauma patients appear to be receiving generic numbers of opioid pain medication doses after fracture surgery due to universal rather than injury-specific prescribing patterns. Further study is required to determine the appropriate number of doses per injury type.

Evaluating the Utility of the Pixel Value Ratio in the Determination of Time to Full Weight-bearing in Patients Undergoing Intramedullary Limb Lengthening.

INTRODUCTION: Limb lengthening using intramedullary nails is an increasingly popular method of achieving limb length equalisation. Currently, the decision regarding when to commence full weight-bearing (FWB) remains largely subjective. Objective criteria for determining the proper timing of FWB would be helpful to limb lengthening surgeons. This study examines using the pixel value ratio (PVR) as an objective method to determine the time to FWB for patients being lengthened with an intramedullary nail. MATERIALS AND METHODS: A retrospective chart review of 42 patients who underwent unilateral lengthening of the femur was undertaken. The PVR of all four cortices of the regenerate bone was monitored throughout the distraction and consolidation stages to determine the ratio at the time of FWB. RESULTS: Clinically and radiologically determined FWB was achieved at a mean time of 125.7 ± 30.1 days from surgery. The mean PVR at the time of FWB was 0.94. The medial cortex healed fastest with a mean PVR of 0.96, while the posterior cortex healed slowest with a mean PVR of 0.92. CONCLUSION: The PVR is a quick and reliable method to objectively assess the state of healing of the regenerate bone during distraction osteogenesis. We observed that there were no adverse effects when subjects commenced FWB when three out of the four cortices had a PVR of at least 0.93. HOW TO CITE THIS ARTICLE: Bafor A, Duncan ME, Iobst CA. Evaluating the Utility of the Pixel Value Ratio in the Determination of Time to Full Weight-bearing in Patients Undergoing Intramedullary Limb Lengthening. Strategies Trauma Limb Reconstr 2020;15(2):74-78.

Influence of Insurance Type on the Access to Pediatric Care for Children With Distal Radius Torus Fractures.

BACKGROUND: Previous literature has demonstrated that pediatric orthopaedic patients with private insurance have less difficulty obtaining appointments than those with Medicaid. Not all injuries of an orthopaedic nature, however, require specialist care. This study evaluated the willingness of pediatricians to provide care for minor orthopaedic injuries and whether or not the patient's insurance status influenced the decision to provide care. METHODS: Ninety-nine pediatric primary care offices were randomly selected from 2 regions in Florida. Each office was contacted twice, 2 to 3 months apart, and presented with a fictionalized account of a patient that had sustained a torus ("buckle") fracture of the distal radius. In the first call, the patient was presented as having private insurance, and in the second call as having Medicaid insurance. If the patient was denied an appointment, the reason was recorded. RESULTS: Of the 99 offices, 100% were willing to treat the patient's injury if the child had private insurance, compared with 76% if the child had Medicaid. All Medicaid patient refusals were based on the insurance status of the patient. No office refused to see the patient due to the nature of the injury. Ninety-four percent of offices in South Florida were willing to see the Medicaid patient, compared with 58% in Central Florida. These differences were statistically significant (P<0.0001). CONCLUSIONS: It was previously unknown whether pediatricians felt comfortable managing minor orthopaedic injuries. This study demonstrates that 100% of the pediatricians surveyed were willing to treat a child with a distal radius buckle fracture with proper insurance. This information potentially can provide additional avenues for patients to achieve timely access to care. However, as seen in previous studies, there was a statistically significant difference in access to care for the same child with Medicaid. Until reimbursement rates for Medicaid improve, these patients will continue to have difficulty obtaining access to care to both primary care providers and specialists. LEVEL OF EVIDENCE: Prospective survey study.

Understanding Skeletal Growth and Predicting Limb-Length Inequality in Pediatric Patients.

Limb-length inequality in a child can be a complex condition for patients, parents, and medical providers. Managing these patients and explaining the treatment options to families requires knowledge of the potential risks associated with leaving a discrepancy untreated and a thorough understanding of skeletal growth. The provider must also be familiar with the available growth prediction methods as treatment is influenced by the anticipated discrepancy at skeletal maturity. This article provides an overview to skeletal growth, assessing skeletal maturity and growth prediction to help providers develop an organized and thoughtful approach to treating pediatric patients with limb-length inequalities.

New Technologies in Pediatric Deformity Correction.

The ability to correct limb deformities is one of the core elements of pediatric orthopedics. The term, orthopedics, is derived from the Greek language and means straightening (ortho) children (paidos). New advances in the evaluation and management of children with limb alignment or limb length issues are constantly appearing. This review highlights some of the recent technologies that have been developed to improve the care of these children.