Clinical Outcomes Following Surgical Management of Post-Traumatic Elbow Contractures in the Pediatric Age Group: A Meta-Analysis and Systematic Review.

PURPOSE: Post-traumatic elbow stiffness is a common occurrence resulting in potentially substantial functional limitations in both daily activities and recreational endeavors. In children, this can be particularly difficult given the early stages of childhood and development and the challenges of rehabilitation. Several studies have reported favorable results of elbow contracture releases in children, resulting in improvements in outcomes. This meta-analysis aimed to determine the efficacy and safety of elbow contracture releases in the pediatric population (<18 years), along with subgroup analyses comparing age groups, operative approach, and post-traumatic versus nontraumatic etiologies. METHODS: Meta-analysis was performed with a multidatabase search (PubMed, OVID, EMBASE, and Medline) according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines on September 25, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed. RESULTS: Seven studies were included, comprising 114 post-traumatic elbow contractures. Mean age was 13.7 years. Contracture releases of the elbow led to improvements in flexion-extension arc of motion by 48º, and pronosupination arc of motion by 22º. Subgroup analysis comparing age groups of <10, 10-14 and 15-18 years showed greater improvements in flexion-extension arc in the older age group, whereas subgroup analysis comparing injury patterns revealed a larger improvement in pronosupination motion for radial head fractures. Comparing open and arthroscopic procedures, open releases had greater improvement in both flexion-extension and pronosupination motion by 18º and 21º, respectively, although there were limited patients in the arthroscopy group. CONCLUSION: Operative management of pediatric elbow contractures is effective. Older children, children with radial head fractures, and those receiving open contracture releases may be more likely to have greater improvements. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population.

Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.

Effect of tranexamic acid on shoulder surgery: an updated meta-analysis of randomized studies.

BACKGROUND: The effect of tranexamic acid (TXA) has been proven to be effective in reducing blood loss in lower limb arthroplasty. The aim of this study is to investigate the effect of TXA in shoulder surgery with the updated studies. MATERIALS AND METHODS: A systematic review and meta-analysis of all the randomized controlled trials were conducted. We compared the outcomes of patients with and without TXA. The PubMed, MEDLINE, EMBASE, and CENTRAL databases were systematically searched for relevant studies. RESULTS: A total of 14 studies, enrolling 1131 patients, were included for qualitative and quantitative analysis. Our results revealed that TXA was associated with a significant reduction in total volume blood loss (mean difference [MD]: -112.97, P = .0006), drain output (MD: -81.90, P < .00001), hemoglobin changes (MD: -0.55, P = .02), shorter operative time (MD: -6.19, P = .01), and lower risk of hematoma formation (odds ratio: -0.20, P = .01). The postoperative visual analog scale pain score was also significantly better in the TXA group (MD: -0.78, P < .00001). No significant difference was detected in length of hospital stay and incidence of thromboembolization. CONCLUSION: The usage of TXA in shoulder surgery appeared to be safe and effective in reducing blood loss without any significant complication.

Presence of anomalous flexor carpi radialis brevis (FCRB) in Madelung's deformity.

An anomalous flexor carpi radialis brevis (FCRB) muscle was present in four of nine patients undergoing surgery for Madelung's deformity. This disproportionately frequent finding suggests an embryologic dysgenesis of forearm formation rather than a developmental tethering of Vicker's ligament.Level of evidence: IV (case series).

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review.

Background: Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae. Methods: A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed. Findings: Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%. Conclusion: Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

Median Nerve Palsy in Pediatric Supracondylar Humerus Fractures Recovers Faster With Open Than Closed Reduction.

BACKGROUND: Management of supracondylar humerus fractures (SCHF) with coexisting median nerve injury is controversial. Although many nerve injuries improve with the reduction and stabilization of the fracture, the speed and completeness of recovery are unclear. This study investigates median nerve recovery time using the serial examination. METHODS: A prospectively maintained database of SCHF-related nerve injuries referred to a tertiary hand therapy unit between 2017 and 2021 was interrogated. Factors related to the injury (vascularity, Gartland grade, open vs. closed fracture) and treatment (fixation modality, adequacy, timing of reduction, vascular and nerve intervention, and secondary procedures) were assessed.Primary outcomes were the motor recovery of Medical Research Council (MRC) grade 4 or 5 in flexor pollicis longus or flexor digitorum profundus (index) and detection of the 2.83 Semmes Weinstein monofilament.A retrospective clinical note review of all SCHF presenting during the same period was also conducted. RESULTS: Of 1096 SCHF, 74 (7%) had an associated median nerve palsy. Twenty-one patients [mean age 7 years (SD 1.6)] with SCHF-related median nerve injuries underwent serial examination. Nineteen (90%) were modified Gartland III or IV, and 10 (48%) were pulseless on presentation. The mean follow-up was 324 days.The mean motor recovery time was 120 days (SD 71). Four (27%) and 2 (13%) patients had not achieved MRC grade 4 by 6 months and 2 years, respectively. Only 50% attained MRC grade 5 at 2 years.When compared with closed reduction, those who underwent open reduction recovered motor function 80 days faster (mean 71 vs. 151 d, P =0.03) and sensory function 110 days faster (52 vs. 162, P =0.02). Fewer patients recovered after closed reduction (8 of 10) than open (5 of 5).Modified Gartland grade, vascular status, adequacy of reduction, and secondary surgery were not associated with recovery time. CONCLUSIONS: Median nerve recovery seems to occur slower than previously thought, is often incomplete, and is affected by treatment decisions (open vs. closed reduction). Retrospective reporting methods may overestimate median nerve recovery. LEVEL OF EVIDENCE: Level III-therapeutic.

Minimizing Surgeon Radiation Exposure During Operative Treatment of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Orthopaedic surgeons are exposed to high levels of radiation, which may lead to higher rates of cancer among orthopaedic surgeons. There are a series of techniques currently practiced to pin supracondylar humerus fractures including pinning the arm on the C-arm itself, using a plexiglass rectangle or a graphite floating arm board; however, the variation in radiation exposure to the surgeon is unknown. We aimed to determine how the position of the C-arm affects radiation exposure to the surgeon during the treatment of a pediatric supracondylar humerus fracture. MATERIAL AND METHODS: A simulated operating room was created to simulate a closed reduction and percutaneous pinning of a supracondylar humerus fracture. A phantom model was used to simulate the patient's arm. We assessed performing the procedure with the arm on plexiglass, graphite, or on top of the C-arm image receptor. The C-arm was positioned either with the source down and image receptor up (standard position) or with the source up and image receptor down (inverted position). Radiation exposure was recorded from levels corresponding to the surgeon's head, midline, and groin. The estimated effective dose equivalent was calculated to account for the varying radiation sensitivity of different organs. RESULTS: We found the effective dose equivalent, or the overall body damage from radiation, was 5.4 to 7.8% higher than the surgeon when the C-arm was in the inverted position (source up, image receptor down). We did not find any differences in radiation exposure to the surgeon when the arm was supported on plexiglass versus graphite. CONCLUSION: The C-arm positioned in the standard fashion exposes the surgeon to less damaging radiation. Therefore, when the surgeon is standing, we recommend using the C-arm in the standard position. CLINICAL RELEVANCE: Orthopaedic surgeons who stand should use the C-arm in the standard position to pin supracondylar humerus fractures to lower the risk of ionizing radiation exposure.

Closed Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

Background: The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV)1-4. The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. Description: A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Alternatives: Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction5. Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. Rationale: This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. Expected Outcomes: This technique provided satisfactory clinical outcomes in our previous study6, with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. Important Tips: The steps need to be followed sequentially as described in order to achieve an anatomical reduction.After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex.This technique may not work in complex fractures with elbow dislocation because of the lack of ligamentous integrity.In the final step, the elbow is pronated and flexed simultaneously, with sustained pressure over the radial head in order to obtain further correction. This is the most critical step of the technique because anatomic reduction of the partially reduced fracture is achieved at this time. Acronyms and Abbreviations: Percut. = percutaneousAP = anteroposteriorCR = closed reductionORIF = open reduction and internal fixation.

Role of Tranexamic Acid in Arthroscopic Osteocapsular Release of the Elbow for Degenerative Arthritis.

Background: Minimizing intra-articular bleeding and swelling is crucial in preventing the development of stiffness around the elbow. Tranexamic acid (TXA) has been shown to be an effective adjunct in reducing perioperative bleeding after surgery. Purpose: To determine the effect of intravenous (IV) TXA on postoperative drain tube output in arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of 83 consecutive patients with primary degenerative elbow arthritis who underwent an arthroscopic osteocapsular release between 2015 and 2018. They organized patients into a no-TXA group (control) and a group that was given 1.0 g of IV TXA before tourniquet release. The primary outcome measure was drain tube output, and secondary outcome measures included postoperative day 1 pain levels on a visual analog scale and early range of motion at 8 weeks. Differences between groups were analyzed using 1-way analysis of variance, the Mann-Whitney U test, or the Fisher exact test. Results: There were 43 patients in the no-TXA group and 40 patients in the TXA group. Administration of IV TXA resulted in a 51% decrease in mean intra-articular bleeding for the TXA group, as measured via drain tube output (88.8 ± 80.5 mL [no-TXA] vs 43.4 ± 52.4 mL [TXA]; P = .0016). In both groups, there were significant increases in elbow arc of motion when compared with preoperative measurements. There were no between-group differences in early range of motion (129.7° ± 12.4° [no-TXA] vs 131.7° ± 9.2° [TXA]; P = .549) or postoperative pain (1.9 ± 2.2 [no-TXA] vs 1.5 ± 1.7 [TXA]; P = .89). Conclusion: In this study, IV TXA significantly reduced postoperative intra-articular bleeding in patients who underwent arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. However, there were no differences in postoperative range of motion or pain between patients who received TXA and controls.

Arthroscopic Ulnohumeral Joint Debridement and Transolecranon Microfracture for Osteochondritis Dissecans of the Humeral Trochlea.

Osteochondritis dissecans of the humeral trochlea is a rare cause of elbow pain adolescents. Despite being a juvenile form of osteochondritis dissecans, spontaneous resolution is not uniform, and more than one-half of patients experience ongoing pain, crepitus and loss of motion. Traditionally, nonsurgical management has been favoured as distal trochlea articular lesions were only accessible via olecranon osteotomy. Consequently, the threshold for intervention is high as the recovery prolonged. We present our technique of accessing the trochlear osteochondritis dissecans via ulnohumeral joint arthroscopy with transolecranon microfracture, which enables these lesions to be managed with reduced morbidity.

Close Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

INTRODUCTION: Radial neck fractures account for 5-10% of paediatric elbow trauma. Radial neck fractures have been classified by Judet into five types (I-IVb). There is a global agreement to reduce radial neck fractures with angulation more than 30° (Type III, IVa and IVb). Various maneuvers have been described but none of them uniformly achieved complete reduction in severely displaced radial neck fractures (Type IVa and Type IVb Judet). In this case series, we are presenting our experience with close reduction of ten severely displaced paediatric radial neck fractures to achieve complete anatomical reduction. METHODS: We attempted close reduction in ten consecutive children with average age of 8.59 ± 1.68 years (range, 6-12 years) who presented with severely displaced radial neck fracture (Type IVa and IVb Judet). There were five girls. All patients had close injuries and presented to us within 24-48 h. One of the patients had associated undisplaced lateral condyle fracture. We have excluded two patients with associated elbow dislocation. Close reduction was performed within 48 h of initial injury. RESULTS: We were able to obtain complete anatomical reduction in all of our patients with this technique. None of the patients required fixation of fracture. At 1 year of follow-up, (12 ± 2.07 months, range 9-16 months) all patients demonstrated almost full range of elbow and forearm motion. Final radiographs revealed complete union without any evidence of avascular necrosis. CONCLUSION: This technique offers an option of close reduction for the most severely displaced radial neck fractures, which were otherwise being treated by surgical intervention. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s43465-020-00168-6) contains supplementary material, which is available to authorized users.

Sprengel's deformity: an analysis of surgically and nonsurgically treated patients.

BACKGROUND: Sprengel's deformity is a congenital anomaly of the scapula and can be associated with reduced shoulder mobility and esthetic concerns. Controversies remain regarding its natural history, radiographic findings, and optimal treatment strategy. METHODS: A total of 74 Sprengel's shoulders in 71 patients presenting to a pediatric referral hospital were retrospectively reviewed including 24 surgically treated shoulders. Median age at initial presentation was 3.8 years. Median age at the final follow-up was 9.6 years. RESULTS: Twenty shoulders were analyzed for range of motion across time. The median composite abduction range was initially 105° and at the last time-point 98°, with a median loss of 15° over 5 years (P = .007). A total of 26% of the nonsurgical shoulders reported pain at the latest follow-up, compared with 1 surgical patient (4%) (P = .028). Older age was independently associated with pain (P < .001); this effect was only seen in nonsurgical patients. Radiographically, the glenoid inclination angle (GIA) independently correlated with the abduction range (P = .001). Surgically treated shoulders underwent a modified Woodward procedure at a median 4.8 years of age. At a median follow-up of 41 months, the abduction range improved in the surgical group from 90° preoperatively to 110° postoperatively, with a median gain of 40° (P < .001). The median GIA changed from -2° to 4° with a median gain of 9° (P = .004). CONCLUSIONS: The natural history of untreated Sprengel's deformity may be one of gradual decline in the abduction range, with a proportion of patients developing pain in adolescence. The GIA correlates with the shoulder abduction range. Surgery with a modified Woodward procedure may alter the natural history of the condition by improving motion and reducing risk of pain later in life.

Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review.

BACKGROUND: Proximal humeral fractures are difficult injuries to treat and obtain satisfactory outcomes. For those treated with arthroplasty, humeral fracture stems have been popular due to better ability for reduction and fixation of tuberosities. This study aims to investigate the outcomes of fracture stems in shoulder arthroplasty for proximal humeral fracture and the comparison of outcomes between fracture vs. nonfracture stems. METHODS: A meta-analysis was conducted with a multidatabase search (PubMed, OVID, EMBASE, Medline) according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines on May 19, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed. FINDINGS: Eleven studies were included for analysis, including 383 hemiarthroplasties (HA) (294 fracture stems, 89 nonfracture stems) and 358 reverse total shoulder arthroplasties (RTSA) (309 fracture stems, 49 nonfracture stems). At the final follow-up, meta-analysis shows favorable overall ASES score in all fracture stem prosthesis (mean = 74.0, 95% confidence interval [CI]: 69.3-78.7), Constant-Murley score (mean = 67.2, 95% CI: 61.6-72.8), external rotation (mean difference [MD] = 7°, 95% CI: 3°-10°, P < .001), and forward flexion (MD = 17°, 95% CI: 10°-25°, P < .001). Pooled proportion (PP) of greater tuberosity healing (PP = 0.786, 95% CI: 0.686-0.886) was high, whereas all-cause revisions (PP = 0.034, 95% CI: 0.018-0.061) remained low. With the exception of RTSA scapular notching (PP = 0.109, 95% CI: 0.020-0.343), other complication metrics had PP of ≤0.023. In the 4 studies comparing fracture (138 HA, 54 RTSA) vs. nonfracture stems (89 HA, 49 RTSA), fracture stems had statistically significant better American Shoulder and Elbow Surgeons scores (MD = 14.29, 95% CI: 8.18-20.41, P < .001), external rotation (MD = 6°, 95% CI: 2°-9°, P = .003), forward flexion (MD = 16°, 95% CI: 7°-24°, P < .001), and greater tuberosity healing (odds ratio = 2.20, 95% CI: 1.28-3.77, P = .004). There was no statistically significant difference in complications. CONCLUSION: Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. The use of fracture stems is also associated with greater chance of tuberosity healing compared with nonfracture stems. There is increasing evidence to suggest the superiority of fracture stems over nonfracture stems in clinical outcomes, while maintaining similar complication rates.

Single-Bone Forearm as a Salvage Procedure in Recalcitrant Pediatric Forearm Pathologies.

PURPOSE: To report on the outcome of single-bone forearm reconstruction (SBFR) as a salvage procedure in pediatric forearm pathologies. METHODS: Twenty-eight forearms in 27 patients (median age, 9.6 years; range, 3.4-29.7 years) treated with SBFR at a pediatric referral center were included in the study. Records and radiographs were retrospectively analyzed. Median follow-up was 84 months (range, 24-261 months). The most common underlying condition was multiple hereditary exostoses (MHEs) (17 of 28), followed by brachial plexus birth injury (5 of 28), Ollier disease (2 of 28), congenital radial head dislocation (2 of 28), and others (2 of 28). RESULTS: By 4 months (range, 2-10 months) after surgery, 21 of 28 forearms had united. Median resting postoperative forearm rotation was 10° pronation (range, neutral to 25° pronation). Before surgery, pain was present in 23 of 28 forearms. At the latest follow-up, pain was present in 5 of 28 forearms. In three of the 5 forearms with residual pain, this was attributed to ulnohumeral degenerative changes that existed prior to SBFR. Following SBFR, elbow flexion-extension range was maintained. In the subgroup with MHEs, radial articular angle was maintained (median, 37°-30°) and carpal slip percentage improved significantly (median, 40%-12%). Complications occurred in 8 forearms: 3 cases of nonunion in older patients (age, 30, 20, and 14 years), 2 cases of traumatic juxtaimplant fractures following successful union, 1 case of infection, 1 case of compartment syndrome, and 1 case of persistent radiocapitellar impingement. All complications were successfully treated. When stratified by age, none of the patients in the younger group (16 forearms, age < 12 years) had nonunions or pain at latest follow-up. CONCLUSIONS: The SBFR is an old, but generally reliable, option as a single-stage salvage procedure for a number of recalcitrant pediatric forearm pathologies. Success rate may be higher in younger patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of Gustilo-Anderson Type II and IIIA Open Long Bone Fractures in Children: Which Wounds Require a Second Washout?

INTRODUCTION: Timing of wound closure in pediatric Gustilo-Anderson grade II and IIIA open long bone fracture remain controversial. Our aims are (1) to determine the proportion of patients with these fractures whose wounds can be treated with early primary wound closure (EPWC); (2) to compare the complication rates between EPWC and delayed wound closure (DWC); and (3) to determine factors associated with higher likelihood of undergoing DWC. PATIENTS AND METHODS: At a level-1 pediatric trauma center, 96 patients (younger than 18 y) who sustained Gustilo-Anderson grade II and IIIA open long bone fractures (humerus, radius, ulnar, femur, or tibia) within a 10-year period (2006-2016) were included for this study. Decision for EPWC versus DWC was at the discretion of the attending surgeon at time of initial surgery. Data collection was via retrospective review of charts and radiographs. Particular attention was paid to the incidence of return to operating room rate, nonunion, compartment syndrome, and infection. Median follow-up duration was 7.5 months (interquartile range: 3.6 to 25.3 mo). All patients were followed-up at least until bony union. RESULTS: Overall, 81% of patients (78/96) underwent EPWC. Of the grade II fractures, 86% underwent EPWC. Four patients (5%) in the EPWC group and 1 patient (6%) in the DWC group had at least 1 complication. When controlling for mechanism of injury, Gustilo-Anderson fracture type and age, there was no difference in rate of complications between the EPWC and the DWC groups. Grade IIIA fractures and being involved in a motor vehicle accident were factors associated with a higher likelihood of undergoing DWC. CONCLUSION: The majority of grade II and IIIA pediatric long bone fractures may be safely treatable with EPWC without additional washouts. Future prospective research is required to further define the subgroups that can benefit from DWC. LEVEL OF EVIDENCE: Level IV-therapeutic, case cohort study.

Brachial Plexus Birth Injury in the Preterm Infant: Suspecting the Unsuspected.

BACKGROUND: Prematurity is usually considered as a protective factor for brachial plexus birth injury (BPBI). However, BPBI can occur in the preterm infant, and can cause significant dysfunction and morbidity. There is scant literature regarding this subgroup of patients with BPBI. METHODS: Patients were identified through a retrospective search of a prospective BPBI registry at a single tertiary pediatric referral center. Prematurity was defined as birth at or before gestational age of 36 (6/7) weeks. Thirty-six arms in 34 patients were included in this study. Data were obtained from patient charts documenting standardized brachial plexus clinical examinations at each visit, medical imaging, questionnaires for parents, and outside perinatal records brought in by parents. RESULTS: The youngest infant identified with BPBI was born at 23 weeks' gestation. Median birth weight was 3005 g (range: 580 to 4600 g). Twenty-nine arms in 28 patients were categorized into the "late preterm group" [34 to 36 (6/7) weeks gestation], and 7 arms in 6 patients were categorized into the "early preterm group" (<34 wk). Four of 6 (67%) subjects in the early preterm group were delivered vaginally in the breech position, compared with 4 of 28 subjects (14%) in the late preterm group (P=0.02). All 3 twin gestation infants with BPBI were the younger twin and born vaginally in the breech position. Delayed diagnosis (>7 d) occurred in 11 arms in 10 subjects (31%). Median delay in diagnosis was 73 days (range: 10 to 1340 d). Spontaneous recovery of antigravity elbow flexion occurred in 65% of arms (at median 5 mo, range: 1 to 17 mo). Overall, 89% (32/36) of arms with BPBI had residual neurological deficit and 53% (19/36) of arms underwent at least 1 surgical intervention at latest follow-up (median age at latest follow-up: 60 mo, range: 1 to 237 mo). CONCLUSIONS: BPBI in preterm infants is rare but does occur and can cause significant morbidity. Delayed diagnosis of BPBI is common in preterm infants. A high index of suspicion should be maintained to avoid delayed diagnosis that may jeopardize treatment options. Preterm infants may be more susceptible to birth trauma from breech deliveries and shoulder dystocia, as evidenced by far higher incidence of these factors compared with term infants with BPBI in literature. LEVEL OF EVIDENCE: Level IV-case series.

Congenital Pseudarthrosis of the Fibula: Controlling Ankle Valgus in a Heterogenous Condition.

BACKGROUND: Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature. METHODS: Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery. RESULTS: The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P<0.05). In the absence of surgical intervention, group 1 patients did not undergo progressive ankle valgus (defined as the valgus change in tibiotalar angle by ≥4 degrees), whereas all patients in groups 2 and 3 did (P<0.001). Fibular osteosynthesis was performed in 6 patients, with union seen only in group 1 patients. Ten patients underwent distal tibiofibular fusion, with no cases of nonunion seen. Distal tibiofibular fusion with or without medial distal tibial hemiepiphysiodesis halted the progression of ankle valgus in 8 of the 10 patients. Further progression of ankle valgus occurred only in patients who did not undergo concurrent medial distal tibial hemiepiphysiodesis and with considerable wedging of the distal tibial epiphysis at the time of fusion. CONCLUSIONS: Tibial dysplasia and CPF are intimately related. Grouping patients on this basis may help guide natural history and treatment and may explain discrepancies in findings in the literature. Fibular osteosynthesis, distal tibiofibular fusion, and medial distal tibial hemiepiphysiodesis may all have an important role in the treatment of CPF. LEVEL OF EVIDENCE: Level IV-case series.

Early Radiographic Healing and Functional Results After Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum: Introduction of a New Magnetic Resonance Imaging-Based Scoring System.

BACKGROUND: Autologous osteochondral grafting (OG) is an option in the treatment of capitellar osteochondritis dissecans (COCD). However, radiographic healing after this procedure has not been well documented. PURPOSE: To develop a magnetic resonance imaging (MRI)-based scoring system specific for evaluating healing after single-plug OG in COCD and to evaluate correlation between radiographic healing and early clinical outcomes. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Between 2014 and 2017, 183 elbows with COCD were enrolled in a prospective registry. A total of 61 elbows in 59 patients underwent single-plug OG. Of these, 52 elbows in 50 patients had pre- and postoperative MRI scans. Postoperative MRI and clinical outcome data from this group were used to develop the novel BOGIE score (Boston Osteochondral Graft Incorporation in the Elbow), with a possible range of 4 to 12. RESULTS: Median age at surgery was 14.2 years (interquartile range, 13.1-15.0 years). Median clinical follow-up after OG was 12.4 months (interquartile range, 9.5-16.9 months; range, 6-53 months). Compared with before surgery, elbow function at 6 months after surgery and at latest follow-up was significantly improved as measured by the Timmerman and Andrews score (TAS; median: 145 before surgery, 185 at 6 months after surgery, 190 at latest follow-up; P < .001, before vs after surgery), as well as the short version of Disabilities of the Arm, Shoulder and Hand score; median: 21 before surgery, 7 at 6 months after surgery, and 0 at latest follow-up; P < .001 before surgery vs after surgery). Median BOGIE score at 6 months after surgery was 10 (range, 4-12). BOGIE score intraobserver reliability was 0.90 (95% CI, 0.82-0.94) for reader 1 and 0.91 (95% CI, 0.86-0.95) for reader 2. Interobserver reliability between the readers was 0.86 (95% CI, 0.78-0.92). Correlation was observed between the 6-month BOGIE score and the concurrent postoperative objective TAS (P < .001) as well as total TAS (P = .01) but not the subjective TAS (P = .08). Patients who underwent subsequent secondary surgery for persistent symptoms had a significantly lower postoperative BOGIE score at 6 months than those who did not (median, 7.8 vs 10.3; P = .016). CONCLUSION: Quantitative evaluation for radiologic healing after single-plug OG in COCD is possible. The MRI-based BOGIE score appears to correlate with early clinical function and may be useful as an adjunct tool in decision making on activity progression. The use of a standardized MRI score may improve comparability of outcomes after OG in the literature.

Surgical Management of Fibroadipose Vascular Anomaly of the Lower Extremities.

BACKGROUND: Fibroadipose vascular anomaly (FAVA) is a recently-defined vascular malformation often involving the extremities and presenting in childhood. Patients may present to orthopaedic surgeons with pain, swelling, joint contractures, and leg length discrepancy. There is no established therapy or treatment paradigm. We report on outcomes following surgical excision for patients with this condition. METHODS: Between 2007 and 2016, all 35 patients that underwent excision of lower-extremity FAVA were retrospectively reviewed using a combination of medical records, radiologic findings, and telemedicine reviews. RESULTS: Mean age at initial presentation was 12.3±6.8 years. Mean follow-up from time of definitive diagnosis at our institution was 66 months (range: 12 to 161 mo). Mean follow-up after surgery was 35 months (range: 6 to 138 mo). Females were affected more than males (71% vs. 29%). The most common location of FAVA was in the calf (49%), followed by the thigh (40%). The most commonly involved muscle was gastrocnemius (29%), followed by the quadriceps (26%). At latest follow-up after surgery, there was an improvement in the proportion of patients with pain at rest (63% vs. 29%), pain with activity (100% vs. 60%), as well as analgesia use (94% vs. 37%). Fourteen patients (40%) had symptomatic residual disease or recurrence of FAVA requiring further treatment. Six patients (17%) required further surgery and 6 (17%) required further interventional radiologic procedures. Three patients (9%) required eventual amputation for intractable pain and loss of function. Lesions with direct nerve involvement were associated with persistent neuropathic symptoms at latest follow-up (P=0.002) as well as symptomatic residual disease and/or recurrence requiring further treatment (P=0.01). Seventeen patients (49%) had 19 preoperative joint contractures. Eighteen of the 19 contractures (95%) had sustained improvement at latest follow-up. CONCLUSIONS: In carefully selected patients, surgical excision of FAVA results in improvement of symptoms. However, symptomatic residual disease and/or recurrence are not uncommon. Direct nerve involvement is associated with a worse outcome. LEVEL OF EVIDENCE: Level IV-case series.