Neuroma Treatment With the Acellular Nerve Allograft Reconstruction Technique.

Treatment of a painful neuroma is a challenging problem for both the patient and the providers. Current surgical treatment options typically include excision of the neuroma and stump relation. However, with both treatment options, patients have high rates of persistent pain and rates of neuroma recurrence. We describe two patients with neuromas treated with our acellular nerve allograft reconstruction technique. This technique involves the excision of the neuroma and bridging the proximal nerve end to the surrounding tissue with an acellular nerve allograft. Both patients had immediate resolution of their neuropathic pain that was maintained at their final follow-up. Acellular nerve allograft reconstruction is a promising treatment option for the treatment of painful neuromas.

Treatment of Iatrogenic Saphenous Neuroma after Knee Arthroscopy with Excision and Allograft Reconstruction.

The treatment of postoperative, painful sensory neuromas is an ongoing challenge for surgeons. Here, we describe a technique for treatment with excision and allograft reconstruction and report on early results of its use in treating painful saphenous neuromas after knee arthroscopy. METHODS: A retrospective review of a single surgeon's peripheral nerve clinic from January 1, 2013, to December 31, 2019, was conducted to identify post-knee arthroscopy saphenous neuroma cases in which reconstruction with processed human nerve allograft distally implanted into healthy muscle belly was performed. We examined the outcomes for each patient, including subjective pain self-assessment and need for further surgical treatment. RESULTS: In total, 9 cases were identified, with patient ages ranging from 21 to 74 years. The average time to referral to peripheral nerve clinic was 31 months (range: 4-143 months). Upon exploration, all nerves were found to have a neuroma in continuity. Six of the 9 patients reported subjective improvement through final follow-up. Three of the 9 patients reported initial improvement, with recurrence of pain at/near the site of the neuroma. The average follow-up time was 9 months (range: 1-21 months). CONCLUSIONS: Here, we report on a novel technique of using a processed human nerve allograft after neuroma resection to provide an organized environment for bridging regenerated axons into muscle tissue. We also describe our early results using this technique to treat iatrogenic saphenous neuromas after knee arthroscopy. Results are encouraging, with 6 of the 9 patients experiencing subjective reduction in pain at final follow-up.

Obesity as a Predictor of Outcomes in Type III and Type IV Supracondylar Humerus Fractures.

OBJECTIVES: To investigate the association of obesity with fracture characteristics and outcomes of operatively treated pediatric supracondylar humerus fractures. DESIGN: Retrospective multicenter. SETTING: Two Level I pediatric hospitals. PATIENTS: Patients (age <18 years) with operatively treated Gartland type III and type IV fractures 2010-2014. INTERVENTION: Closed or open reduction and percutaneous pinning of supracondylar humerus fractures. MAIN OUTCOME MEASURE: Incidence of Gartland IV fracture, preoperative nerve palsy, open reduction and complication rates. RESULTS: Patients in the obese group had a significantly higher likelihood of having a Gartland IV fracture (not obese: 17%; obese: 35%; P = 0.007). There was a significantly higher incidence of nerve palsy on presentation in the obese group (not obese: 20%; obese: 33%; P = 0.03). No significant differences were found between groups regarding incidence of open reduction, compartment syndrome, and rates of reoperation. CONCLUSIONS: The present study demonstrates that obese children with a completely displaced supracondylar humerus fractures have an increased risk of Gartland type IV and preoperative nerve palsy compared with normal weight children. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pelvic Obliquity Correction in Distraction-Based Growth Friendly Implants.

DESIGN: Multicenter retrospective review. OBJECTIVE: To evaluate radiographic outcomes and complication rates of patients treated with distraction based implants and pelvic fixation with either screws (sacral-alar-iliac [SAI] screws or iliac screws) or hooks (S hook iliac fixation). SUMMARY OF BACKGROUND DATA: Multiple options exist for pelvic fixation in distraction-based growing rod systems; however, limited comparative data are available. METHODS: Early-onset scoliosis (EOS) patients of all diagnoses with distraction-based implants that had pelvic fixation from 2000 to 2013 were reviewed from two EOS multicenter databases. Patients were divided into two groups by type of pelvic fixation: (1) screw group (SAI screws or iliac screws) or (2) S hooks. Exclusion criteria were as follows: index instrumentation ≥10 years old and follow up <2 years. A total of 153 patients met the inclusion criteria. Mean age at index surgery was 6.1 years (range 1.0-9.9 years) and mean follow-up was 4.9 years. RESULTS: Pelvic fixation in the 153 patients was as follows: screw group = 42 and S hook group = 111. When comparing patients with >20° of initial pelvic obliquity, the screw group had significantly more correction; mean 26° ± 13° for the screw group versus mean 17° ± 7° in the S hook group (p = .039). There was no significant difference in change in T1-S1 length (40 vs. 39 mm, p = .89) or correction of Cobb angle (30° vs. 24°, p = .24). The total complication rate for the screw group was 14% (6/42) versus 25% (28/111) in the S hook group, though this did not achieve significance (p = .25). The most common complications were device migration (13), implant failure (8), and implant prominence (4) for S hooks and implant failure (3), implant prominence (2), and device migration (1) for the screw group. CONCLUSION: In distraction-based growth-friendly constructs, pelvic fixation with screws achieved better correction of pelvic obliquity than S hooks. Complications were almost twice as common with S hooks than screws, though this did not reach statistical significance.

Hoverboard injuries in children and adolescents: results of a multicenter study.

With the increasing popularity of hoverboards in recent years, multiple centers have noted associated orthopaedic injuries of riders. We report the results of a multi-center study regarding hoverboard injuries in children and adolescents. who presented with extremity fractures while riding hoverboards to 12 paediatric orthopaedic centers during a 2-month period were included in the study. Circumstances of the injury, location, severity, associated injuries, and the required treatment were recorded and analysed using descriptive analysis to report the most common injuries. Between-group differences in injury location were examined using chi-squared statistics among (1) children versus adolescents and (2) males versus females. Seventy-eight patients (M/F ratio: 1.8) with average age of 11 ± 2.4 years were included in the study. Of the 78 documented injuries, upper extremity fractures were the most common (84.6%) and the most frequent fracture location overall was at the distal radius and ulna (52.6%), while ankle fractures comprised most of the lower extremity fractures (66.6%). Majority of the distal radius fractures (58.3%) and ankle fractures (62.5%) were treated with immobilization only. Seventeen displaced distal radius fractures and three displaced ankle fractures were treated with closed reduction in the majority of cases (94.1% versus 66.7%, respectively). The distal radius and ulna are the most common fracture location. Use of appropriate protective gear such as wrist guards, as well as adult supervision, may help mitigate the injuries associated with the use of this device; however, further studies are necessary to demonstrate the real effectiveness of these preventions.

Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room: A Multicenter Perspective.

BACKGROUND: The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management). METHODS: A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded. RESULTS: In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P<0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P<0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group. CONCLUSIONS: There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures. LEVEL OF EVIDENCE: Level III.

Unicortical Fixation is Sufficient for Surgical Treatment of Tibial Tubercle Avulsion Fractures in Children.

BACKGROUND: Although open reduction and internal fixation are recommended for displaced tibial tubercle avulsion fractures in young athletes, whether to use unicortical or bicortical fixation is debatable. The purpose of this study is to compare the outcomes of unicortical versus bicortical fixation in a series of pediatric tibial tubercle avulsion fractures. METHODS: We reviewed a consecutive series of patients with tibial tubercle fractures treated surgically at 2 level-1 pediatric tertiary care centers over a 12.5-year period. Patients aged below 18 years of age who received surgical treatment for displaced tibial tubercle fractures with postoperative follow-up were included. Fractures were classified using a modified Ogden classification system. The relative proportion of fracture types treated and incidence of complications were compared. RESULTS: The cohort included 90 fractures in 86 patients. There were 82 male and 4 female individuals; average age was 14.7 years (range, 9.0 to 18 y). In total, 87 of 90 were treated with open reduction and internal screw fixation [51 unicortical (59%), 13 mixed (15%), 23 bicortical (26%)] and 3 with percutaneous pinning. All patients were followed-up until healing and postoperative follow-up average was 8 months (range, 3 to 34 mo). There were no significant differences between the 2 groups with regard to patient age (P=0.22), patient weight (P=0.22), and activity clearance times [unicortical: 19.9 wk (range, 10.4 to 42.3 wk); bicortical: 17.7 wk (range, 12.1 to 32 wk); P=0.19]. The mixed cortical group was cleared at an average of 19.9 weeks (range, 10.6 to 29.1 wk). The relative proportion of fracture patterns treated differed negligibly between the unicortical and bicortical groups. Complications were noted in 9 of 90 procedures (10% rate); all subjects showed evidence of full radiographic healing at last follow-up. CONCLUSIONS: There was no difference in outcome whether unicortical or bicortical fixation was used. All patients exhibited full healing and return to activities with very low-complication rates. The results of this study suggest the adequacy of unicortical fixation for treating tibial tubercle fractures in young athletes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Intraoperative Hypothermia is Common, but not Associated With Blood Loss or Transfusion in Pediatric Posterior Spinal Fusion.

BACKGROUND: Intraoperative hypothermia may be associated with increased blood loss due to the effects of temperature on clotting but this has not been evaluated in the setting of pediatric posterior spinal fusion (PSF). The purpose of this study was to determine if a correlation exists between intraoperative hypothermia and estimated blood loss (EBL) or transfusion requirements in pediatric patients undergoing PSF. METHODS: A retrospective review of consecutive patients undergoing PSF for scoliosis at a single institution between 6/2004 and 3/2012 was performed. Exclusion criteria were fewer than 10 levels fused, anterior spinal fusion, and patients below 9 years old at time of surgery. Temperature was measured every 15 seconds using esophageal temperature probe. Input variable of hypothermia was analyzed as a binary variable Tmin ≤35°C at any point during anesthesia and as integrated temperature area under the curve (TAUC). RESULTS: A total of 510 with an average age of 14.6 years (range, 9.0 to 24.3 y) met inclusion criteria. Totally, 56% (287/510) had idiopathic scoliosis (IS) and 44% (223/510) were non-IS. Hypothermia (Tmin≤35°C) was experienced by 45% (230/510) of all patients [48% (137/287) of IS; 42% (93/223) of non-IS]. A total of 63% (323/510) of patients were transfused with packed red blood cells (PRBC) [49% (141/287) of IS patients; 82% (182/223) of non-IS patients]. There was no correlation between Tmin≤35°C and transfusion of PRBC in all included patients (P=0.49); (IS patients P=0.45, non-IS patients P=0.61). There was no significant difference in EBL between patients who experienced hypothermia and those who did not (P=0.33; IS patients P=0.21, non-IS patients P=0.87). There was no significant correlation between TAUC and transfusion of PRBC for all patients (P=0.35), IS patients (P=0.26) and non-IS patients (P=0.54) or between TAUC and EBL (P=0.80); (IS patients P=0.57. non-IS patients P=0.62). CONCLUSIONS: There was no significant correlation between intraoperative hypothermia and EBL or transfusion of PRBC in pediatric patients undergoing PSF. LEVEL OF EVIDENCE: Level III.

Compartment syndrome in infants and toddlers.

PURPOSE: To study the cause, diagnosis, treatment and outcome of acute compartment syndrome in infants and toddlers aged <3 years. METHODS: Fifteen patients aged <3 years with acute compartment syndrome were identified from two large pediatric trauma centers over a fifteen-year period. All children underwent fasciotomy. The mechanism of injury, time of injury, time to diagnosis, compartment pressures, time to fasciotomy, and outcome at the time of the latest follow-up were recorded. RESULTS: Nine (60 %) of fifteen patients developed compartment syndrome secondary to trauma, four (4/15, 27 %) due to infection, and two (2/15, 13 %) due to intravenous infiltration. The average time from injury or hospital admission to fasciotomy was 31.8 h (range 2.9-136.3 h). In general, the functional outcome was excellent at the latest follow-up with thirteen (13/15, 87 %) patients having an excellent outcome. No cases of Volkmann's ischemia were noted at the time of fasciotomy, even when performed as late as 5 days after injury. CONCLUSIONS: Compared to the general pediatric population, the diagnosis of compartment syndrome in infants and toddlers may be further delayed, i.e., >24 h after injury. Despite delays in diagnosis and time to treatment, the present study shows that outcomes in infants and toddlers remain favorable even when fasciotomy is performed 48-72 h after injury. LEVEL OF EVIDENCE: Case series, level IV.

Continuing Delay in the Diagnosis of Slipped Capital Femoral Epiphysis.

OBJECTIVE: To evaluate whether the time from symptom onset to diagnosis of slipped capital femoral epiphysis (SCFE) has improved over a recent decade compared with reports of previous decades. STUDY DESIGN: Retrospective review of 481 patients admitted with a diagnosis of SCFE at three large pediatric hospitals between January 2003 and December 2012. RESULTS: The average time from symptom onset to diagnosis of SCFE was 17 weeks (range, 0-to 169). There were no significant differences in time from symptom onset to diagnosis across 2-year intervals of the 10-year study period (P = .94). The time from evaluation by first provider to diagnosis was significantly shorter for patients evaluated at an orthopedic clinic (mean, 0 weeks; range, 0-0 weeks) compared with patients evaluated by a primary care provider (mean, 4 weeks; range, 0-52 weeks; r = 0.24; P = .003) or at an emergency department (mean, 6 weeks, range, 0-104 weeks; r = 0.36; P = .008). Fifty-two patients (10.8%) developed a second SCFE after treatment of the first affected side. The time from the onset of symptoms to diagnosis for the second episode of SCFE was significantly shorter (r = 0.19; P < .001), with mean interval of 11 weeks (range, 0-104 weeks) from symptom onset to diagnosis. There were significantly more cases of mildly severe SCFE, as defined by the Wilson classification scheme, in second episodes of SCFE compared with first episodes of SCFE (OR, 4.44; P = .001). CONCLUSION: Despite reports documenting a lag in time to the diagnosis of SCFE more than a decade ago, there has been no improvement in the speed of diagnosis. Decreases in both the time to diagnosis and the severity of findings for the second episode of SCFE suggest that the education of at-risk children and their families (or providers) may be of benefit in decreasing this delay.

Risk factors for avascular necrosis after closed reduction for developmental dysplasia of the hip.

PURPOSE: The purpose of this study was to identify and evaluate risk factors of avascular necrosis (AVN) after closed treatment for developmental dysplasia of the hip (DDH). METHODS: A retrospective review of children diagnosed with DDH at a tertiary-care children's hospital between 1986 and 2009 was performed. The presence of AVN was assessed according to Salter's classification system. RESULTS: Eighty-two affected hips in 70 children with an average age of 10 months at closed reduction (range 1-31 months) and 5 years (range 2-19 years) of follow-up met the inclusion criteria. Twenty-nine (of 82, 35 %) affected hips developed AVN. The use of pre-reduction traction (p = 0.019) increased the risk of AVN, while preoperative Pavlik harness or brace trial (p = 0.28), presence of ossific nucleus at the time of closed reduction (p = 0.16), and adductor tenotomy (p = 0.37) were not significant factors. Laterality (right vs. left) was also not a significant risk factor (p = 0.75), but patients who underwent closed reduction for bilateral DDH were less likely to develop AVN (p = 0.027). Overall, the degree of abduction did not affect the rate of AVN (p = 0.87). However, in patients treated with closed reduction younger than 6 months of age, the rate of AVN was increased with abduction ≥50° (9/15, 60 %) compared to abduction <50° (0/8, 0 %) (p = 0.007). Patients who developed AVN were more likely to require subsequent surgery (p = 0.034) and more likely to report a fair/poor clinical outcome (p = 0.049). CONCLUSIONS: The risk of AVN (35 %) following closed reduction and spica casting for DDH is high. The degree of abduction in spica casts appears to be a risk factor in patients ≤6 months old. The authors recommend that abduction in spica casts should be limited to <50° in children younger than 6 months of age. LEVEL OF EVIDENCE: IV.

Microbial keratitis in los angeles: the doheny eye institute and the los angeles county hospital experience.

OBJECTIVE: To evaluate the spectrum and antibiotic susceptibility panel of infectious keratitis at a major tertiary care referral eye center and a major county hospital in Southern California. DESIGN: Retrospective case series. PARTICIPANTS: All cultured infectious keratitis cases from July 1, 2008, through December 31, 2012, from the Doheny Eye Institute (DEI) and the Los Angeles County + University of Southern California Medical Center (LAC+USC) were evaluated. METHODS: Microbiology records were reviewed retrospectively. MAIN OUTCOME MEASURES: Microbial isolates as well as antibiotic susceptibility patterns were analyzed. RESULTS: One hundred eighty-four (63%) of 290 cases showed positive culture results at DEI and 152 (82%) of 186 cases showed positive culture results at LAC+USC. Gram-positive pathogens were found to be the most common at both DEI (70%) and LAC+USC (68%), with coagulase-negative Staphylococcus being the most common gram-positive organism (58% at DEI and 44% at LAC+USC). Pseudomonas aeruginosa was the most common gram-negative organism (57% at DEI and 43% at LAC+USC). Ciprofloxacin and levofloxacin susceptibility for all tested pathogens was 73% at DEI and 81% at LAC+USC (P = 0.16). Oxacillin-resistant Staphylococcus aureus (ORSA) was found in 42% of cases at DEI and in 45% of cases at LAC+USC (P = 1.00). CONCLUSIONS: There is no significant difference in the spectrum of pathogens or antibiotic susceptibility of pathogens at DEI versus LAC+USC, and ORSA was found in approximately half of all S. aureus samples.

PID1 (NYGGF4), a new growth-inhibitory gene in embryonal brain tumors and gliomas.

PURPOSE: We present here the first report of PID1 (Phosphotyrosine Interaction Domain containing 1; NYGGF4) in cancer. PID1 was identified in 2006 as a gene that modulates insulin signaling and mitochondrial function in adipocytes and muscle cells. EXPERIMENTAL DESIGN AND RESULTS: Using four independent medulloblastoma datasets, we show that mean PID1 mRNA levels were lower in unfavorable medulloblastomas (groups 3 and 4, and anaplastic histology) compared with favorable medulloblastomas (SHH and WNT groups, and desmoplastic/nodular histology) and with fetal cerebellum. In two large independent glioma datasets, PID1 mRNA was lower in glioblastomas (GBM), the most malignant gliomas, compared with other astrocytomas, oligodendrogliomas and nontumor brains. Neural and proneural GBM subtypes had higher PID1 mRNA compared with classical and mesenchymal GBM. Importantly, overall survival and radiation-free progression-free survival were longer in medulloblastoma patients whose tumors had higher PID1 mRNA (univariate and multivariate analyses). Higher PID1 mRNA also correlated with longer overall survival in patients with glioma and GBM. In cell culture, overexpression of PID1 inhibited colony formation in medulloblastoma, atypical teratoid rhabdoid tumor (ATRT), and GBM cell lines. Increasing PID1 also increased cell death and apoptosis, inhibited proliferation, induced mitochondrial depolaization, and decreased serum-mediated phosphorylation of AKT and ERK in medulloblastoma, ATRT, and/or GBM cell lines, whereas siRNA to PID1 diminished mitochondrial depolarization. CONCLUSIONS: These data are the first to link PID1 to cancer and suggest that PID1 may have a tumor inhibitory function in these pediatric and adult brain tumors.