Langerhans Cell Histiocytosis in the Pediatric Spine Requiring Stabilization: A Literature Review and Report of 3 Cases.

CASE: This report describes 3 cases of Langerhans cell histiocytosis (LCH) of the cervical and thoracic spine in patients aged 4 to 10 years. Each patient had painful lytic spinal lesions with vertebral body collapse and posterior involvement suggesting instability requiring corpectomy, grafting, and fusion. All 3 patients were doing well at their most recent follow-up without pain or recurrence. CONCLUSION: Although LCH of the pediatric spine is usually successfully treated non-operatively, we recommend corpectomy and fusion when there is instability of the spinal column and/or severe stenosis. Posterior element involvement occurred in all 3 cases and may lead to instability.

Operating Room Intervention Rates After Orthopaedic Resident-reduced Pediatric Both-Bone Forearm Fractures Relative to the Academic Calendar.

BACKGROUND: The purpose of this study was to evaluate the operating room (OR) intervention rates and quality of fracture reductions for pediatric diaphyseal both-bone forearm fractures performed by orthopaedic residents relative to the academic year. OR intervention was defined as any procedure performed in the OR, including closed reduction and casting, and was used to identify fractures that required secondary intervention after initial closed reduction performed by an orthopaedic resident in the emergency department. METHODS: A retrospective analysis identified pediatric patients presenting at our institution with both-bone forearm fractures from July 2010 to June 2016. Emergency-room sedation time, highest experience of orthopaedic resident documented to be present at the time of sedation (in postgraduate months), and frequencies of OR intervention were obtained by chart review. Fracture characteristics were determined by radiographic review. Immediate postreduction radiographs were used to measure cast indices, and adequacy of reduction was determined by postreduction angulation and translation. RESULTS: During the time period studied, 470 both-bone forearm reductions under sedation were performed by an orthopaedic resident at our institution. Of these, 41 fractures (41 patients) required 42 OR interventions (40 involved surgical fixation and 2 were repeat closed reductions). The academic year was divided into quartiles. The April to June quartile had the highest overall percentage of OR intervention (10.6%), followed by July to September (8.6%); however, there was no significant difference between quartiles in the percentages of reductions that needed OR intervention (P=0.553). There was also no correlation between the experience level of the resident performing the reduction (based on postgraduate months) and the frequency of OR intervention (P=0.244). The anteroposterior (AP) and lateral reduction grades did not vary based on quarters (P=0.584; 0.353). The ability to obtain adequate reduction and the rate of unacceptable cast index were also not significantly different between quarters (P=0.347 and 0.465). CONCLUSIONS: We found no significant difference in rates of OR intervention or the quality of reduction for pediatric both-bone diaphyseal forearm fractures treated by orthopaedic residents relative to the academic year. LEVEL OF EVIDENCE: Level III-comparative cohort study.

Safe cross-pinning of pediatric supracondylar humerus fractures with a flexion-extension-external rotation technique.

The issue of pin configuration for fixation of displaced supracondylar humerus fractures continues to be controversial. In this article, we report on a large single-surgeon 12-year series in which a flexion-extension-external rotation technique of cross-pinning was used. We retrospectively reviewed all pediatric extension-type supracondylar humerus fractures treated by a single surgeon. The cases of 214 children (mean age, 5.8 years) and 215 medial-entry pins were reviewed in the final analysis. Surgical technique involved a classic hyperflexion maneuver and placement of lateral-entry pins. Indications for medial-entry pins included instability to intraoperative torsional stress examination or medial column comminution. The elbow was then extended to no more than 60° of flexion. The glenohumeral joint was externally rotated to position the medial epicondyle directly en face to the radiographic beam before placement of a medial-entry Kirschner wire. All reviewed patients had medial-entry pin placement with a flexion-extension-external rotation technique. Mean follow-up was 13 weeks. No ulnar nerve neurapraxias were reported. Consistent protection of the ulnar nerve during percutaneous placement of a medial epicondylar pin for supracondylar humerus fracture can be accomplished with partial elbow extension and glenohumeral external rotation after placement of lateral-entry pins.

Spinal cord position in adolescent idiopathic scoliosis.

BACKGROUND: The use of thoracic pedicle screws in deformity surgery provides a stable fixation system. The concept of acceptably positioned screws includes a worrisome subset of screws that perforate the medial pedicle cortex and may result in some compromise of the spinal canal. A significant higher incidence of cortical wall penetration on the concave side compared with the convex was previously found. Although several authors assumed that the spinal cord hugs the concave pedicles when the spinal deformity is scoliosis, the position of spinal cord in adolescent idiopathic scoliosis (AIS) has not been studied in depth. METHODS: We reviewed 45 patients who were candidate for operative treatment for AIS between August 2007 and October 2010 at our institution. Posteroanterior and lateral 3-ft standing preoperative radiographs of the spine were reviewed to determine: Cobb angle of the thoracic curves, apex vertebra of the curves, and end vertebras of the curves. Magnetic resonance images were retrospectively reviewed. The lateral cord space (LCS) ratio, which reflects the relative position of the spinal cord in the spinal canal, was calculated for each level with a thoracic curve. RESULTS: The average LCS for thoracic curves of >50 degrees was 2.123. The average LCS for thoracic curves of <50 degrees was 1.551 (P=0.002). The LCS for the apex vertebra was 1.699. The LCS for the upper end vertebra and lower end vertebra were 1.212, 1.225, respectively (P<0.001). There was a statistically significant difference between right thoracic curves and left thoracic curve regarding the LCS. In right thoracic curve the LCS was 1.487 (1.487+0.45) while in left thoracic curve it was 0.761 (0.761+0.17) meaning that in both curves the spinal cord moved to the concave side of the curve. CONCLUSIONS: Our study confirms that spinal cord in AIS tend to follow the appearance of the curve with its being tethered on the concave side. The spinal cord is close to the pedicle around the apex area.

Bilateral femoral artery ischemia detected by multimodality neuromonitoring during posterior scoliosis surgery: a case report.

STUDY DESIGN: Case report. OBJECTIVE: To report a case of a bilateral femoral artery ischemia detected by neuromonitoring during posterior scoliosis surgery and to review relevant literature regarding this rare complication. SUMMARY OF BACKGROUND DATA: Lower extremity ischemia is a potentially devastating risk of posterior spinal surgery. Ischemia can be a result of thrombotic occlusion or vascular compression during patient positioning. Multimodality neuromonitoring, increasingly used to prevent neurologic injury, can also detect hypoperfusion to the extremities. To date, there have been no reports of bilateral lower extremity ischemia detected by multimodality neuromonitoring during posterior spine surgery. METHODS: A 15-year-old boy with adolescent idiopathic scoliosis underwent posterior spinal fusion with instrumentation. Intraoperative changes in somatosensory-evoked potentials and motor-evoked potentials were noted 1 hour into the case, before instrumentation or the reduction maneuver. After trouble shooting methods did not localize a technical cause for the changes, the patient's lower extremities were noted to be hypoperfused and pulseless. RESULTS: The patients was repositioned and lower extremity perfused improved. Palpable distal pulses were detected. Neuromonitoring signals returned to baseline and the surgery completed. The patient had no postoperative neurologic or vascular deficits. CONCLUSION: Lower extremity ischemia secondary to prone positioning is a rare risk of posterior spinal surgery. This is the first case report of this potentially devastating, but preventable complication detected by multimodality neuromonitoring.

Collar versus collarless cemented HD-II femoral prostheses.

A randomized prospective study was done in 1982 to evaluate the effect of a collar on the cemented femoral component. During a 2-year period, 84 patients were enrolled to receive a collared (44 hips) or a collarless (40 hips) HD-II femoral component at the time of their primary total hip arthroplasty. Three patients were lost to followup, two patients were excluded because of randomization errors, six patients had good clinical results but refused followup, and 30 patients had died. The 43 surviving patients (collar 24, collarless 19) had radiographic and clinical followups at an average of 9.6 years (range, 61-143 months). Harris hip scores were similar, with an average of 89 in the collared group and 78 in the collarless group. There were no differences in the incidence or magnitude of pain between the patients receiving a collared or collarless femoral component. The Kaplan-Meier survivorship analysis predicted an overall survival rate free of revision of 86% at 10 years. There were no statistically significant differences in survival rates between the two groups.