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1.
Spine Deform ; 2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33555599

RESUMO

PURPOSE: Compare radiographic outcomes, complications, and QoL in neuromuscular early-onset scoliosis (EOS) patients treated with single posterior spinal fusion (PSF) versus growth-friendly surgery and definitive fusion (GFDF). METHODS: In a retrospective cohort study, children with neuromuscular EOS, age 8-11 years at index surgery with PSF or GF devices, with minimum 2-year follow-up after final fusion were identified from a multicenter database. RESULTS: 16 PSF and 43 GFDF patients were analyzed. Demographics were similar except PSF patients were older at index surgery and had shorter follow-up. PSF patients had greater percentage major curve correction (62% vs 38%, p = 0.001) and smaller major curve at final follow-up (23° vs 40°, p = 0.005). The GFDF group underwent over five times more surgeries (8.7 vs 1.6, p = 0.0001). Four PSF patients (25%) experienced ten complications, resulting in five unplanned returns to the operating room (UPROR) in three patients (19%). 36 GFDF patients (84%) experienced 83 complications, resulting in 45 UPRORs in 24 patients (56%). Poisson regression adjusted for age showed that the GFDF group had more complications (p = 0.001) and UPRORs (p = 0.01). Although the GFDF patients had smaller preoperative T1-T12 and T1-S1 lengths, these were similar to the PSF patients at final follow-up, indicating that the GFDF patients had greater spinal growth. PSF patients had better postoperative EOSQ-24 Financial Impact and Family Burden scores. CONCLUSION: While there was a difference in age at index surgery, PSF may be more effective than GFDF at controlling neuromuscular EOS. GFDF patients achieved more spinal growth but eight times more complications and nine times more UPRORs.

3.
JBJS Case Connect ; 11(1): e20.00289, 2021 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-33502135

RESUMO

CASE: We report the case of an 18-year-old man with extreme cervicothoracic lordosis and a progressive scoliosis secondary to Emery-Dreifuss Type VI muscular dystrophy. In a staged fashion, the patient underwent posterior cervical muscle release, halo-gravity traction, and posterior instrumented spinal fusion from C3-L4 with multiple posterior column osteotomies. The patient was followed over 2 years postoperatively with restoration of normal spinal alignment in both the coronal and sagittal profiles. CONCLUSION: This is the first reported case illustrating the gradual correction of severe lordoscoliosis in this patient population.

4.
J Bone Joint Surg Am ; 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33439608

RESUMO

BACKGROUND: The Classification of Early-Onset Scoliosis (C-EOS) allows providers to differentiate patients, for clinical and research purposes, on the basis of the etiology of their disease as well as radiographic parameters. The Early Onset Scoliosis Questionnaire (EOSQ) is the first disease-specific, parent-reported HRQOL (health-related quality-of-life) outcome measure for this condition. We sought to determine the influence of the C-EOS etiology designation, radiographic parameters, and medical comorbidities on EOSQ scores to differentiate quality of life in this heterogeneous patient population. We hypothesized that baseline EOSQ scores for patients with EOS would be strongly affected by the C-EOS etiology designation. METHODS: The analysis included prospectively enrolled patients with EOSQ scores recorded in a multicenter EOS database prior to intervention for the EOS. EOSQ scores were compared across C-EOS etiologies, severity of disease based on radiographic measurements, and patient comorbidities prior to scoliosis intervention. RESULTS: Six hundred and ten patients with EOS were available for analysis; 119 had congenital, 201 had idiopathic, 156 had neuromuscular, and 134 had syndromic EOS. In multivariate analysis, neuromuscular and syndromic etiologies were associated with lower scores than congenital and idiopathic etiologies in many EOSQ domains including general health, transfer, daily living, fatigue/energy level, and emotion. Patients with neuromuscular EOS had the lowest EOSQ scores in general. Congenital and idiopathic EOS did not differ from each other in any EOSQ domain. Coronal Cobb and kyphosis angles had significant inverse but generally weak correlations with EOSQ domains. Individual medical comorbidities had a minor effect on certain domains while American Society of Anesthesiologists (ASA) class and total number of comorbidities had inverse correlations with most domains. CONCLUSIONS: The underlying etiology of EOS appears to have a significant influence on the parent-reported HRQOL outcomes of the disease. Specifically, syndromic and neuromuscular C-EOS diagnoses are associated with lower EOSQ scores before treatment compared with congenital and idiopathic diagnoses. Radiographic measurements of severity have a relatively small influence on EOSQ scores. These baseline differences in C-EOS-designated etiology should be accounted for in studies comparing outcomes of treatment for this heterogeneous patient population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

5.
PLoS One ; 15(6): e0234055, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32497101

RESUMO

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.


Assuntos
Infecções/cirurgia , Doenças Musculoesqueléticas/cirurgia , Ortopedia/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Criança , Feminino , Humanos , Infecções/diagnóstico , Infecções/microbiologia , Masculino , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/microbiologia , Estudos Retrospectivos , Estados Unidos
6.
J Med Genet ; 2020 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-32381727

RESUMO

BACKGROUND: Early-onset scoliosis (EOS), defined by an onset age of scoliosis less than 10 years, conveys significant health risk to affected children. Identification of the molecular aetiology underlying patients with EOS could provide valuable information for both clinical management and prenatal screening. METHODS: In this study, we consecutively recruited a cohort of 447 Chinese patients with operative EOS. We performed exome sequencing (ES) screening on these individuals and their available family members (totaling 670 subjects). Another cohort of 13 patients with idiopathic early-onset scoliosis (IEOS) from the USA who underwent ES was also recruited. RESULTS: After ES data processing and variant interpretation, we detected molecular diagnostic variants in 92 out of 447 (20.6%) Chinese patients with EOS, including 8 patients with molecular confirmation of their clinical diagnosis and 84 patients with molecular diagnoses of previously unrecognised diseases underlying scoliosis. One out of 13 patients with IEOS from the US cohort was molecularly diagnosed. The age at presentation, the number of organ systems involved and the Cobb angle were the three top features predictive of a molecular diagnosis. CONCLUSION: ES enabled the molecular diagnosis/classification of patients with EOS. Specific clinical features/feature pairs are able to indicate the likelihood of gaining a molecular diagnosis through ES.

7.
Spine Deform ; 8(4): 695-702, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32152964

RESUMO

STUDY DESIGN: Case-control study. OBJECTIVES: Evaluate the rate and risk factors for perioperative allogeneic blood transfusion (ABT) in primary idiopathic scoliosis surgery at a single institution. Avoiding perioperative ABT is ideal as transfusions are associated with adverse reactions, increased rates of infection, prolonged hospitalization, additional laboratory testing, and increased cost. Risk factors identified in other studies have differed, and to our knowledge, few studies have identified clinical strategies to predict patients at high risk for ABT. METHODS: We reviewed 402 idiopathic scoliosis patients who underwent primary posterior spinal fusion and instrumentation (PSFI) at a single institution from 2015 to 2017. Medical records and radiographs were reviewed for all patients. Transfused patients were compared to the remaining cohort to find significant differences and identify predictors of higher ABT risk. RESULTS: ABT occurred in 73 patients (18.2%), with the majority of transfusions occurring intraoperatively (41%) or postoperatively on the day of surgery (25%). The seven surgeons involved varied significantly in incidence of ABT (2.4-35.8%, p = 0.002). Patients who had ABT were younger (13.3 vs. 14.1 years, p < 0.01), had lower BMI (48th vs. 61st percentile, p < 0.001), and lower preoperative hemoglobin (13.1 vs. 13.7 g/dL, p < 0.01). Greater preoperative major Cobb angle (69° vs. 61.5°, p < 0.001), number of fusion levels (11.8 vs. 10.3, p < 0.001), and estimated blood loss (770 vs. 448 mL, p < 0.001) also predicted ABT. CONCLUSIONS: ABT was associated with several risk factors, five of which are known preoperatively. Surgeons can use knowledge of these risk factors to assess transfusion risk preoperatively and plan surgery, blood management, and laboratory testing accordingly. The development of best practices for ordering ABT is possible given the variation amongst providers. LEVEL OF EVIDENCE: Level III.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Assistência Perioperatória , Escoliose/cirurgia , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Reação Transfusional/prevenção & controle , Adolescente , Adulto , Fatores Etários , Índice de Massa Corporal , Estudos de Casos e Controles , Criança , Feminino , Hemoglobinas , Humanos , Masculino , Fatores de Risco , Escoliose/patologia , Coluna Vertebral/patologia , Adulto Jovem
8.
J Pediatr Orthop B ; 29(2): 137-144, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31789689

RESUMO

This pilot study was performed to describe changes in arterial flow in completely displaced neurovascularly intact Gartland III pediatric supracondylar humerus fractures using Duplex ultrasonography. This is a prospective study of 11 Gartland type III supracondylar humerus fractures with no cortical continuity but with palpable radial pulse and normal neurologic examination. Duplex ultrasonography was performed on injured and uninjured arms, both preoperatively and postpinning, and interpreted by a board-certified pediatric radiologist. Degree of artery stenosis and peak systolic velocity (PSV) of arterial flow were recorded from the duplex. Ultrasound wrist/brachial indexes (WBI) were calculated using the higher value of the radial/brachial or the ulnar/brachial index. Only three patients had normal Duplexes without stenosis and with flow comparable in the brachial, radial, and ulnar arteries of the affected arm, compared to the unaffected arm, both preoperatively and postpinning. One group of six patients had brachial artery stenosis at the fracture site when compared to the artery proximal to the fracture site, increased PSV at the fracture site compared to proximal to the fracture site, and the WBI was variable when compared to the contralateral side. A third group of two patients also had brachial artery stenosis at the fracture site but had decreased PSV and decreased WBI compared to the contralateral side. Type III supracondylar humerus patients with a normal neurovascular examination may have abnormal Duplex ultrasonography with brachial artery stenosis and elevated peak systolic velocity preoperatively although distal flow remains comparable to the contralateral side. Level of evidence: prognostic - Level II.


Assuntos
Artéria Braquial/fisiopatologia , Fraturas do Úmero/fisiopatologia , Adolescente , Velocidade do Fluxo Sanguíneo , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Projetos Piloto , Estudos Prospectivos , Fluxo Pulsátil , Amplitude de Movimento Articular , Ultrassonografia Doppler Dupla
9.
Orthopedics ; 43(1): 30-35, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31693741

RESUMO

Intraoperative arthrograms are commonly used in conjunction with closed reduction and percutaneous pinning (CRPP) of pediatric lateral condyle fractures of the humerus. The authors sought to determine how arthrograms affect management of these fractures. They reviewed all lateral condyle fractures treated surgically at a pediatric level I trauma center from 2008 to 2014. They stratified patients managed with and without an arthrogram as well as by timing of arthrogram. The authors compared injury parameters, initial and postoperative fracture displacement, and complications between groups. They identified 107 patients who were taken to the operating room for attempted closed reduction, which they classified as either CRPP without arthrogram or arthrogram first and then a decision to treat open or with CRPP. Fifty-eight (54.21%) underwent CRPP without arthrogram and 49 (45.79%) underwent arthrogram. Of those who had arthrograms, 27 (25.23%) were prior to fixation and 22 (20.56%) were after fixation. There was no difference in age, weight, or preoperative displacement among the groups. Mean postoperative displacement was significantly lower in the no arthrogram group vs the arthrogram group (0.91 mm vs 1.68 mm; P<.0001), but it did not differ based on timing of arthrogram (P=.836). Arthrograms changed management in 4 (8%) of 49 patients who had them. There was no statistical difference in the rate of changed management by timing of arthrogram (before vs after fixation, 14.8% vs 0%; P=.060). The authors demonstrated that arthrograms may be useful for assessing final fracture alignment after CRPP, but are unlikely to result in a treatment change and are not associated with improved postoperative alignment. [Orthopedics. 2020; 43(1):30-35.].


Assuntos
Artrografia , Fixação Intramedular de Fraturas/métodos , Fraturas do Úmero/cirurgia , Úmero/cirurgia , Pré-Escolar , Feminino , Humanos , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Resultado do Tratamento
10.
J Pediatr Orthop ; 40(3): e203-e209, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31415016

RESUMO

BACKGROUND: Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients. METHODS: A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality. RESULTS: Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%). CONCLUSION: This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes. LEVEL OF EVIDENCE: Level IV.


Assuntos
Moldes Cirúrgicos , Fixação de Fratura/métodos , Fraturas do Úmero , Úmero , Algoritmos , Moldes Cirúrgicos/efeitos adversos , Moldes Cirúrgicos/estatística & dados numéricos , Criança , Feminino , Fixação de Fratura/efeitos adversos , Humanos , Fraturas do Úmero/classificação , Fraturas do Úmero/diagnóstico , Fraturas do Úmero/cirurgia , Úmero/diagnóstico por imagem , Úmero/lesões , Masculino , Avaliação de Resultados em Cuidados de Saúde/métodos , Seleção de Pacientes , Prognóstico , Radiografia/métodos , Reprodutibilidade dos Testes , Estudos Retrospectivos
11.
Spine Deform ; 7(6): 1003-1009, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31731992

RESUMO

INTRODUCTION: Pectus excavatum and scoliosis are associated conditions with a high rate of coincidence. However, there are no reports to guide surgeons on the management of adolescents with moderate scoliosis and pectus excavatum, because there are conflicting conclusions in the literature regarding how the Nuss procedure with substernal bar affects scoliosis. CASES: In 2017, we encountered two patients with moderate scoliosis treated with a spinal orthosis. After undergoing the Nuss procedure for pectus excavatum, their scoliosis acutely progressed into surgical magnitude requiring posterior instrumented spinal fusion. The first patient progressed 26° despite the pre-Nuss radiographs showing him to be Risser 4/5, while the second patient also progressed 26° from the Nuss procedure. Both patients acknowledged noncompliance with brace wear because of discomfort after the Nuss procedure. However, their progression rate still doubles the rate of reported rapid accelerators, indicating that a significant component of curve progression is directly attributed to forces on the spine from the corrective maneuver with substernal bar. CONCLUSION: The purpose of this case report is to describe the features of these two patients to help with clinical decision-making in patients with moderate scoliosis (curves >25°) who are contemplating the Nuss procedure for correction of pectus excavatum. We caution patients and providers that spinal deformity could worsen with surgical intervention of the pectus excavatum via the Nuss procedure and necessitate scoliosis surgery.


Assuntos
Tórax em Funil/cirurgia , Escoliose/cirurgia , Procedimentos Cirúrgicos Torácicos/métodos , Toracoplastia/efeitos adversos , Adolescente , Tomada de Decisão Clínica/ética , Progressão da Doença , Tórax em Funil/complicações , Humanos , Masculino , Aparelhos Ortopédicos/efeitos adversos , Aparelhos Ortopédicos/normas , Cooperação do Paciente/psicologia , Estudos Retrospectivos , Escoliose/complicações , Escoliose/diagnóstico por imagem , Curvaturas da Coluna Vertebral/diagnóstico por imagem , Curvaturas da Coluna Vertebral/etiologia , Fusão Vertebral/métodos , Procedimentos Cirúrgicos Torácicos/tendências , Toracoplastia/métodos
12.
Spine Deform ; 7(3): 395-403, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31053309

RESUMO

For the past 35 years, we have used halo gravity traction (HGT) to treat patients with a wide variety of underlying spinal deformities. This clinical concepts review will cover the indications, contraindications, HGT technique details, and our preferred method of dynamic HGT. Emphasis will be placed on our protocol, and recommendations that help to avoid complications. HGT is best applied by a standardized team approach intending to medically and nutritionally optimize the patient in preparation for an operative or medical/interventional treatment that will maintain and improve on the deformity correction achieved while avoiding peri- and postoperative complications.


Assuntos
Cifose/cirurgia , Escoliose/cirurgia , Tração , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Cifose/patologia , Cifose/fisiopatologia , Complicações Pós-Operatórias , Escoliose/patologia , Escoliose/fisiopatologia , Tração/efeitos adversos , Tração/instrumentação , Tração/métodos
13.
Spine Deform ; 7(3): 428-435, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31053313

RESUMO

DESIGN: A retrospective, multi-institution series of adolescent idiopathic scoliosis (AIS) patients whose date of surgery exceeded six months from date of surgical recommendation were identified. A case-matched comparison of surgical outcomes of skeletally immature patients who delayed surgery versus a cohort of nondelayed patients. OBJECTIVES: We sought to identify 1) whether patients at risk for significant curve progression when delaying surgery could be identified with available clinical and radiographic data and 2) whether patients who delay surgery have longer fusions/more complex procedures. BACKGROUND: Multiple factors can lead to a delay in treatment of AIS once surgical treatment is recommended, and larger Cobb magnitudes have been associated with a more complex surgery. METHODS: 143 AIS patients who delayed surgery had deformity progression (major Cobb angle change over time) analyzed by Risser grade, triradiate cartilage (TRC) status, and menarche status. Comparison of at-risk patients with regard to surgical outcomes to a cohort of matched patients who had not delayed surgery. RESULTS: Risser 0 patients (n = 34) had a greater major Cobb progression than Risser 1-5 patients (n = 109): mean 1.6°/mo versus 0.4°/mo, p < .001. Twenty-eight premenarchal patients had significantly greater increases in Cobb angle measures than their postmenarchal counterparts (n = 86) (13.2° vs. 4.3°, p < .001). An open TRC also conferred increasing rate of progression. Radiographic variables of stable vertebra and last vertebra touched by central sacral vertical line were more likely to change in immature patients, but we did not demonstrate longer fusions or higher estimated blood loss as a result when compared to nondelayed, age-matched peers. CONCLUSION: AIS patients who are premenarchal, TRC open, or Risser 0 who delay surgery greater than 6 months risk clinically significant Cobb angle progression, which is statistically greater than their more mature peers. Clinical ramifications of this remain unclear. Skeletally mature patients do not progress rapidly, allowing elective timing of surgical intervention. LEVEL OF EVIDENCE: Level III.


Assuntos
Escoliose , Fusão Vertebral/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Criança , Progressão da Doença , Feminino , Humanos , Menarca/fisiologia , Estudos Retrospectivos , Escoliose/epidemiologia , Escoliose/patologia , Escoliose/fisiopatologia , Escoliose/cirurgia , Coluna Vertebral/patologia , Coluna Vertebral/fisiopatologia , Coluna Vertebral/cirurgia , Resultado do Tratamento
14.
J Pediatr Orthop ; 39(5): e349-e354, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30531548

RESUMO

BACKGROUND: Either casting or in situ fixation (to prevent displacement) are recommended for minimally displaced pediatric lateral condyle fractures of indeterminate stability with ≤2 mm lateral displacement and narrowed fracture extension to the epiphyseal articular cartilage. This study compares casting only, acute prophylactic in situ pinning, and surgery if casting fails due to displacement. METHODS: In total, 738 fractures at a level 1 trauma center between 2008 and 2014 were reviewed. All fractures were assigned a Song classification and Song 2 fractures followed to union were analyzed. Worsening displacement was defined as an increase in Song stage. Patients were grouped per treatment: (1) cast only; (2) in situ pinning; or (3) closed or open reduction percutaneous pinning after displacement during attempted cast treatment. RESULTS: In total, 139 fractures were included and 45 (32%) underwent surgery. Among 114 fractures intended for casting, only 20 (18%) displaced and needed surgery. This implies 82% of fractures prophylactically pinned in situ may have remained stable in a cast. On average, displaced fractures were noted 6.5 (2 to 13) days after presentation and required 1 extra clinic visit and week of immobilization without increased complications. Surgeons chose open reduction percutaneous pinning more often for displaced fractures. CONCLUSIONS: Our data estimate 82% of Song 2 fractures never meaningfully displace in a cast. Meaningful displacements occur in <2 weeks. Benefits of prophylactic pinning include 1 less x-ray and clinic visit in exchange for a clinically insignificant lateral cortex reduction and inherent surgical risks. Compliance, surgical scheduling, and a higher rate of open reduction after displacement should influence early treatment decisions. LEVEL OF EVIDENCE: Level III.


Assuntos
Moldes Cirúrgicos , Fixação Intramedular de Fraturas , Fraturas do Úmero , Instabilidade Articular , Moldes Cirúrgicos/efeitos adversos , Moldes Cirúrgicos/estatística & dados numéricos , Criança , Pré-Escolar , Articulação do Cotovelo/lesões , Articulação do Cotovelo/fisiopatologia , Feminino , Fixação Intramedular de Fraturas/instrumentação , Fixação Intramedular de Fraturas/métodos , Humanos , Fraturas do Úmero/diagnóstico , Fraturas do Úmero/fisiopatologia , Fraturas do Úmero/cirurgia , Fraturas do Úmero/terapia , Úmero/diagnóstico por imagem , Instabilidade Articular/diagnóstico , Instabilidade Articular/etiologia , Instabilidade Articular/terapia , Masculino , Seleção de Pacientes , Radiografia/métodos , Resultado do Tratamento
15.
Spine Deform ; 7(1): 40-46, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30587319

RESUMO

STUDY DESIGN: Single-center retrospective chart review. OBJECTIVES AND SUMMARY: Halo gravity traction (HGT) is a safe and effective intervention to improve spinal deformity prior to corrective instrumentation. Our study aimed to report on a large series of patients undergoing HGT, demonstrate the correlation between thoracic height achieved and pulmonary function, and evaluate the efficacy of nutritional assessment and intervention while in HGT for these often malnourished or nutritionally compromised patients. METHODS: 107 patients underwent HGT for severe spinal deformity. Major coronal and sagittal Cobb angles, T1-T12 ht, and T1-S1 ht were collected pre-HGT, during HGT, postoperation, and 2 years postoperation. Pulmonary function tests (PFTs) recorded forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Nutritional interventions such as formal nutrition consult, resulting nutritional supplementation, or interventions were recorded. RESULTS: Patients were in HGT for mean of 82.1 days and mean maximum percentage body weight in traction was 49.5%. Mean major coronal Cobb angle prior to HGT was 92.6°, improving to 65.8° in maximal traction and to 47° after surgical intervention. Traction accounted for 78% of T1-T12 height and 79% of T1-S1 length gains from pre- to postoperation. We showed a positive correlation between gain in T1-T12 height and percentage predicted changes in FVC and FEV1. Weight Z score for the entire cohort of patients improved from -2.8 pretraction to -2.4 in traction and then to -2.3 postoperative. CONCLUSIONS: Our study again demonstrated that HGT achieves radiographic improvement safely and effectively in severe spinal deformity. We demonstrated a positive correlation between improvement in PFTs and increase in thoracic height seen with HGT. Additionally, improvement in weight Z score was seen in the entire population and the most at risk patients for malnutrition, results that have not been shown before. LEVEL OF EVIDENCE: Level IV.


Assuntos
Gravitação , Escoliose/diagnóstico por imagem , Escoliose/cirurgia , Tração/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Pulmão/fisiopatologia , Masculino , Radiografia/estatística & dados numéricos , Testes de Função Respiratória , Estudos Retrospectivos , Escoliose/fisiopatologia , Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/cirurgia , Resultado do Tratamento , Adulto Jovem
16.
J Pediatr Orthop ; 39(2): e114-e119, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30234705

RESUMO

BACKGROUND: Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds. METHODS: An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room. RESULTS: A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention. CONCLUSIONS: Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.


Assuntos
Moldes Cirúrgicos/economia , Fraturas do Fêmur , Fixação Intramedular de Fraturas/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Preços Hospitalares/estatística & dados numéricos , Fatores Etários , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/economia , Feminino , Fraturas do Fêmur/economia , Fraturas do Fêmur/terapia , Fixação Intramedular de Fraturas/métodos , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Radiografia/economia , Estudos Retrospectivos , Tração
17.
Spine Deform ; 6(4): 409-416, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29886912

RESUMO

STUDY DESIGN: Single-institution, retrospective review of prospectively collected data on pediatric patients with adolescent idiopathic scoliosis (AIS) undergoing spinal fusion with a minimum two-year follow-up. OBJECTIVE: To determine the rate of reoperation in AIS patients undergoing spine fusion from 2008 to 2012. SUMMARY OF BACKGROUND DATA: Recent trends in the surgical treatment of AIS have included increased use of all-pedicle screw constructs, smaller implants, more posterior-only approaches, and improved correction techniques. METHODS: A retrospective review of 467 patients undergoing spinal fusion from 2008 to 2012 was performed. Demographic, clinical, radiographic, and surgical data were collected prospectively on all patients for the index procedure and any reoperations. Data were compared to previously published cohorts of patients from the authors' institution who underwent spinal fusion for AIS between 1988 and 2007. RESULTS: The rate of reoperation in this five-year cohort of patients was 9.9%. The most common indications for reoperation were infection (4.5%: 2.4% delayed infections and 2.1% acute infections), symptomatic implants (2.1%), and misplaced pedicle screws (1.7%). When compared to the 2003-2007 cohort, the rate of reoperation for acute infection and malpositioned pedicle screws increased significantly (p = .01 and p = .04), whereas the rate of reoperation for curve progression decreased (p = .01). Reoperations for acute infections and malpositioned pedicle screws also increased significantly (p = .047 and p = .042) compared with the 1988-2002 cohort, whereas the rate of reoperation for pseudarthrosis decreased (p = .002). CONCLUSION: Reoperation rates for AIS have not improved with more sophisticated implants and techniques, predominantly because of increased acute infections and malpositioned pedicle screws despite decreasing pseudarthrosis rates and curve progression. LEVEL OF EVIDENCE: Level II.


Assuntos
Reoperação/estatística & dados numéricos , Escoliose/cirurgia , Fusão Vertebral/estatística & dados numéricos , Adolescente , Criança , Feminino , Humanos , Masculino , Parafusos Pediculares/efeitos adversos , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/instrumentação , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/cirurgia , Adulto Jovem
18.
J Pediatr Orthop ; 38(7): 370-374, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27548584

RESUMO

BACKGROUND: Epiphysiodesis is well-established surgical treatment for the management of leg length discrepancy (LLD) in children; however, a variety of complications may occur. This study evaluates the nature, rate, and potential risk factors of complications associated with epiphysiodesis in a large patient population treated in 1 institution. METHODS: We evaluated the medical and radiographic records of 863 children who had lower extremity epiphysiodesis to manage LLD between 1980 and 2011. RESULTS: Sixty patients (7.0%) incurred complications of some type. Twenty-three patients (2.7%) had perioperative complications unrelated to physeal growth; all resolved without surgical treatment. These included 2 patients with transient intraoperative complications (laryngospasm and allergic rash), 7 with transient neurological symptoms (5 cutaneous nerve dysesthesia or numbness and 2 peroneal nerve neuropathies), and 14 with postoperative knee stiffness which resolved with therapy. Thirty-seven patients (4.3%) developed physeal growth-related complications, including 6 patients who developed overcorrection of leg length inequality (3 had contralateral epiphysiodesis to prevent overcorrection, while 3 declined), and 31 patients who developed angular deformity and/or continued growth of the physis. Of these 31 patients, 15 had reexploration of the epiphysiodesis site, 6 underwent corrective osteotomy, while in 10, no treatment was undertaken. Compared with patients who did not develop angular deformity, these 31 patients had significantly greater LLD (5.6 vs. 3.7 cm, respectively, P<0.01), were younger (10.7 vs. 11.7 in girls; 12.4 vs. 13.5 in boys; P<0.01), and were more likely to have a congenital etiology for their LLD (P<0.01). CONCLUSIONS: Epiphysiodesis is a safe and effective procedure for the correction of leg length inequality. The rate of complications in this study was 7.0%, the most prevalent being the development of angular deformity. Congenital etiology, younger age, and larger limb length inequalities were risk factors for the development of angular deformity. Both surgeons and families should be aware of nature and rate of complications associated with epiphysiodesis. LEVEL OF EVIDENCE: Level IV.


Assuntos
Artrodese/efeitos adversos , Epífises/cirurgia , Desigualdade de Membros Inferiores/cirurgia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Adolescente , Fatores Etários , Artrodese/métodos , Criança , Feminino , Humanos , Desigualdade de Membros Inferiores/diagnóstico por imagem , Masculino , Radiografia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos , Fatores de Risco
19.
J Pediatr Orthop ; 38(9): 443-449, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27603197

RESUMO

BACKGROUND: Neurovascular injury in pediatric supracondylar fractures (SCHFx) has been associated with fracture classification but not with soft tissue injury. The purpose of this study is to correlate clinical soft tissue damage to neurovascular injuries in SCHFx. METHODS: This is an institutional review board approved prospective study from January 2010 through December 2013 of 748 operatively treated pediatric SCHFx. Prospective data were gathered both preoperatively and intraoperatively regarding detailed neurovascular examination as well as soft tissue status, with qualitative descriptives for swelling (mild/moderate/severe), ecchymosis, abrasions, skin tenting, and skin puckering. RESULTS: A total of 7.8% of patients (41/526) had a nonpalpable radial pulse preoperatively. Compared with those with a palpable pulse, a nonpalpable pulse was associated with severe elbow swelling (P<0.0001), tenting (P=0.0085), puckering (P=0.0011), ecchymoses (P<0.0001), and open fracture (P=0.044). Ten patients had a loss of a palpable pulse from initial orthopaedic consult to time of surgery, and when compared with the patients who did not have a loss of pulse, this was associated with swelling severity (P=0.0001) and ecchymosis (P=0.053). A total of 14% of patients (71/526) had a neurological injury preoperatively, and this was associated with severe elbow swelling (P<0.0001), tenting (P=0.0008), puckering (P=0.0077), and ecchymoses (P<0.0001) when compared with patients who did not have a neurological injury. In total, 17 patients had a decline in their neurological examination from the time of initial orthopaedic consult to the time of surgery, and this was associated with severe elbow swelling (P=0.0054) and ecchymoses (P=0.011). After multivariate logistic regression analysis, severe swelling and ecchymoses were significantly associated with a nonpalpable pulse as well as neurological injury (P<0.05). No patient had compartment syndrome. CONCLUSIONS: Soft tissue injury, as measured by swelling, ecchymosis, puckering, and tenting, had a clinically significant association with neurovascular compromise in pediatric SCHFx, and assessment of soft tissue injury is as important as the radiographic appearance when examining these patients. The physical examination signs of soft tissue injury may play a factor in determining urgency of surgical treatment in these fractures. LEVEL OF EVIDENCE: Level II-therapeutic.


Assuntos
Fraturas do Úmero/complicações , Escala de Gravidade do Ferimento , Traumatismos dos Nervos Periféricos/etiologia , Lesões dos Tecidos Moles/etiologia , Lesões do Sistema Vascular/etiologia , Criança , Pré-Escolar , Cotovelo/irrigação sanguínea , Feminino , Humanos , Fraturas do Úmero/classificação , Fraturas do Úmero/cirurgia , Masculino , Estudos Prospectivos , Lesões dos Tecidos Moles/diagnóstico , Lesões do Sistema Vascular/diagnóstico
20.
J Pediatr Orthop ; 38(1): 16-21, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26866641

RESUMO

BACKGROUND: The Tonnis radiographic classification of developmental dysplasia of the hip (DDH) has been used as a prognostic indicator for patients with walking-age DDH. The International Hip Dysplasia Institute (IHDI) classification, a new radiographic classification system, has been proposed to be more reliable by its creators. We sought to validate its reliability using independent observers, to compare it to the Tonnis method, and to assess its prognostic significance in a large cohort of patients. METHODS: A consecutive series of walking-age DDH patients were examined radiographically and classified by the Tonnis and IHDI schemes by 3 independent observers. Interobserver agreement was determined using the Kappa method. Clinical data were collected on patients with regard to success of closed reduction, need for later pelvic osteotomy, and presence of subsequent radiographic avascular necrosis (AVN). The prognostic value of the Tonnis and IHDI classifications to predict these clinical outcomes was determined. RESULTS: A total of 287 hips were available for analysis of the classification schemes. In total, 235 hips underwent attempted closed reduction and were eligible for analysis of successful closed reduction, and 131 hips had >4-year follow-up and were utilized for analysis of late pelvic osteotomy and AVN. Both classifications showed excellent interobserver reliability and in general, there was nonstatistically significant better reliability for the IHDI versus the Tonnis classification. In multivariate analysis, both IHDI and Tonnis classifications were found to be predictive of successful closed reduction and need for late pelvic osteotomy. Both methods showed trends toward being predictive of AVN rate, without statistical significance. CONCLUSIONS: The IHDI classification is subjectively more facile to use and has excellent interrelater agreement for classifying the radiographic severity of DDH. It is also reliable in predicting success of closed reduction and need for late pelvic osteotomy. SIGNIFICANCE: practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. SIGNIFICANCE: Practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. LEVEL OF EVIDENCE: Level III.


Assuntos
Luxação Congênita de Quadril/classificação , Osteotomia , Pré-Escolar , Feminino , Luxação Congênita de Quadril/diagnóstico por imagem , Luxação Congênita de Quadril/cirurgia , Humanos , Lactente , Masculino , Variações Dependentes do Observador , Radiografia , Reprodutibilidade dos Testes , Estudos Retrospectivos
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