Stomaching the pain of spinal fusion: gastrointestinal discomfort is as severe as back pain in 50% of adolescent idiopathic scoliosis patients following posterior spinal fusion.

PURPOSE: There have been no prospective studies investigating gastrointestinal (GI) symptoms of patients with adolescent idiopathic scoliosis (AIS) following posterior spinal fusion (PSF). The purpose of this study was to evaluate the incidence and severity of self-reported GI symptoms following PSF. METHODS: In all, 40 AIS patients undergoing PSF were prospectively enrolled between March 2015 and October 2016. Patients completed a survey on each postoperative, inpatient day regarding nausea, emesis, constipation, abdominal pain and back pain, rating their pain on a scale of 1 to 10. RESULTS: Abdominal pain (50%), emesis (63%), nausea (65%) and constipation (68%) were experienced by the majority of patients. Of those reporting back pain, the mean pain level during the postoperative period was 5.1 (0.2 to 9.6). Of those reporting abdominal pain, the mean pain level during the postoperative period was 5.5 (1.4 to 8.6), which was not different than the severity of their back-pain levels (mean = 6.0, p = 0.31). CONCLUSIONS: Gastrointestinal issues in AIS patients following PSF are common. Abdominal pain was as severe as the back pain for half of the patients. LEVEL OF EVIDENCE: II.

Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture.

BACKGROUND: There is an uncommon subset of supracondylar humeral fractures in children that are so unstable they can displace into both flexion and extension. The purposes of this study were to describe this subset of supracondylar fractures and to report a new technique of closed reduction and percutaneous pinning for their treatment. METHODS: In a retrospective review of 297 consecutive displaced supracondylar humeral fractures in children treated operatively at our institution, we identified nine that were completely unstable with documented displacement into both flexion and extension as seen on fluoroscopic examination with the patient under anesthesia. We used a new technique for closed reduction and fixation of these fractures, and then we assessed fracture-healing and complications from the injury and treatment. RESULTS: All nine fractures were treated satisfactorily with closed reduction and percutaneous pinning. The complication rate associated with these unstable fractures was no higher than that associated with the 288 more stable fractures. Seven of the nine fractures were stabilized with lateral entry pin placement, and two fractures were stabilized with crossed medial and lateral pins. None of the patients had a nonunion, cubitus varus, malunion, additional surgery, or loss of motion. CONCLUSIONS: In rare supracondylar fractures in children, multidirectional instability results in displacement into flexion and/or extension. This fracture can be classified as type IV according to the Gartland system, as it is less stable than a Gartland type-III extension supracondylar fracture. These fractures can be treated successfully with a new technique of closed reduction and percutaneous pinning, thus avoiding open reduction.

Molecular cloning of the human CAK1 gene encoding a cyclin-dependent kinase-activating kinase.

Cyclin-dependent, proline-directed protein kinases normally function to execute critical cell cycle transitions; abnormal expression and/or viral subversion of the positive (cyclins) and negative (Pic1) regulatory subunits may contribute to neoplastic transformation and tumorigenesis. In addition to the binding of regulatory subunits, the enzymatic activities of the cyclin-dependent kinases, Cdc2 and Cdk2, are tightly regulated by site-specific protein phosphorylation events. Recent studies have identified a critical phosphorylation site (Thr-161) located within kinase Subdomain VIII that is necessary for Cdc2 activation, and enzymatic activities capable of carrying out this heterologous phosphorylation event have been detected in both Xenopus oocytes and human somatic cells. In this report, we characterize by molecular cloning a human homologue of the Xenopus Cdk-activating kinase (Cak, encoded by MO15); the novel human gene is designated (HS)CAK1. While only 75% identity is observed at the nucleotide level, the deduced amino acid sequence encoded by (HS)CAK1 is approximately 87% identical to that of the Xenopus MO15 gene in corresponding regions. The catalytic domain of (HS)Cak1, defined by conserved kinase Subdomains I through XI, exhibits considerable homology with (HS)Cdc2, suggesting that this kinase cascade involves closely related enzymes. Immunological studies with anti-Cak antibodies confirm the presence of specific immunoreactivity in highly purified preparations of the human Cdc2-activating kinase. The molecular characterization of (HS)CAK1 should facilitate studies of its physiological regulation, as well as its potential utility as a target for therapeutic intervention in the treatment of proliferative disorders.

Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years.

Long-term review of fifty-two displaced supracondylar humeral fractures in children treated by open reduction and crossed Kirschner-wire fixation demonstrated functional results similar to those obtained by closed methods, but fewer and milder cases of cubitus varus deformity (only 25 per cent of patients). The deformity appeared to result from faulty reduction with medial angulation of the distal fragment. Surgical treatment of these fractures may offer, as its principal advantages: reduced hospitalization time, fewer sequelae, more stable fixation, and slightly better anatomical results. No infections or other specific complications (such as myositis ossificans or Volkmann's contracture) were encountered.

Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia.

Free vascularized fibular bone grafts were used in nineteen children, seen consecutively, who had congenital pseudarthrosis of the tibia. The average age was 5.1 years (range, 1.4 to 11.4 years). Sixteen of the patients had been treated with electrical stimulation for at least one year, and the tibia had not united. All but four patients had had at least one previous operative procedure. At an average follow-up of 6.3 years (range, 2.0 to 11.0 years), eighteen (95 per cent) of the nineteen pseudarthroses had healed. The leg-length discrepancy averaged 1.6 centimeters (range, 0 to 4.0 centimeters), but ten tibiae had residual or progressive valgus or anteroposterior malalignment despite bracing. There was minimum morbidity at the donor site.

Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement.

BACKGROUND: The commonly accepted treatment of displaced supracondylar fractures of the humerus in children is fracture reduction and percutaneous pin fixation; however, there is controversy about the optimal placement of the pins. A crossed-pin configuration is believed to be mechanically more stable than lateral pins alone; however, the ulnar nerve can be injured with the use of a medial pin. It has not been proved that the added stability of a medial pin is clinically necessary since, in young children, pin fixation is always augmented with immobilization in a splint or cast. METHODS: We retrospectively reviewed the results of reduction and Kirschner wire fixation of 345 extension-type supracondylar fractures in children. Maintenance of fracture reduction and evidence of ulnar nerve injury were evaluated in relation to pin configuration and fracture pattern. Of 141 children who had a Gartland type-2 fracture (a partially intact posterior cortex), seventy-four were treated with lateral pins only and sixty-seven were treated with crossed pins. Of 204 children who had a Gartland type-3 (unstable) fracture, fifty-one were treated with lateral pins only and 153 were treated with crossed pins. RESULTS: There was no difference with regard to maintenance of fracture reduction, as seen on anteroposterior and lateral radiographs, between the crossed pins and the lateral pins. The configuration of the pins did not affect the maintenance of reduction of either the Gartland type-2 fractures or the Gartland type-3 fractures. Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used. The use of a medial pin was associated with ulnar nerve injury in 4% (six) of 149 patients in whom the pin was applied without hyperflexion of the elbow and in 15% (eleven) of seventy-one in whom the medial pin was applied with the elbow hyperflexed. Two years after the pinning, one of the seventeen children with ulnar nerve injury had persistent motor weakness and a sensory deficit. CONCLUSIONS: Fixation with only lateral pins is safe and effective for both Gartland type-2 and Gartland type-3 (unstable) supracondylar fractures of the humerus in children. The use of only lateral pins prevents iatrogenic injury to the ulnar nerve. On the basis of our findings, we do not recommend the routine use of crossed pins in the treatment of supracondylar fractures of the humerus in children. If a medial pin is used, the elbow should not be hyperflexed during its insertion.

Progression in scoliosis. A 360 degrees change in 75 years.

With the proliferation of school screening programs for spinal deformity, attention has been directed to methods of scoliosis evaluation and follow-up that avoid serial x-ray exposure. An historical review of the scoliosis literature prior to the extensive use of x-ray in scoliosis care has demonstrated much that is now being "rediscovered." By 1900, screening for spinal deformity in the schools had been instituted, pertinent findings of the physical examination in patients with scoliosis had been well described, and early natural history information had been obtained regarding the behavior of small curves and curves associated with thoracic lordosis. Recordings of surface contours and rib humps, using inclinometers, lead rulers, and other measuring devices, were used to assess the progression of curves. Low contour braces were widely available. Although our orthopaedic forefathers had many erroneous ideas, a perusal of the early orthopaedic writings from around the turn of the century has shown how little is "new" (other than changes in material and spinal instrumentation techniques) from what was recognized 75 years ago.

Outcome of Wisconsin instrumentation in idiopathic scoliosis. Minimum 5-year follow-up.

Wisconsin segmental spinal instrumentation was developed by Drummond et al to provide rigid fixation for correction of spinal deformities without the risk of neurologic injury associated with the passage of sublaminar wires. Up to this point, there have been no outcome studies with follow-up of longer than 2 years. Thirty-five patients with adolescent idiopathic scoliosis treated by the Wisconsin procedure between 1984 and 1987 were reviewed by radiographs, physical examination, and an outcome scale. Minimum length of follow-up was 5 years with an average of 6.3 years. Curves were corrected from a mean of 59 degrees preoperatively to 32 degrees postoperatively (46%), and 36 degrees at final follow-up (39%). Wisconsin segmental spinal instrumentation did not increase thoracic kyphosis. There was evidence of slight lumbar flattening in long fusions. According to the criteria described, 92% had a successful outcome. Complications of the procedure included two wound infections (one superficial, one deep), one rod displacement, and two wire breakages. No pseudarthroses or neurologic complications were identified in this series. Wisconsin segmental spinal instrumentation safely achieves the objectives of partial correction, arthrodesis, and early return to function. The technique may still have a role, particularly in the thoracic region, in selective thoracic fusion of King type II curves, rigid curves, and double thoracic curves.

Avoiding paraplegia during anterior spinal surgery. The role of somatosensory evoked potential monitoring with temporary occlusion of segmental spinal arteries.

Three patients paraplegic following anterior spinal fusion for congenital kyphoscoliosis were noted to have complete somatosensory evoked potential signal loss shortly after segmental arterial ligations at the apex of their respective kyphosis. This has prompted us to use temporary segmental arterial occlusion with somatosensory evoked potential monitoring prior to ligation during anterior spinal fusion. As a result, we have noted seven additional cases, out of a total of 44 cases monitored in this fashion, in which complete loss of somatosensory evoked potential signals, reversible by release of vascular clips, has occurred. For each of these additional cases the critical segmental arteries were identified and were not ligated, usually resulting in some modifications in the planned surgical procedure, and the patients remained neurologically intact. We recommend temporary segmental arterial occlusion with somatosensory evoked potential monitoring during thoracolumbar anterior spinal fusion to potentially avert ischemic neurologic injury. Based on published data and the experience described herein, this technique should be especially important in anterior spinal fusion for congenital kyphoscoliosis.

Complications of posterior iliac crest bone grafting in spine surgery in children.

STUDY DESIGN: The perioperative and postoperative complications associated with harvesting posterior iliac crest bone graft in children were reviewed. A retrospective study was performed and a questionnaire interview conducted. OBJECTIVES: To determine the morbidity associated with posterior iliac crest bone graft in children. SUMMARY OF BACKGROUND DATA: Iliac crest bone is commonly used as a source of bone graft in spine surgery. Although there are multiple reports of complications in adults, there are no reports in children. METHODS: A retrospective chart review was performed of 214 consecutive children who underwent spinal fusion with posterior iliac crest bone graft from 1990 through 1996. An interview was conducted of 87 patients with normal mental status, predominantly those with idiopathic scoliosis with a minimum of 2 years' follow-up (mean, 55 months). RESULTS: The review showed one (0.5%) instance of arterial injury in the sciatic notch. Two (1%) patients had infections, both of which resolved with a single irrigation and débridement. There was one documented instance of sacroiliac penetration that did not cause clinical problems. The chart review showed three (1.4%) instances of continued pain and one (0.5%) of numbness. By contrast to the few reports of pain in the chart review, responses to an interview of 87 patients showed 21 (24%) children reporting pain at the iliac crest site, with 13 (15%) reporting problems with daily activities. The self-reported pain, on a scale of 1 to 10, ranged from 1 to 10 with a mean of 4. Nonsteroidal anti-inflammatory drugs (NSAIDS) were taken by eight (9%) children for pain at the bone graft site. Five (6%) reported skin irritation, and 18 (20%) mentioned numbness surrounding the scar. CONCLUSION: The perioperative rate of complications in iliac crest bone grafting in children is low (2%). The complication of pain (24%) and pain that is severe enough to interfere with daily activity (15%) is significant at a mean follow-up of more than 4 years. The true extent of pain and numbness after posterior iliac crest bone grafting in children was severely underreported in the medical records and may be underrecognized.

The characteristics of juvenile idiopathic scoliosis and results of its treatment.

Fifty-nine children with juvenile idiopathic scoliosis have been reviewed. In six of eighteen who had no treatment the curvatures did not increase over eighteen months or more, while in twelve they increased at a median annual rate of six degrees. The pattern and magnitude of the curvature and the age at diagnosis could not be used accurately to predict progression. In forty-two patients progression occurred and Milwaukee brace treatment was begun, thirty being managed with periods of part-time wear. The median correction was 13 per cent. Serial measurements of the rib-vertebra angle difference (RVAD) were useful to predict a tendency to progress. Part-time wear of the brace was successful in cases where the RVAD values fell towards zero or became negative with treatment. Sixteen patients required surgical treatment; all had high positive RVAD values. However, with the plan of brace treatment outlined, part-time wear controlled many of the curvatures.

External fixation in multiply injured children.

External fixation treatment for selected fractures can be as readily applied to children as to adults, although only a small percentage of pediatric fractures require this method. The best situations for the use of external fixation in children are in cases of multiple organ system injuries and in fractures associated with skin loss or large wounds. In these situations, while the child's other problems are being treated, external fixation provides excellent temporary stabilization to facilitate fracture management.

Spinal deformity in short-stature syndromes.

Although almost any spinal deformity can occur in any skeletal dysplasia, there are specific spinal problems in each disorder that require periodic assessment and a particular awareness. Atlantoaxial instability frequently accompanies spondyloepiphyseal dysplasia congenita and Morquio's syndrome. Severe progressive kyphoscoliosis is found in diastrophic dysplasia. Although scoliosis can be found in many of these syndromes to some degree, it is very rare in achondroplasia. The most common deformity found in skeletal dysplasias as a whole seems to be kyphosis: cervical kyphosis in diastrophic dysplasia and thoracolumbar kyphosis in achondroplasia, pseudoachondroplasia, and many of the short-stature syndromes of metabolic etiology. Spinal stenosis is extremely common in achondroplasia, both at the lumbar and cervical areas. It is important to establish the correct diagnosis early so that the orthopaedist is able to focus on the areas at highest risk of developing spinal problems, and proceed with efficacious and timely treatment.

Surgical treatment of adolescent idiopathic scoliosis.

The surgical management of idiopathic scoliosis requires knowledge in several areas. In selecting patients for surgical care, it is necessary to know the natural history for the type of curve present during the teenage years, as well as what can be expected of this type of curve during adult life. Preoperative evaluation must include screening for other than idiopathic causes before surgery is advised. Appropriate attention to preoperative radiographs, possible autologous blood utilization, and planning for spinal cord monitoring are essential. Finally, the ability to use a variety of techniques in spinal deformity surgery is needed, as is the knowledge of which technique or instrumentation is best in each situation. Although the surgical care of spinal deformity has become more complex and requires attention in several areas, the advances in surgical care and in spinal instrumentation allow us to correct spinal deformity more safely and predictably in a more three-dimensional manner than was feasible even a decade ago.

Outcome of hamstring lengthening and distal rectus femoris transfer surgery.

To evaluate the outcome of hamstring lengthening and distal rectus femoris transfer, a retrospective study was performed comparing preoperative and postoperative gait analysis data from 16 children with neurologic involvement. Postoperatively, the timing of peak knee flexion during swing and the total arc of knee motion significantly improved. Hamstring range of motion and knee extension at terminal swing significantly improved, but stride length and gait velocity did not for the overall population. Patients who used braces postoperatively showed an improvement in stride length and velocity when wearing orthoses. This suggests that postoperative bracing may be needed in some patients to maximize the surgical outcome.

A simplified valgus osteotomy of the proximal femur in children.

Valgus osteotomy of the hip is required in a number of orthopedic conditions in children. We present a simplified valgus osteotomy in which a dynamic compression plate is used. This technique has the advantages of using easily available equipment, requiring only one osteotomy, and providing immediate rigid fixation while not violating the proximal femoral physis. We have used this simplified technique for valgus osteotomy in six hips in four children with excellent fixation, good maintenance of correction, and no complications.

Soleus neurectomy for dynamic ankle equinus in children with cerebral palsy.

Problems with the gastrocnemius-soleus muscle group can severely impair the gait of children with cerebral palsy. Treatments, including bracing, muscle lengthening, neurectomy, or a combination, have been used with mixed results. Soleus neurectomy was performed as the primary treatment for ankle clonus in 38 legs of 21 children with a variety of cerebral palsies. Concurrent heel cord or muscle lengthening was performed if needed. Patients were followed for an average of 9 years (range, 2 to 14 years). Clonus recurred in 4 treated ankles. In 2 cases, this was due to a nerve anomaly. Postneurectomy Achilles tendon lengthening was required in 8 of the treated ankles. Neurectomy was beneficial for 19 of 21 children. Functional improvements included better control of stopping, better balance, and less toe walking. The greatest improvement was seen in those patients who did not also have heel cord contractures.