Blood pressure in adults with short stature skeletal dysplasias.

Hypertension, compounded by obesity, contributes to cardiovascular disease and mortality. Data describing hypertension prevalence in adults with short stature skeletal dysplasias are lacking, perhaps due to poor fit of typical adult blood pressure cuffs on rhizomelic or contracted upper extremities. Through health screening research, blood pressure was measured in short stature adults attending support group meetings and skeletal dysplasia clinics. Blood pressure was measured with a commercially available, narrower adult cuff on the upper and/or lower segment of the arm. Height, weight, age, gender, diagnosis, exercise, and medications were collected. Subjects were classified as normotensive, prehypertensive, or hypertensive for group analysis; no individual clinical diagnoses were made. In 403 short stature adults, 42% were hypertensive (systolic >140, diastolic >90 OR taking antihypertensive medications). For every BMI unit and 1 kg weight increase in males, there was a 9% and an 8% increase, respectively, in the odds of hypertension versus normotension. In females, the increase was 10% and 6%, respectively. In those with achondroplasia, the most common short stature dysplasia, males (n = 106) had 10% greater odds of hypertension versus normotension for every BMI unit and kilogram increase. In females with achondroplasia (n = 128), the odds of hypertension versus normotension was 8% greater for each BMI unit and 7% for each additional kilogram. These data suggest a high population prevalence of hypertension among short stature adults. Blood pressure must be monitored as part of routine medical care, and measuring at the forearm may be the only viable clinical option in rhizomelic short stature adults with elbow contractures.

Medical Malpractice in Pediatric Orthopaedics: A Systematic Review of US Case Law.

BACKGROUND: Compared with other orthopaedic subspecialties, pediatric orthopaedic surgeons are thought to be at greater risk for malpractice claims; however, there is scant research on this topic. The purpose of our study was to characterize publicly available malpractice cases pertaining to pediatric orthopaedics to determine the (1) most common specialties of the physicians implicated, (2) most common diagnoses involved, (3) rate of verdicts in favor of the plaintiff, (4) amount of indemnity payments resulting from all verdicts versus verdicts in which only an orthopaedic surgeon was involved, and (5) outcomes of cases that were appealed. METHODS: The Westlaw legal database was queried for jury verdicts, settlements, and appellate cases using the search terms "pediatric" AND "orthopaedic" from December 31, 1984, to January 1, 2016, yielding 176 appellate court cases and 189 jury reports/settlements. After excluding duplicate cases and those involving patients aged 21 years or older, 36 appellate and 84 jury reports/settlement cases remained for analysis. RESULTS: Lawsuits against orthopaedic surgeons and pediatricians were most common, in cases involving fracture diagnosis and misdiagnosis of developmental dysplasia of the hip, respectively. Of the 84 cases, 43 rulings favored the plaintiffs. The median (interquartile range) indemnity payment was $900,000 ($1.9 million), and for cases in which only the orthopaedic surgeon was named as the defendant, the median (interquartile range) indemnity payment was $675,000 ($827,000). Of the 34 appellate cases, 16 cases initially ruled in favor of the defendant were upheld and 13 were reversed/remanded. Five cases initially ruled in favor of the plaintiff were upheld, and none was reversed/remanded. CONCLUSIONS: Malpractice lawsuits named orthopaedic surgeons and pediatricians more often than physicians in other specialties. Orthopaedic surgeons were sued most often for management of fractures and pediatricians for mismanagement of developmental dysplasia of the hip. Nearly 51% of malpractice cases were ruled in favor of the plaintiff, with high indemnity payments. However, when cases that were ruled in favor of the physician were appealed, most verdicts were upheld. LEVEL OF EVIDENCE: Level IV.

Walking Out of the Curve: Thoracolumbar Kyphosis in Achondroplasia.

BACKGROUND: Thoracolumbar kyphosis (TLK) is common in infants with achondroplasia. Our goals were to examine the natural history of TLK and identify factors associated with persistent TLK. METHODS: We reviewed records of patients with achondroplasia seen by a board-certified orthopaedic surgeon at a tertiary care medical center between 1997 and 2013. Inclusion criteria were minimum 2-year follow-up and radiographs taken at time of presentation, within 6 months of walking age, and within 6 months of the first anniversary of walking age. We defined TLK as kyphosis of ≥20 degrees centered at T12 and L1. We assessed patient demographic characteristics, radiographic parameters (Cobb angle, apical vertebral translation, and apical vertebral wedging for vertebral height and width), and clinical parameters (developmental motor delay, hydrocephalus, presence of a ventriculoperitoneal shunt, and foramen magnum decompression). Developmental motor delay was defined as the inability to sit or ambulate independently by age 14 or 30 months, respectively. Associations between these factors and persistent TLK (ie, unresolved at final follow-up) were evaluated using logistic regression and χ, Fisher exact, and independent t tests. Significance was set at P<0.05. RESULTS: A total of 60 patients were included. Mean values were as follows: age at presentation, 10.9±7.0 months; length of follow-up, 5.7±3.6 years; initial curve, 43.8±11.0 degrees; independent sitting age, 12.6±5.5 months; and independent walking age, 21.1±7.8 months. At walking age and 1 year after walking age, 15% and 58% of patients, respectively, had spontaneous TLK resolution. In total, 30% of patients had persistent TLK at final follow-up. Apical vertebral translation (P=0.001), percentage of apical vertebral wedging for vertebral height (P=0.031), and developmental motor delay (P=0.043) were associated with unresolved TLK. CONCLUSIONS: In patients with achondroplasia, TLK resolved at walking age in 15% of patients and after a year of walking in 58% of patients. Earlier bracing may slow TLK progression in patients with achondroplasia and developmental motor delay. Patients with kyphotic curves between 20 and 40 degrees should be examined intermittently for progressive deformity or worsening symptoms of spinal cord compression. LEVEL OF EVIDENCE: Level II.

Factors associated with health-related quality of life (HRQOL) in adults with short stature skeletal dysplasias.

INTRODUCTION: Numerous factors associate with health disparities. The extent to which such factors influence health-related quality of life (HRQOL) among adults with short stature skeletal dysplasias (SD) is unknown. In an effort to update and clarify knowledge about the HRQOL of adults with SD, this study aimed to quantify HRQOL scores relative to the American average and assess whether specific indicators are associated with lower scores. METHODS: Members (>18 years) of Little People of America were invited to complete an online survey assessing HRQOL using the SF-12 supplemented with indicator-specific questions. SF-12 components (Physical Component Summary, PCS; Mental Component Summary, MCS) were compared to the standardized national American mean. Scores were divided at the median to identify factors associated with lower scores using multivariable logistic regression, adjusting for age, gender, race, education, and employment. RESULTS: A total of 189 surveys were completed. Mean and median PCS and MCS were below the national mean of 50 (p < 0.001). Advancing decade of age corresponded to a significant decline in PCS (p < 0.001) but not MCS (p = 0.366). Pain prevalence was high (79.4%); however, only 5.9% visited a pain specialist. Significant factors for lower PCS included age >40 years (p = 0.020), having spondyloepiphyseal dysplasia congenita (SED) or diastrophic dysplasia relative to achondroplasia (p = 0.023), pain (p < 0.001), and "partial" versus "full" health insurance coverage (p = 0.034). For MCS, significant factors included a lack of social support (p = 0.002) and being treated differently/feeling stigmatized by health care providers (p = 0.022). CONCLUSIONS: Individuals with SD face documented disparities and report lower HRQOL. Further research and interventions are needed to modify nuanced factors influencing these results and address the high prevalence of pain.

Risk factors associated with short-term complications and mortality after pediatric spinal arthrodesis.

OBJECTIVE Spinal arthrodesis is routinely performed in the pediatric population. However, there is limited information on the short-term outcomes of pediatric patients who have undergone spine fusion. Thus, the authors conducted a retrospective review of the Pediatric National Surgical Quality Improvement Program (NSQIP) database to determine the short-term mortality, complication, reoperation, and readmission rates of pediatric patients who underwent spinal arthrodesis for all indications. METHODS The Pediatric NSQIP database was queried for all patients who underwent spinal arthrodesis between 2012 and 2014. Patient demographics, comorbidities, body mass index, American Society of Anesthesiologists classification, and operative time were abstracted. Short-term mortality, reoperation, and readmission rates and complications were also noted. Univariate and multivariate analyses were performed to delineate patient risk factors that influence short-term mortality, complications, reoperation, and readmission rates. RESULTS A total of 4420 pediatric patients who underwent spinal fusion were identified. Common indications for surgical intervention included acquired/idiopathic scoliosis or kyphoscoliosis (71.2%) and genetic/syndromic scoliosis (10.7%). The mean patient age was 13.7 ± 2.9 years, and 70% of patients were female. The overall 30-day mortality was 0.14%. Multivariate analysis showed that female sex and pulmonary comorbidities significantly increased the odds of reoperation, with odds ratios of 1.43 and 1.78, respectively. CONCLUSIONS In the NSQIP database for pediatric patients undergoing spinal arthrodesis for all causes, there was a 3.6% unplanned reoperation rate, a 3.96% unplanned readmission rate, and a 9.0% complication rate. This analysis provides data for risk stratification of pediatric patients undergoing spinal arthrodesis, allowing for optimized care.

Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated With Lower Rates of Open Reduction and Infection Than Pin Fixation.

BACKGROUND: Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation. METHODS: From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications. RESULTS: Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05). CONCLUSIONS: Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation. LEVEL OF EVIDENCE: Level III-Therapeutic.

Low Prevalence of Anterior and Posterior Cruciate Ligament Injuries in Patients With Achondroplasia.

BACKGROUND: Anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries and their subsequent reconstructions are common in the general population, but there has been no research regarding ACL or PCL injuries in patients with achondroplasia, the most common skeletal dysplasia. Our goals were to (1) evaluate the prevalence of ACL and PCL injuries in adolescents and adults with achondroplasia, (2) compare this prevalence with that reported for the general population, (3) determine how many patients with ACL or PCL injuries underwent ligament reconstruction as treatment, and (4) determine patient activity levels as they relate to the rate of ACL/PCL injuries and reconstructions. METHODS: We reviewed medical records of 430 patients with achondroplasia seen in the senior author's clinic from 2002 through 2014. Demographic data were reviewed, as well as any documentation of ACL or PCL injury or reconstruction. We called all 430 patients by telephone, and 148 agreed to participate in our survey, whereas 1 declined. We asked these patients about their history of ACL or PCL injury or reconstruction, as well as current and past physical activity levels. RESULTS: No ACL or PCL injuries were found on chart review. One patient reached by telephone reported an ACL injury that did not require reconstruction. This yielded a theoretical prevalence of 3/430 (0.7%). Of the 148 patients surveyed, 43 (29%) reported low physical activity, 75 (51%) reported moderate physical activity, and 26 (17%) reported high physical activity. There was no significant difference in the rate of ACL injury when stratified by physical activity level (P=0.102). CONCLUSIONS: ACL and PCL injuries and reconstructions are extremely rare in patients with achondroplasia, which cannot be completely ascribed to a low level of physical activity. One possible explanation is that patients with achondroplasia, on an average, have a more anterior tibial slope compared with those without achondroplasia, which decreases the force generated within the ACL and may protect against ACL injury. Further research is needed to explore possible causes. LEVEL OF EVIDENCE: Level IV-retrospective review.

The Tibial Slope in Patients With Achondroplasia: Its Characterization and Possible Role in Genu Recurvatum Development.

BACKGROUND: Genu recurvatum, a posterior resting position of the knee, is a common lower extremity deformity in patients with achondroplasia and has been thought to be secondary to ligamentous laxity. To the best of our knowledge, the role of the tibial slope has not been investigated, and no studies describe the tibial slope in patients with achondroplasia. Our goals were to characterize the tibial slope in children and adults with achondroplasia, explore its possible role in the development of genu recurvatum, and compare the tibial slope in patients with achondroplasia to that in the general population. METHODS: We reviewed 252 lateral knee radiographs of 130 patients with achondroplasia seen at our clinic from November 2007 through September 2013. Patients were excluded if they had previous lower extremity surgery or radiographs with extreme rotation. We analyzed patient demographics and, on all radiographs, the tibial slope. We then compared the mean tibial slope to norms in the literature. Tibial slopes >90 degrees had an anterior tibial slope and received a positive prefix. Statistical analysis included intraclass and interclass reliability, Pearson correlation coefficient, and the Student t tests (significance, P<0.05). RESULTS: The overall mean tibial slope for the 252 knees was +1.32±7 degrees, which was significantly more anterior than the normal slopes reported in the literature for adults (7.2 to 10.7 degrees, P=0.0001) and children (10 to 11 degrees, P=0.0001). The Pearson correlation coefficient for mean tibial slope and age showed negative correlations of -0.4011 and -0.4335 for left and right knees, respectively. This anterior tibial slope produces proximal and posterior vector force components, which may shift the knee posteriorly in weightbearing. CONCLUSIONS: The mean tibial slope is significantly more anterior in patients with achondroplasia than in the general population; however, this difference diminishes as patients' age. An anterior tibial slope may predispose to a more posterior resting knee position, also known as genu recurvatum. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Implant-related Fractures in Children With Proximal Femoral Osteotomy: Blade Plate Versus Screw-side Plate Constructs.

BACKGROUND: Implant design may affect risk of fracture, especially in the proximal femur, which has been shown to have the highest risk of implant-related fracture (IRF). Blade plate (BPL) and screw-side plate (SSP) implants are used to stabilize proximal femoral osteotomies (PFOs). Our goal was to compare BPL and SSP constructs with regard to the rate, location, and timing of IRF in children undergoing PFOs. METHODS: We retrospectively reviewed clinical and radiographic records from 1 pediatric orthopaedic practice from 1995 through 2010. We identified 734 children 18 years or younger who underwent PFO with a BPL (480 patients) or an SSP (254 patients). Manufacture and style of implants were consistent throughout this period. There were no significant differences between the 2 groups in terms of mean age, sex, race, or diagnosis. The 2 groups were compared with respect to the rate, location, and timing of IRF. The t, Z, χ, and Fisher exact tests were used to analyze the data (statistical significance, P<0.05 for all analyses). RESULTS: The IRF rates were 2.9% and 1.6% in the BPL and SSP groups, respectively (P=0.27). The overall rate of IRF in all patients was 2.5%. Fractures distal to the implant occurred in 7 of 14 patients in the BPL group and 3 of 4 patients in the SSP group. There was no significant difference between the 2 groups in location of fracture with respect to the implant (P=0.78). The mean times to fracture were 3.8±2.9 and 2.4±2.3 years (P=0.39) in the BPL and SSP groups, respectively. CONCLUSIONS: The risk of IRF in children after PFO is substantial. Despite differences in design, there was no significant difference between BPL and SSP implants with respect to IRF risk. LEVEL OF EVIDENCE: Level III.

Spinal decompression in achondroplastic patients using high-speed drill versus ultrasonic bone curette: technical note and outcomes in 30 cases.

BACKGROUND: This manuscript describes the clinical and operative characteristics of achondroplastic children who undergo multilevel thoracolumbar decompressions using either the high-speed drill or the ultrasonic bone curette (BoneScalpel). METHODS: We retrospectively reviewed 30 thoracolumbar decompressions in achondroplastic patients at a single institution between 2008 and 2013. Patients were classified into either the high-speed drill cohort or the BoneScalpel cohort, depending on which instrument was utilized to perform the decompression. A technical note on the role of the ultrasonic bone curette in decompressing stenotic achondroplastic spines is also provided. RESULTS: In comparison with the high-speed drill cohort, the BoneScalpel cohort experienced less overall perioperative complications, including durotomy, cerebrospinal fluid leak, pseudomeningoceles, wound infection, and wound dehiscence. Although 45.0% of patients experienced a durotomy in the high-speed drill cohort, only 30.0% of patients experienced a durotomy in the BoneScalpel cohort (P = 0.694). In the high-speed drill cohort, the number of patients complaining of sensory disturbances, back pain, ataxia, incontinence, neurogenic claudication, radiculopathy, ataxia, and/or weakness decreased postoperatively. Similar results were observed in the BoneScalpel cohort. CONCLUSIONS: Although spinal decompression provides symptomatic resolution in patients with achondroplasia, intraoperative complications, in general, and durotomies, in particular, are common. Here, we report a decreased incidence in intraoperative durotomy and overall perioperative complication rates in the BoneScalpel cohort, although this did not reach the level of statistical significance. Nonetheless, the data demonstrate that the BoneScalpel is a safe and efficacious alternative to the high-speed drill in these challenging patients. LEVEL OF EVIDENCE: Level II-retrospective study.

A retrospective identification of gastroesophageal reflux disease as a new risk factor for surgical site infection in cerebral palsy patients after spine surgery.

BACKGROUND: Neuromuscular scoliosis is a known risk factor for surgical site infection (SSI) after spinal fusion, with reported infection rates as high as 11.2%. Although risk factors such as antibiotic timing have been previously addressed, our objective was to identify intrinsic risk factors for SSI in cerebral palsy (CP) patients with neuromuscular scoliosis. We hypothesized that CP patients who develop SSI after spine fusion would have a risk profile similar to those who develop nosocomial infection. METHODS: We retrospectively analyzed records from patients with CP who developed infections after spinal fusion from January 1998 until July 2008, who were identified by our Infection Control Officer using National Nosocomial Infection Surveillance System criteria (N = 34). Demographically and procedurally matched controls without infection were identified from our spine database (N = 37). We compared these groups for gastroesophageal reflux disease (GERD), use of gastric acid inhibitors, presence of preoperative decubitus ulcer, previous infection, and postoperative ventilation. Multivariable logistic regression was then performed to assess the relative contributions of the predictors to "deep infection" and "any infection." RESULTS: Of 30 evaluable infected patients, 70% had incisional SSI. Although many of the infections were polymicrobial, the most common pathogens identified were Gram-negative bacilli. Many significant predictors were identified by univariable logistic regression for any infection and deep infection. Multivariable logistic regression found a significant effect only for GERD (odds ratio, 6.4; 95% confidence interval, 1.9-21.3; P = 0.002) for any infection, whereas the effect of therapy with gastric acid inhibitors did not reach statistical significance (odds ratio, 6.1 [95% confidence interval, 0.84-44.6]; P = 0.07). No significant interaction between the 2 factors was detected. Among our controls and infected patients altogether, 46.3% had GERD. CONCLUSIONS: We show that GERD increases the risk for infection in CP patients after spine fusion. Prospective multicenter studies are necessary to further validate the predictive value of this risk factor.

Implant-related fractures in children: a 15-year review.

BACKGROUND: To our knowledge, there are no comprehensive clinical studies of implant-related fractures in children. Our goal was to identify the incidence, skeletal location, and associated diagnoses of implant-related fractures. METHODS: We reviewed our institutional database to identify cases of implant insertion (7584 cases) in patients less than 18 years old from January 1, 1995 through December 31, 2009. We calculated the overall incidence of these fractures and stratified the incidence by skeletal location and preoperative diagnoses. Fisher exact test was used to ascertain differences in fracture incidence. Risk ratios were calculated when appropriate. Significance was set at P<0.05. RESULTS: There were 25 cases of implant-related fractures: 22 in the femur, 2 in the tibia, and 1 in the radius. The overall incidence of implant-related fracture was 0.33%; the incidence by skeletal location was: femur, 0.89%; tibia, 0.1%; and radius, 0.14%. Associated diagnoses were cerebral palsy (9 cases), hip dysplasia (3 cases), spina bifida (2 cases), and avascular necrosis (1 case); 10 cases were associated with "other diagnoses," which included various skeletal syndromes (5 cases) and traumatic fractures (5 cases). The incidences of implant-related fractures by diagnoses were: cerebral palsy, 1.1%; hip dysplasia, 1.1%; spina bifida, 1.3%; and avascular necrosis, 0.35%. The incidence of implant-related fracture in the "other diagnoses" group was 0.16%, and the incidence of fracture in otherwise healthy patients was 0.084%. The femur was 15.2 times more likely to fracture than other bones (P<0.001). Diagnoses of cerebral palsy, hip dysplasia, spina bifida, and avascular necrosis were 6.1 times more likely to be associated with implant-related fractures than the "other diagnoses" (P<0.001). The mean time to fracture in the study was 2.8 years. The overall implant removal rate at our institution was 24.3%, and it varied significantly by patient diagnosis (P<0.01). CONCLUSIONS: Skeletal location and preoperative diagnosis should be factors of consideration in a surgeon's decision about removing implants to prevent implant-related fractures. LEVEL OF EVIDENCE: Prognostic Level III.

Enhanced biomechanical stiffness with large pins in the operative treatment of pediatric supracondylar humerus fractures.

BACKGROUND: Various pin configurations have been recommended for the treatment of supracondylar humerus fractures on the basis of the choice between stability versus the risk of iatrogenic nerve injury. However, little attention has been paid to pin size. The purpose of this study was to evaluate the stability of large (2.8 mm or 0.110 inch) and small (1.6 mm or 0.062 inch) pin constructs in 6 configurations. METHODS: A transverse fracture pattern was created by sectioning synthetic humeri in the midolecranon fossa. The specimens were then reduced and pinned in one of 6 configurations: 2 small pins (Kirschner wires) placed crossed or lateral divergent, 2 large pins (Steinmann pins) placed crossed or lateral divergent, or 3 small pins placed crossed or lateral divergent. All specimens were then tested in sagittal extension bending. We investigated the effect of pin configuration and cycle on the sagittal stiffness using multiple linear regression. RESULTS: The 2 small lateral divergent pin configuration was significantly less stable than small crossed pins and large pins in a crossed or a lateral configuration. The addition of a third (lateral) pin to the small crossed pin construct made it significantly less stable than 2 large crossed pins. Although the stability between the remaining configurations was not significantly different, the 2 large crossed pins required the greatest torque to rotate the fragment 20 degrees. There was a significant reduction in torque as a function of cycle, suggesting a loss of fixation during cycling (P<0.05). CONCLUSIONS: Large pins (2.8 mm) in any configuration and the placement of small pins (1.6 mm) in a crossed configuration provided more stable reduction in sagittal extension bending than did the conventional 2 small pins in a lateral divergent pin configuration. The most stable configurations involve crossing the medial and lateral pins. CLINICAL RELEVANCE: There are more stable options than the traditional 2 small lateral pin configuration for fixation of unstable supracondylar fractures. The addition of a third pin is not always advantageous.

The role of clinically significant venous thromboembolism and thromboprophylaxis in pediatric patients with pelvic or femoral fractures.

BACKGROUND: In adults, pelvic and femoral fractures have a known association with venous thromboembolic disease and, thus, thromboprophylaxis is the standard of care. However, similar data for children are scarce, and recommendations for pediatric prophylaxis are less clear. Our goals were to: (1) analyze the predisposing risk factors, prevalence, and outcome (including mortality) of clinically significant venous thromboembolism; (2) investigate the use of thromboprophylaxis in pediatric trauma patients and ages at which it was given; and (3) determine the impact that central venous catheters had on the occurrence of venous thromboembolism. METHODS: We reviewed the records of all pediatric patients with pelvic or femoral fracture admitted to our hospital from 1990 through 2009 for occurrence of venous thromboembolism and related mortality, use and effect of central venous catheters, use of thromboprophylaxis (heparin, warfarin, enoxaparin, or factor-X inhibitors), and patient age at administration. Of the 1782 patients, 948 had electronically searchable medication (and device) records. Ninety-five percent confidence intervals were found for all proportions with sample sizes >100, and an unpaired t test was used to compare the average age at which thromboprophylaxis was given with the average age of the total population. RESULTS: Of the 1782 patients, there were 3 (0.17%) diagnoses of deep vein thrombosis and no diagnoses of pulmonary embolism; there was no related mortality. Of the medication subset (948 patients) only 83 (8.8%) received some type of thromboprophylaxis. The average age of patients given thromboprophylaxis was 14.65 years (SD, 2.34). No central venous catheter was associated with any of the patients who had a venous thromboembolic event. CONCLUSIONS: Thromboprophylaxis was used only occasionally at our institution; >91% of patients did not receive such treatment. No morbidity or mortality was reported related to venous thromboembolism in pediatric patients with femur or pelvic fracture for whom thromboprophylaxis was used. LEVEL OF EVIDENCE: Level II, retrospective study.

Surgical decompression for lumbar stenosis in pediatric achondroplasia.

BACKGROUND: Spinal stenosis is a common complication of achondroplasia. To our knowledge, no study has evaluated a greater than 2-year outcome after surgical intervention for spinal stenosis in such children or compared decompression with and without instrumentation in relation to revision surgery. Our purpose was to assess the efficacy of lumbar decompression and instrumentation for symptomatic stenosis in children with achondroplasia. METHODS: We retrospectively reviewed our institution's database to identify children (< or =18 y old) with achondroplasia undergoing initial spinal decompression for lumbar stenosis from 1995 through 2003. We identified 18 such patients and reviewed their medical records for demographic data, presenting signs and symptoms, and treatment and outcome data. Mean follow-up was 72.0+/-27.6 months. We determined each patient's symptom score (SS) based on presence of leg weakness, numbness, or pain; abnormal reflexes; incontinence; and walking intolerance (unable to walk > or =5 blocks). Each finding was scored 1 point (6 points maximum). Nine patients requiring revision surgery were assigned a revision postoperative SS. All patients were contacted at the end of data collection and assigned a final follow-up SS. Baseline SS values were compared with postoperative, revision postoperative, and final follow-up scores using a paired t test (alpha=0.05). RESULTS: The mean preoperative and final SS values were significantly different: 4.0+/-0.9 (most common symptoms, leg weakness and incontinence) and 1.6+/-1.7 (most common symptom, leg weakness), respectively. Nine patients underwent decompression with instrumentation initially; 9 did not; 7 of the latter required instrumentation during revision; and 2 of the former also required revision. Those without initial instrumentation were 3.5 times more likely (odds ratio=12.3) to require revision. CONCLUSIONS: Surgical decompression with instrumentation significantly reduced the symptoms of lumbar stenosis and the likelihood of revision surgery in children with achondroplasia. LEVEL OF EVIDENCE: Level III therapeutic study.

Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures.

BACKGROUND: No study examining pin constructs has adequately addressed pin size and its role in fracture fixation. Our goal was to review our experience with Wilkins-modified Gartland type-III pediatric supracondylar humerus fractures treated with closed reduction and percutaneous pinning to evaluate the effects of pin size within 2 different pin constructs on maintenance of reduction and on the risk of surgical complications. METHODS: We retrospectively reviewed the medical records of pediatric patients with Wilkins-modified Gartland type-III supracondylar humerus fractures that were closed reduced and percutaneously pinned at our institution from March 1999 through December 2008. We grouped those 159 patients by fracture stabilization method (lateral-entry-pin or crossed-pin constructs), by pin size ratio (ie, ratio of pin diameter to the humeral midshaft cortical thickness: small ≤0.9; large >0.9), and then by 4 combinations of pin construct and pin size ratio. For each group, we evaluated radiographs for immediate postoperative reduction (coronal and sagittal alignment), maintenance of reduction at last follow-up, and the number of surgical complications. We used the Student t test, χ² test, Mann-Whitney U test, and Wilcoxon Signed Rank test to examine for significance, which was set at P<0.05. RESULTS: Although we found no significant differences between the groups immediately after surgery, final follow-up sagittal alignment was significantly more likely to be maintained in the large pin size ratio group than in the small pin size ratio group. For 2 types of surgical complications, infection and nerve palsy, we found no statistically significant differences in these complications between the pin construct or pin size ratio groups. CONCLUSIONS: Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. LEVEL OF EVIDENCE: Level III Therapeutic Study.

Achondroplasia: manifestations and treatment.

Achondroplasia, the most common skeletal dysplasia, is caused by a mutation of fibroblast growth factor receptor-3. This disorder is characterized by frontal bossing, midface hypoplasia, otolaryngeal system dysfunction, and rhizomelic short stature. Orthopaedic manifestations are exhibited in the spine and the extremities. In the infant with achondroplasia, foramen magnum stenosis may result in brainstem compression with apnea and sudden death. Thoracolumbar kyphosis is seen in most infants, but typically it resolves when the child begins to walk. Anatomic anomalies of the vertebral column place the patient at risk for spinal stenosis as early as the first decade and especially during adulthood. Radial head dislocation is one manifestation in the upper extremity. Lower extremity alignment often is characterized by genu varum, which may require correction osteotomy. Medical and surgical options are available to increase patient height, but indications are controversial, and treatment often consumes a large portion of the child's life.

Lumbar fusion in achondroplasia: does fusion to the sacrum affect function?

BACKGROUND: Stenosis and kyphosis are common in achondroplasia, often requiring lumbar fusion, sometimes to the sacrum. The purpose of this study was to determine the functional effect of lumbar fusion to the sacrum in patients with achondroplasia. METHODS: Functional and SF-36 questionnaires were sent to the 66 patients with achondroplasia who underwent instrumented lumbar fusion at our institution from 1991 to 2006. Of the 35 who returned questionnaires, 13 had fusions to the sacrum and 22 did not. Chi-square analysis and a t test were used to evaluate outcomes. Significance was set at P<0.05 or a 95% confidence interval that did not cross 1. RESULTS: There were no statistical differences in SF-36 scores. There was a trend toward more pain in the group fused to the sacrum (P=0.1). There were no statistically significant differences in difficulty with activities, but there was a trend toward increased difficulty with hygiene after toileting in the group with fusion to the sacrum (odds ratio: 3.76, confidence interval: 0.53-26.87, P=0.19). CONCLUSIONS: Fusion to the sacrum did not significantly affect function in patients with achondroplasia, although there was a trend toward increased pain and greater difficulty with hygiene after toileting.

Improvement in documentation of compartment syndrome with a chart insert.

To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.

External fixation and surgical fusion for pediatric cervical spine injuries: Short-term outcomes.

OBJECTIVE: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion. PATIENTS AND METHODS: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication. RESULTS: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001). CONCLUSION: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury.