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1.
J Pediatr Orthop ; 40(6): e420-e423, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32501902

RESUMO

BACKGROUND: A previous study showed significantly higher serum titanium levels in patients with early-onset scoliosis (EOS) treated with traditional growing rods (TGR) and magnetically controlled growing rods (MCGR) compared with controls. Children with vertical expandable prosthetic titanium rib (VEPTR) were not assessed. The purpose of this study was to compare serum titanium levels in EOS patients treated with TGR, MCGR, and VEPTR. We hypothesized that EOS patients treated with all forms of growth-friendly instrumentation (GFI) have elevated serum titanium levels. METHODS: This was a prospective cross-sectional case series. Serum titanium levels were collected from patients with GFI who were enrolled in an EOS database. Blood samples were collected at a clinic visit or lengthening/exchange procedure between April and December 2018. The normal range for serum titanium is 0 to 1 ng/mL. Analyses were conducted using analysis of variance and Bonferroni post hoc test. RESULTS: A total of 23 patients (2 TGR, 8 MCGR, 13 VEPTR) were analyzed. There was a significant difference in age at the time of blood sample collection (12.5 vs. 9.8 vs. 7.5 y, P=0.015) and serum titanium level (1.5 vs. 4.5 vs. 7.6 ng/mL, P=0.021) between TGR, MCGR, and VEPTR, respectively. All of the MCGR and VEPTR patients had a serum titanium level ≥2 ng/mL. Binary comparisons showed that VEPTR had a significantly higher serum titanium level than TGR (P=0.046). There was no difference in serum titanium level when MCGR was compared with TGR and VEPTR. Time from implant insertion to blood sample collection, number of rods currently implanted, total number of rods implanted throughout treatment, and number of lengthenings per patient was similar between the groups. CONCLUSIONS: Elevated serum titanium levels may be present in EOS patients treated with all forms of GFI. Although our TGR patients had indwelling implants for the longest period of time, they had the lowest serum titanium level. Repetitive chest wall motion during respiration may lead to continued wear and metal ion release with VEPTR. LEVEL OF EVIDENCE: Level II-therapeutic.

2.
J Pediatr Orthop ; 40(3): e182-e185, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31157754

RESUMO

BACKGROUND: The 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24) and 22-item Scoliosis Research Society (SRS-22) questionnaire measure health-related quality of life in patients with scoliosis. The EOSQ-24 has been recently validated in early-onset scoliosis (EOS), including congenital scoliosis (CS). The SRS-22 has been validated in idiopathic scoliosis. The EOSQ-24 is completed by the caregiver and the SRS-22 is completed by the patient. The primary purpose of this study was to compare the EOSQ-24 and SRS-22 in patients with CS. The secondary purpose was to compare scores by age and also in developmentally delayed patients. We hypothesized that the SRS-22 is appropriate for children with EOS from CS who do not have a diagnosis of developmental delay. METHODS: This was a prospective comparative study. A prospective institutional CS database was queried to identify patients who had the EOSQ-24 and SRS-22 completed at the same time point. Children without a diagnosis of developmental delay completed both questionnaires if they understood the questions, regardless of age. Otherwise, the caregiver completed both questionnaires. For the analysis, similar questions were matched so that the EOSQ-24 questions fit into the SRS-22 domains of Function, Pain, Mental Health, and Satisfaction. Pearson correlation coefficients (r) were used to compare domain scores, with r≥0.70 indicating a strong relationship. RESULTS: The final study group included 98 patients. The average age at completion of the questionnaires was 9.5 years. A strong correlation was found for all domains except Satisfaction when the patient or caregiver completed both questionnaires. Subanalysis demonstrated the strongest relationship between domains in the age group 0 to 5 years. In developmentally delayed patients, a weak correlation was noted for all domain scores except Pain, which showed a strong correlation. There was a strong correlation for Pain and a weak correlation for Satisfaction domains across all subgroups. CONCLUSIONS: The SRS-22 may be appropriate for children with EOS from CS who do not have a diagnosis of developmental delay. Our findings suggest that the results of previous studies that collected the SRS-22 and future studies that collect the EOSQ-24 can be correlated. It remains unclear which questionnaire is more suitable for developmentally delayed patients. LEVEL OF EVIDENCE: Level I-diagnostic.

3.
J Pediatr Orthop ; 40(5): e341-e345, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31498195

RESUMO

BACKGROUND: Magnetically controlled growing rods (MCGR) have become a popular surgical option for the treatment of early-onset scoliosis. Both radiographs and ultrasound are currently used to measure the amount of length achieved when MCGRs are distracted. Previous studies have investigated the intraobserver and interobserver reliability of radiographic and ultrasound measurements of MCGR distraction. Some authors have reported that there is a "learning curve" in measuring MCGR lengthening with ultrasound, suggesting that new users require several months of experience before they can accurately perform the measurements. The goal of this study was to determine whether surgical experience of the rater is associated with the accuracy of radiographic and ultrasound measurements of MCGR distraction. METHODS: Six raters evaluated 29 deidentified radiographs and 30 ultrasound images from early-onset scoliosis patients with MCGR. Raters had varying levels of experience, ranging from a senior fellowship-trained pediatric orthopaedic surgeon to a junior orthopaedic surgery resident. Raters measured the amount of rod distraction in 2 sessions spaced 2 weeks apart. All raters were provided with a document demonstrating the radiographic and ultrasound measurement techniques before the first round of measurements. Intraclass correlation coefficients were calculated. RESULTS: Excellent intraobserver and interobserver agreement was achieved for both radiographic and ultrasound measurements of MCGR distraction. Subanalysis based on experience level showed that excellent intraobserver agreement was maintained with no evidence of decreased reliability in raters with less experience. CONCLUSIONS: Excellent intraobserver and interobserver agreement was obtained with radiographic and ultrasound measurements of MCGR distraction, regardless of the experience level of the rater. Posting a document with the radiographic and ultrasound measurement techniques in the orthopaedic surgery clinic, and perhaps also the radiology reading room may help avoid inaccurate measurements of distraction length secondary to a learning curve. LEVEL OF EVIDENCE: Level III-diagnostic.

4.
J Pediatr Orthop ; 40(2): e127-e130, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31095010

RESUMO

BACKGROUND: Current estimates suggest that one third of children and adolescents are overweight and 1 in 5 are obese. Obese children are at increased risk of sustaining more complex fractures, failing nonoperative treatment, and experiencing more complications during treatment. The purpose of this study was to compare forearm fracture characteristics, treatment, and complications in grouped overweight and obese [OW+OB; body mass index-for-age percentile (BMI%) ≥85] pediatric patients compared with normal-weight (NW; BMI%≤84) patients. METHODS: This was a retrospective comparative study of patients aged 2 to 17 years old who presented with a forearm fracture resulting from low-energy trauma between January 2010 and September 2017. Patients with incomplete height and weight data; an underlying condition that predisposes to fractures or altered fracture healing; and torus, greenstick, pathologic, and high-energy fractures were excluded. Demographics, fracture characteristics, treatment, and complications were recorded. Descriptive and inferential analyses were conducted. RESULTS: A total of 565 patients (403 NW, 162 OW+OB) met the inclusion criteria. NW children sustained open fractures nearly twice as frequently as the OW+OB children but this was not statistically significant (9.7% vs. 4.9%; P=0.065). Subanalysis showed that NW children were 4.1 times more likely to sustain an open fracture compared with obese (BMI%≥95) children (9.7% vs. 2.4%; P=0.029). A significant relationship was found between BMI% and location of the fracture, the bones involved, and fracture type. The OW+OB children sustained more distal forearm fractures than midshaft and proximal forearm fractures. Isolated radial shaft fractures were more common in the OW+OB group, whereas isolated ulnar shaft fractures were more common in the NW group. There was no difference in associated neurovascular injury, initial nonoperative versus operative management, failure of nonoperative treatment, and treatment complications. CONCLUSIONS: OW+OB children have different forearm fracture characteristics compared with their NW peers. The thick soft tissue envelope in obese children may be protective against an open forearm fracture. In contrast to previous studies, obesity was not associated with failure of nonoperative treatment or a higher rate of complications. LEVEL OF EVIDENCE: Level III-prognostic.


Assuntos
Fraturas Expostas/epidemiologia , Obesidade/epidemiologia , Fraturas do Rádio/epidemiologia , Fraturas da Ulna/epidemiologia , Índice de Massa Corporal , Criança , Pré-Escolar , Feminino , Humanos , Peso Corporal Ideal , Masculino , Fatores de Proteção , Fraturas do Rádio/patologia , Fraturas do Rádio/terapia , Estudos Retrospectivos , Falha de Tratamento , Fraturas da Ulna/patologia , Fraturas da Ulna/terapia
5.
Pediatrics ; 145(1)2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31871245

RESUMO

OBJECTIVES: Leftover prescription opioids pose risks to children and adolescents, yet many parents keep these medications in the home. Our objective in this study was to determine if providing a behavioral disposal method (ie, Nudge) with or without a Scenario-Tailored Opioid Messaging Program (STOMP) (risk-enhancement education) improves parents' opioid-disposal behavior after their children's use. METHODS: Parents whose children were prescribed a short course of opioids were recruited and randomly assigned to the Nudge or control groups with or without STOMP. Parents completed surveys at baseline and 7 and 14 days. Main outcomes were (1) prompt disposal (ie, immediate disposal of leftovers after use) and (2) planned retention (intention to keep leftovers). RESULTS: There were 517 parents who took part, and 93% had leftovers after use. Prompt disposal behavior was higher for parents who received both the STOMP and Nudge interventions (38.5%), Nudge alone (33.3%), or STOMP alone (31%) compared with controls (19.2%; P ≤ .02). Furthermore, the STOMP intervention independently decreased planned retention rates (5.6% vs 12.5% no STOMP; adjusted odds ratio [aOR] 0.40 [95% confidence interval (CI) 0.19-0.85]). Higher risk perception lowered the odds of planned retention (aOR 0.87 [95% CI 0.79-0.96]), whereas parental past opioid misuse increased those odds (aOR 4.44 [95% CI 1.67-11.79]). CONCLUSIONS: Providing a disposal method nudged parents to dispose of their children's leftover opioids promptly after use, whereas STOMP boosted prompt disposal and reduced planned retention. Such strategies can reduce the presence of risky leftover medications in the home and decrease the risks posed to children and adolescents.


Assuntos
Analgésicos Opioides , Controle de Medicamentos e Entorpecentes/métodos , Pais/educação , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Prospectivos , Fatores de Tempo
6.
J Pediatr Orthop ; 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31688816

RESUMO

BACKGROUND: A previous study showed significantly higher serum titanium levels in patients with early-onset scoliosis (EOS) treated with traditional growing rods (TGR) and magnetically controlled growing rods (MCGR) compared with controls. Children with vertical expandable prosthetic titanium rib (VEPTR) were not assessed. The purpose of this study was to compare serum titanium levels in EOS patients treated with TGR, MCGR, and VEPTR. We hypothesized that EOS patients treated with all forms of growth-friendly instrumentation (GFI) have elevated serum titanium levels. METHODS: This was a prospective cross-sectional case series. Serum titanium levels were collected from patients with GFI who were enrolled in an EOS database. Blood samples were collected at a clinic visit or lengthening/exchange procedure between April and December 2018. The normal range for serum titanium is 0 to 1 ng/mL. Analyses were conducted using analysis of variance and Bonferroni post hoc test. RESULTS: A total of 23 patients (2 TGR, 8 MCGR, 13 VEPTR) were analyzed. There was a significant difference in age at the time of blood sample collection (12.5 vs. 9.8 vs. 7.5 y, P=0.015) and serum titanium level (1.5 vs. 4.5 vs. 7.6 ng/mL, P=0.021) between TGR, MCGR, and VEPTR, respectively. All of the MCGR and VEPTR patients had a serum titanium level ≥2 ng/mL. Binary comparisons showed that VEPTR had a significantly higher serum titanium level than TGR (P=0.046). There was no difference in serum titanium level when MCGR was compared with TGR and VEPTR. Time from implant insertion to blood sample collection, number of rods currently implanted, total number of rods implanted throughout treatment, and number of lengthenings per patient was similar between the groups. CONCLUSIONS: Elevated serum titanium levels may be present in EOS patients treated with all forms of GFI. Although our TGR patients had indwelling implants for the longest period of time, they had the lowest serum titanium level. Repetitive chest wall motion during respiration may lead to continued wear and metal ion release with VEPTR. LEVEL OF EVIDENCE: Level II-therapeutic.

7.
J Pediatr Orthop ; 39(2): e125-e129, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28984686

RESUMO

BACKGROUND: Multiple studies have shown low intrarater and interrater agreement of radiographic classification systems for proximal humerus fractures (PHFs) in adults. There is no standardized method of measuring angulation of pediatric PHFs, nor is there consensus as to the amount of angulation and displacement that require operative fixation of adolescent PHFs. We propose a new standardized method to measure fracture angulation that is similar to the method used to measure the epiphyseal-shaft angle for slipped capital femoral epiphysis. The primary purpose of this study was to evaluate the intraobserver and interobserver reliability of our proposed method compared with a nonstandardized method. The secondary purpose was to evaluate the intrarater and interrater agreement of the Neer and Horowitz (NH), and Salter-Harris (SH) classification systems. METHODS: Seven raters evaluated 26 deidentified anteroposterior shoulder radiographs of patients 10 to 16 years of age with PHFs. Raters classified each fracture using the NH and SH systems, and used their own method to measure fracture angulation. This process was repeated 2 weeks later. During the second round, raters also measured fracture angulation using our proposed standardized method. Two weeks after the second round, raters reevaluated the radiographs using the standardized method. Intraclass correlation coefficients were calculated. RESULTS: Excellent intraobserver and interobserver agreement was achieved for the standardized method of measuring fracture angulation. All of the raters had an intrarater reliability classified as excellent (>0.80) using the standardized method. Good intrarater and excellent interrater agreement was achieved when raters used their own fracture angulation measurement method but wide confidence intervals suggested that the results were less precise. Fair to moderate intrarater and interrater reliability was seen for the NH and SH classifications. CONCLUSIONS: Our standardized method for measuring angulation in adolescent PHFs demonstrated excellent intrarater and interrater reliability. We propose that this technique may be a more precise method of measuring fracture angulation and this method should be used in future studies that evaluate indications for operative management of adolescent PHFs. LEVEL OF EVIDENCE: Level III-diagnostic.


Assuntos
Radiografia/normas , Fraturas do Ombro/diagnóstico por imagem , Ombro/diagnóstico por imagem , Adolescente , Criança , Consenso , Feminino , Humanos , Masculino , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Fraturas do Ombro/classificação , Escorregamento das Epífises Proximais do Fêmur/diagnóstico por imagem
8.
Paediatr Anaesth ; 28(10): 873-880, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30302887

RESUMO

BACKGROUND: Persistent postoperative pain is a significant problem for many children, particularly for those undergoing major surgery such as posterior spine fusion. More than two-thirds report persistent pain after spine fusion, yet factors that may contribute to poorer outcomes remain poorly understood. AIMS: This prospective, longitudinal study examined how psychologic and somatic symptoms cluster together in children aged 10-17 years with idiopathic scoliosis, and tested the hypothesis that a higher psychological and somatic symptom cluster would predict worse pain outcomes 1 year after fusion. METHODS: Otherwise healthy children with idiopathic scoliosis completed preoperative surveys measuring recent pain intensity, pain location(s), somatic symptom severity, painDETECT (neuropathic-type pain symptoms), pain interference, fatigue, depression, anxiety, and pain catastrophizing. Pain outcome data were collected during hospitalization, and at 1 year after surgery. RESULTS: Ninety-five children completed baseline surveys and a cluster analysis differentiated 28 (30%) with a high symptom profile that included; higher depression, fatigue, pain interference, catastrophizing, and painDETECT scores. High symptom cluster membership independently predicted higher pain interference at 1 year (ß 9.92 [95% CI 6.63, 13.2], P < 0.001). Furthermore, children in this high symptom cluster reported significantly higher pain intensity and painDETECT scores, and had a 50% higher probability of continued analgesic use at 1 year compared to those in the Low Symptom Cluster (95% CI 21.3-78.5, P = 0.001). CONCLUSION: Findings from this exploratory study suggest a need to comprehensively assess children with scoliosis for preoperative signs and symptoms that may indicate an underlying vulnerability for persistent pain. This, in turn may help guide a comprehensive perioperative treatment strategy to mitigate the potential for long-term pain trajectories.


Assuntos
Analgésicos/administração & dosagem , Dor Crônica/etiologia , Sintomas Inexplicáveis , Dor Pós-Operatória/etiologia , Escoliose/diagnóstico , Adolescente , Criança , Dor Crônica/tratamento farmacológico , Feminino , Humanos , Estudos Longitudinais , Masculino , Dor Pós-Operatória/tratamento farmacológico , Valor Preditivo dos Testes , Estudos Prospectivos , Escoliose/fisiopatologia , Escoliose/psicologia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos
10.
J Pediatr Orthop ; 38(7): 350-353, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27379787

RESUMO

BACKGROUND: Operative treatment of displaced pediatric midshaft clavicle fractures has become increasingly popular, despite lack of evidence that surgical management leads to superior outcomes. Complications, such as plate irritation necessitating removal and wound infection, have been reported in adults. The purpose of this study was to evaluate complications after plate fixation of midshaft clavicle fractures in the pediatric population. METHODS: We retrospectively identified patients 10 to 18 years old who had undergone plate fixation of a displaced midshaft clavicle fracture between 2009 and 2014. Patients who had surgery for a malunion or nonunion, and patients with <6 months of follow-up were excluded. Demographic data, radiographic union, time to return to activity, and complications were recorded. Any complication that led to unplanned surgery was considered a major complication. RESULTS: We analyzed 36 patients (25 males, 11 females) with 37 fractures. The average age at surgery was 14.5±1.7 years and mean follow-up was 1.3±1.0 years. All of the fractures healed and average time to return to activity was 58±28 days. The overall postoperative complication rate was 86% (32/37): 59% (22/37) implant prominence or irritation, 16% (6/37) anterior chest wall numbness, 5% (2/37) superficial wound dehiscence or infection, 3% (1/37) refracture adjacent to the plate, and 3% (1/37) refracture after implant removal. The major complication rate was 43% (16/37). Fifteen patients underwent a second surgery for implant removal secondary to prominence or pain. One patient underwent revision open reduction and internal fixation after he sustained a refracture at the distal aspect of the plate that resulted in a painful nonunion. Only 1 patient had a refracture after implant removal and this was treated nonoperatively. CONCLUSIONS: Implant prominence or irritation is common after plate fixation of displaced pediatric midshaft clavicle fractures. A second surgery for implant removal may be necessary. Patients should be appropriately counseled regarding complications before plate fixation of midshaft clavicle fractures. LEVEL OF EVIDENCE: Level IV-therapeutic.


Assuntos
Placas Ósseas/efeitos adversos , Clavícula/lesões , Fixação Interna de Fraturas/efeitos adversos , Fraturas Ósseas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Criança , Clavícula/diagnóstico por imagem , Feminino , Fraturas Ósseas/diagnóstico por imagem , Humanos , Masculino , Radiografia , Reoperação , Estudos Retrospectivos
11.
Spine (Phila Pa 1976) ; 43(2): E98-E104, 2018 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-28538591

RESUMO

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The aim of this study was to demonstrate that intrathecal morphine (ITM) and oral analgesics provide effective pain control after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), and this protocol has a low complication rate so patients can be admitted to a general care floor. SUMMARY OF BACKGROUND DATA: Previous studies have shown that ITM combined with intravenous patient-controlled analgesia or epidural infusion (EPI) provides effective pain control after PSF for AIS. Owing to concerns for respiratory depression, ITM patients were routinely admitted to the intensive care unit (ICU) postoperatively. There are little data on ITM combined with oral analgesics. METHODS: We identified AIS patients aged 10 to 17 years who had undergone PSF. Twenty-eight patients who received ITM were matched to 28 patients who received a hydromorphone EPI. The ITM group received oral oxycodone starting at 16 hours postinjection. The EPI group received oxycodone after the epidural catheter was removed on postoperative day 2. Pain scores, adverse events, and length of stay were recorded. RESULTS: A higher number of EPI patients received fentanyl (11 vs. 3, P = 0.014) in the post-anesthesia care unit (PACU). The ITM group had lower pain scores between PACU discharge and midnight (mean 2.9 vs. 4.2, P = 0.034). Pain scores were similar during the remaining postoperative periods. All ITM patients transitioned to oxycodone without intravenous opioids. Time to ambulation (19.9 vs. 26.5 hours, P = 0.010) and Foley catheter removal (21.3 vs. 41.9 hours, P < 0.001) were earlier in the ITM patients. Length of hospital stay was shorter in the ITM group (3.1 vs. 3.5 days, P = 0.043). Adverse events occurred at similar rates in both groups. CONCLUSION: ITM and oral analgesics provide safe and effective pain control after PSF for AIS. Routine postoperative admission to the ICU is not necessary. LEVEL OF EVIDENCE: 3.


Assuntos
Analgésicos Opioides/uso terapêutico , Morfina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Escoliose/cirurgia , Fusão Vertebral/métodos , Adolescente , Analgesia Epidural/métodos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Criança , Feminino , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Humanos , Masculino , Morfina/administração & dosagem , Oxicodona/administração & dosagem , Oxicodona/uso terapêutico , Manejo da Dor , Medição da Dor , Dor Pós-Operatória/etiologia , Período Pós-Operatório , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Resultado do Tratamento
12.
J Shoulder Elbow Surg ; 27(1): 29-35, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28844421

RESUMO

BACKGROUND: Clavicle nonunions in adolescent patients are exceedingly rare. The purpose of this study was to evaluate a series of clavicle nonunions from a pediatric multicenter study group to assess potential risk factors and treatment outcomes. METHODS: A retrospective review of all clavicle nonunions in patients younger than 19 years was performed at 9 pediatric hospitals between 2006 and 2016. Demographic and surgical data were documented. Radiographs were evaluated for initial fracture classification, displacement, shortening, angulation, and nonunion type. Clinical outcomes were evaluated, including rate of healing, time to union, return to sports, and complications. Risk factors for nonunion were assessed by comparing the study cohort with a separate cohort of age-matched patients with a diaphyseal clavicle fracture. RESULTS: There were 25 nonunions (mean age, 14.5 years; range, 10.0-18.9 years) identified, all of which underwent surgical fixation. Most fractures were completely displaced (68%) initially, but 21% were partially displaced and 11% were nondisplaced. Bone grafting was performed in 24 of 25 cases, typically using the hypertrophic callus. Radiographic healing was achieved in 96% of cases. One patient (4%) required 2 additional procedures to achieve union. The primary risk factor for development of a nonunion was a previous history of an ipsilateral clavicle fracture. CONCLUSIONS: Clavicle nonunions can occur in the adolescent population but are an uncommon clinical entity. The majority occur in male patients with displaced fractures, many of whom have sustained previous fractures of the same clavicle. High rates of union were achieved with plate fixation and the use of bone graft.


Assuntos
Clavícula/lesões , Clavícula/cirurgia , Fraturas não Consolidadas/cirurgia , Adolescente , Placas Ósseas , Transplante Ósseo , Criança , Clavícula/diagnóstico por imagem , Diáfises/diagnóstico por imagem , Diáfises/lesões , Feminino , Fixação Interna de Fraturas , Consolidação da Fratura , Fraturas não Consolidadas/diagnóstico por imagem , Humanos , Masculino , Radiografia , Recidiva , Reoperação , Estudos Retrospectivos , Volta ao Esporte , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
Instr Course Lect ; 66: 475-480, 2017 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-28594523

RESUMO

Congenital scoliosis is lateral curvature of the spine caused by vertebral anomalies. Congenital scoliosis is associated with congenital anomalies of other organ systems. Traditionally, treatment options for patients with congenital scoliosis focused on posterior spinal fusion. Current surgical treatment options for young children include growing rods, vertical expandable prosthetic titanium ribs, and, most recently, magnetic rods. Hemivertebrae resection is an important early treatment option for patients who have a hemivertebra. Intraoperative navigation may be an important tool that can be used to improve the accuracy of pedicle screw placement in patients who have abnormal pedicles.


Assuntos
Escoliose , Fusão Vertebral , Criança , Humanos , Escoliose/congênito , Escoliose/cirurgia , Resultado do Tratamento
14.
Spine (Phila Pa 1976) ; 42(23): E1366-E1370, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-28338577

RESUMO

STUDY DESIGN: Prospective comparative study. OBJECTIVE: To evaluate whether weight percentile (WP) increases after vertical expandable prosthetic titanium rib (VEPTR) insertion, and whether WP correlates with nutrition laboratories and pulmonary function. SUMMARY OF BACKGROUND DATA: Children with thoracic insufficiency syndrome often have "failure to thrive" (WP ≤5). Previous authors have reported an increase in WP after VEPTR surgery. Weight gain was hypothesized to be secondary to improved pulmonary function. The presence of a correlation between WP and nutrition laboratories and pulmonary function tests (PFT) after VEPTR insertion has not been studied. METHODS: Demographic, nutrition, radiographic, and PFT data were collected on 35 VEPTR patients with a minimum follow-up of 2 years. The relationship between WP and nutrition laboratories and pulmonary function was analyzed. RESULTS: Preoperative WP was ≤5 (PREOP≤5) in 13 patients (37%) and >5 (PREOP>5) in 22 patients (63%). Although all children gained weight, the PREOP≤5 group was more likely to have an increase in WP (P = 0.014). Sixty-eight percent of the PREOP>5 group had a decrease in WP and 32% of the PREOP>5 patients met the criteria for failure to thrive at final follow-up. Overall, there was no change in the number of children with a WP ≤5 (13 vs. 15). Forty-two percent of the children who maintained or increased their WP had a gastrostomy tube, compared to 19% of those who decreased their WP. Seventy-three percent of the patients with failure to thrive at final follow-up did not have a gastrostomy tube. No significant correlations were found between WP and nutrition laboratories, radiographic measures, or PFTs. CONCLUSION: We did not find an overall change in WP after VEPTR insertion. We did not find any correlation between WP and nutrition laboratories or pulmonary function. Weight gain after VEPTR surgery may be secondary to nutritional optimization in high-risk patients. Children who do not have failure to thrive at presentation also require attention. LEVEL OF EVIDENCE: 2.


Assuntos
Insuficiência de Crescimento/fisiopatologia , Próteses e Implantes , Insuficiência Respiratória/cirurgia , Costelas/cirurgia , Ganho de Peso , Criança , Pré-Escolar , Nutrição Enteral , Feminino , Gastrostomia , Humanos , Lactente , Masculino , Estado Nutricional , Estudos Prospectivos , Testes de Função Respiratória , Insuficiência Respiratória/fisiopatologia , Síndrome , Titânio , Resultado do Tratamento
15.
Anesth Analg ; 124(5): 1594-1602, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28319509

RESUMO

BACKGROUND: Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes. METHODS: Seventy children (aged 10-17 years) scheduled for correction of idiopathic scoliosis completed pain and symptom surveys during their preoperative visit (ie, pain intensity [0-10 numeric rating scores], a pediatric version of the 2011 fibromyalgia survey criteria [including pain locations and symptom severity scale], neuropathic pain symptoms [painDETECT], and Patient-Reported Outcome Measurement System measures of fatigue, depression, function, pain interference, and pain catastrophizing). Pain intensity and total analgesic use were recorded daily postoperatively and for 2 weeks after discharge. A 2-step cluster analysis differentiated a high and low pain and symptom profile at baseline, and a multivariate main effects regression model examined the association between pain profile and posthospital discharge pain and analgesic outcomes. RESULTS: The cluster analysis differentiated 2 groups of children well characterized by their baseline symptom reporting. Thirty percent (95% confidence interval [CI], 20.2%-41.8%) had a high symptom profile with higher depression, fatigue, pain interference, a pediatric version of the fibromyalgia survey criteria symptoms, neuropathic pain, and catastrophizing. Girls were more likely than boys to be clustered in the high symptom profile (odds ratio [OR], 5.76 [95% CI, 1.20-27.58]; P = .022) as were those with preoperative pain lasting >3 months (OR, 3.42 [95% CI, 1.21-9.70]; P = .018). Adjusting for sex, age, and total in-hospital opioid consumption, high cluster membership was independently associated with higher self-reported pain after discharge (mean difference +1.13 point [97.5% CI, 0.09-2.17]; P = .015). Children in the high symptom cluster were more likely to report ongoing opioid use at 2 weeks compared with the low symptom group (87% vs 50%; OR, 6.5 [95% CI, 1.30-33.03]; P = .015). At 6 months, high symptom cluster membership was associated with higher pain intensity, higher pain interference, and ongoing analgesic use (P ≤ .018). CONCLUSIONS: A behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain. Further study is needed to elucidate the potential mechanisms behind our observations.


Assuntos
Dor Pós-Operatória/epidemiologia , Dor/complicações , Período Pré-Operatório , Fusão Vertebral/efeitos adversos , Adolescente , Catastrofização , Criança , Feminino , Fibromialgia/epidemiologia , Fibromialgia/psicologia , Humanos , Masculino , Neuralgia/epidemiologia , Neuralgia/psicologia , Dor/etiologia , Medição da Dor , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/psicologia , Valor Preditivo dos Testes , Estudos Prospectivos , Escoliose/complicações , Escoliose/cirurgia , Caracteres Sexuais
16.
J Pediatr Orthop ; 37(1): e23-e27, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26523702

RESUMO

BACKGROUND: Routine prophylactic screw fixation for skeletally immature patients with slipped capital femoral epiphysis (SCFE) continues to be debated. The purpose of this study was to assess the slip severity of a second SCFE in skeletally immature versus more mature patients and determine necessity of contralateral hip prophylactic screw fixation. METHODS: All patients treated for SCFE at 3 pediatric hospitals over a 10-year time period (January 1, 2002 to December 31, 2011) were evaluated. Patients were included if they had a unilateral SCFE and a contralateral asynchronous SCFE, and were divided into immature (Oxford triradiate score 1) versus more mature (Oxford triradiate score 2 and 3) groups. Data evaluation included age, time between slips, body mass index, Southwick angles of first then second SCFEs, and follow-up duration. RESULTS: There were a total of 45 patients: 16 patients in the skeletally immature and 29 patients in the more mature group. Average age at first SCFE in immature patients was 10.9 years and in more mature patients 12.1 years (P=0.70). Age at second SCFE in immature patients was 11.5 years and in more mature patients 13.0 years (P=0.023). Average time between SCFEs was 6.6 months for immature and 11.4 months for more mature patients (P=0.093). Southwick angles for immature patient first and second SCFEs were 25 and 12.9 degrees, respectively, and for more mature patient first and second SCFEs were 31 and 21 degrees, respectively. Southwick angles were higher at first and second slips in the more mature group, significant only at the second slip (P=0.032). SCFE severity at initial event was predictive of severity of second SCFE regardless of maturity (P=0.043). Regression analysis of slip severity against multiple patient factors demonstrated triradiate score was not a factor assessing subsequent SCFE magnitude (P=0.099). CONCLUSIONS: There was no significant difference between first and second SCFEs regardless of skeletal maturity but severity of initial SCFE did correlate with severity of the second SCFE. Deciding not to prophylactically pin an unaffected hip does not lead to worse deformity if a second SCFE occurs in skeletally immature or more mature patients, unless the initial event is severe. Prophylactic pin fixation in skeletally immature patients should occur as a shared decision between patient, guardians, and treating surgeon. LEVEL OF EVIDENCE: Level III-retrospective comparative study.


Assuntos
Fêmur , Procedimentos Ortopédicos , Procedimentos Cirúrgicos Profiláticos , Escorregamento das Epífises Proximais do Fêmur , Adolescente , Fatores Etários , Criança , Desenvolvimento Infantil , Feminino , Fêmur/crescimento & desenvolvimento , Fêmur/cirurgia , Humanos , Masculino , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde , Procedimentos Cirúrgicos Profiláticos/efeitos adversos , Procedimentos Cirúrgicos Profiláticos/métodos , Procedimentos Cirúrgicos Profiláticos/estatística & dados numéricos , Radiografia/métodos , Estudos Retrospectivos , Fatores de Risco , Escorregamento das Epífises Proximais do Fêmur/diagnóstico , Escorregamento das Epífises Proximais do Fêmur/cirurgia
17.
J Pediatr Orthop ; 37(6): 363-367, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26558958

RESUMO

BACKGROUND: Pediatric supracondylar humerus fractures are common injuries that are often treated surgically with closed reduction and percutaneous pinning. Although surgical-site infections are rare, postoperative antibiotics are frequently administered without evidence or guidelines for their use. With the increasing prevalence of antibiotic-resistant organisms and heightened focus on health care costs, appropriate and evidence-based use of antibiotics is needed. We hypothesized that postoperative antibiotic administration would not decrease the rate of surgical-site infection. METHODS: A billing query identified 951 patients with operatively treated supracondylar humerus fractures at our institution over a 15-year period. Records were reviewed for demographic data, perioperative antibiotic use, and the presence of surgical-site infection. Exclusion criteria were open fractures, open reduction, pathologic fractures, metabolic bone disease, the presence of other injuries that required operative treatment, and follow-up <2 weeks after pin removal. χ and Fisher exact test were used to compare antibiotic use to the incidence of surgical-site infection. RESULTS: Six hundred eighteen patients met our inclusion criteria. Two hundred thirty-eight patients (38.5%) received postoperative antibiotics. Eleven surgical-site infections were identified for an overall rate of 1.8%. The use of postoperative antibiotics was not associated with a lower rate of surgical-site infection (P=0.883). Patients with a type III fracture (P<0.001), diminished preoperative vascular (P=0.001) and neurological status (P=0.019), and postoperative hospital admission (P<0.001) were significantly more likely to receive postoperative antibiotics. CONCLUSIONS: Administration of postoperative antibiotics after closed reduction and percutaneous pinning of pediatric supracondylar humerus fractures does not decrease the rate of surgical-site infection. LEVEL OF EVIDENCE: Level III-therapeutic.


Assuntos
Antibacterianos/uso terapêutico , Fixação Intramedular de Fraturas/métodos , Fraturas do Úmero/cirurgia , Infecção da Ferida Cirúrgica/epidemiologia , Pinos Ortopédicos , Criança , Pré-Escolar , Feminino , Humanos , Fraturas do Úmero/tratamento farmacológico , Incidência , Lactente , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/prevenção & controle , Resultado do Tratamento
18.
Spine (Phila Pa 1976) ; 42(3): E156-E162, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27254656

RESUMO

STUDY DESIGN: A multicenter retrospective study of preoperative characteristics and surgical outcomes in adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine the effect of obesity on (i) curve magnitude at first presentation to an orthopedic surgeon, and (ii) surgical outcomes. SUMMARY OF BACKGROUND DATA: Clinical findings for scoliosis may be less apparent in overweight adolescents. The effect of obesity on curve magnitude at presentation to an orthopedic surgeon has not been studied. It is unclear whether obesity is associated with worse surgical outcomes in AIS. METHODS: Demographic, radiographic, perioperative, and complications data were collected on AIS patients who had undergone posterior spinal fusion (PSF). Descriptive and inferential analyses were conducted to compare healthy-weight (HW) [body mass index percentile for age (BMI%) ≤ 84], overweight (OW; BMI% ≥ 85), and obese (OB; BMI% ≥ 95) adolescents. RESULTS: We analyzed 588 patients (454 HW, 134 OW, and 71 OB). In comparison with the HW adolescents, major curve magnitude at presentation to orthopedics was larger in the OW adolescents (49.3° vs. 43.9°) (P < 0.0001) and OB adolescents (50.4° vs. 43.9°) (P = 0.001). The OW and OB groups had increased preoperative major curve magnitude [(59.1° vs. 55.4°) (P = 0.001); (59.9° vs. 55.4°) (P = 0.001)], preoperative minor curve magnitude [(42.2° vs. 37.2°) (P < 0.0001); (43.0° vs. 37.2°) (P = 0.001)], preoperative thoracic kyphosis [(30.8° vs. 25.7°) (P < 0.0001); (33.7° vs. 25.7°) (P < 0.0001)], and surgical time [(307 vs. 276 mins) (P = 0.009); (320 vs. 276 mins) (P = 0.005)] than the HW group.Subgroup analysis of the patients with a minimum 2-year follow-up (n = 245) showed a trend towards a higher complication rate in the OB group (47.8% vs. 28.3%) (P = 0.054). The OB group had significantly more superficial infections than the HW group (13.0% vs. 1.6%) (P = 0.001). CONCLUSION: OW patients with AIS have a larger curve magnitude at presentation to an orthopedic surgeon. OW patients who undergo PSF for AIS have increased surgical times. OB patients may be at higher risk of postoperative complications. LEVEL OF EVIDENCE: 3.


Assuntos
Parafusos Ósseos , Obesidade/complicações , Escoliose/etiologia , Escoliose/cirurgia , Vértebras Torácicas/cirurgia , Adolescente , Feminino , Humanos , Cifose/cirurgia , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fusão Vertebral/métodos , Resultado do Tratamento
19.
J Pediatr Orthop ; 37(8): e536-e542, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27137901

RESUMO

BACKGROUND: Adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) experience variations in their hospital care, which may lead to differences in objective and patient-reported outcomes. The purpose of this study was to demonstrate that using plan of care-educating families preoperatively and standardizing some aspects of care-would decrease time to mobility and time to discharge while maintaining pain control and patient satisfaction. METHODS: Chart review was conducted in 3 groups-preprotocol (December 2008 to December 2009, n=51), first protocol (December 2, 2009 to July 24, 2013, n=100), and second protocol (July 25, 2013 to June 1, 2014, n=39)-to track pain scores (0 to 10), time to regular diet, Foley catheter removal, epidural catheter removal, mobility, and discharge. Patient satisfaction surveys (0 to 10) were administered before discharge. Statistical analysis was performed using a 1-way analysis of variance test with Tukey post hoc analysis. RESULTS: Average pain scores were similar in all groups. Time to sitting was significantly reduced in both first protocol (27.2±9.8 h, P=1×10) and second protocol (28.4±13.6 h, P=3×10) compared with preprotocol (40.2±15.4 h). Time to discharge was significantly lower in second protocol (84.3±27.2 h, P=0.036) compared with first protocol (98.4±27.8 h). Patient satisfaction with care was significantly higher in first protocol (9.1/10, P=2×10) and second protocol (8.6/10, P=5×10) compared with preprotocol (6.5/10). CONCLUSIONS: By educating families preoperatively and standardizing portions of postoperative care in PSF for AIS, pain scores were significantly reduced while overall satisfaction remained high. Specifically, by removing the epidural and Foley catheters on postoperative day 2, time to discharge was dramatically decreased by 15 hours. The application of a multidisciplinary, evidence-driven plan of care for AIS patients undergoing PSF improves throughput and has beneficial effects on objective and patient-reported outcomes. LEVEL OF EVIDENCE: Level III-retrospective case series.


Assuntos
Tempo de Internação , Satisfação do Paciente , Escoliose/psicologia , Fusão Vertebral/psicologia , Adolescente , Feminino , Humanos , Masculino , Manejo da Dor , Medidas de Resultados Relatados pelo Paciente , Período Pós-Operatório , Estudos Retrospectivos , Escoliose/cirurgia , Fusão Vertebral/métodos , Resultado do Tratamento
20.
Cold Spring Harb Mol Case Stud ; 2(4): a000943, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27551683

RESUMO

Mutations in FGD1 cause Aarskog-Scott syndrome (AAS), an X-linked condition characterized by abnormal facial, skeletal, and genital development due to abnormal embryonic morphogenesis and skeletal formation. Here we report a novel FGD1 mutation in a family with atypical features of AAS, specifically bilateral upper and lower limb congenital joint contractures and cardiac abnormalities. The male proband and his affected maternal uncle are hemizygous for the novel FGD1 mutation p.Arg921X. This variant is the most carboxy-terminal FGD1 mutation identified in a family with AAS and is predicted to truncate the FGD1 protein at the second to last amino acid of the carboxy-terminal pleckstrin homology (PH) domain. Our study emphasizes the importance of the 3' peptide sequence in the structure and/or function of the FGD1 protein and further demonstrates the need to screen patients with X-linked congenital joint contractures for FGD1 mutations.

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