The Association Between the Utilization of Traction and Postoperative Complications Following Growing Rod Instrumentation for Early-onset Scoliosis.

BACKGROUND: Preoperative and/or intraoperative traction have been proposed as adjunctive methods to limit complications associated with growth-friendly instrumentation for early-onset scoliosis (EOS). By gradually correcting the deformity before instrumentation, traction can, theoretically, allow for better overall correction without the complications associated with the immediate intraoperative correction. The purpose of this multicenter study was to investigate the association between preoperative/intraoperative traction and complications following growth-friendly instrumentation for EOS. METHODS: Patients with EOS who underwent growth rod instrumentation before 2017 were identified from 2 registries. Patients were divided into 2 groups: preoperative traction group versus no preoperative traction group. A subgroup analysis was done to compare intraoperative traction only versus no traction. Data was collected on any postoperative complication from implantation to up to 2 years postimplantation. RESULTS: Of 381 patients identified, 57 (15%) and 69 (18%) patients received preoperative and intraoperative traction, respectively. After adjusting for etiology and degree of kyphosis, there was no evidence to suggest that preoperative halo traction reduced the risk of any complication following surgical intervention. Although not statistically significant, a subgroup analysis of patients with severe curves demonstrated a trend toward a markedly reduced hardware failure rate in patients undergoing preoperative halo traction [preoperative traction: 1 (3.1%) vs. no preoperative traction: 11 (14.7%), P=0.083]. Nonidiopathic, hyperkyphotic patients treated with intraoperative traction were 61% less likely to experience any postoperative complication (P=0.067) and were 74% (P=0.091) less likely to experience an unplanned return to the operating room when compared with patients treated without traction. CONCLUSIONS: This multicenter study with a large sample size provides the best evidence to date of the association between the use of traction and postoperative complications. Our results justify the need for future Level I studies aimed at characterizing the complete benefit and risk profile for the use of traction in surgical intervention for EOS. LEVEL OF EVIDENCE: Level III.

Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries.

BACKGROUND: Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. METHODS: Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). RESULTS: Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). CONCLUSION: This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi.

Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.

Functional Changes in Patients and Morphological Changes in the Lumbar Intervertebral Disc after Applying Lordotic Curve-Controlled Traction: A Double-Blind Randomized Controlled Study.

Background and Objectives: Lumbar traction is widely used as a non-operative treatment for lumbar intervertebral disc disease. The effect of traditional traction (TT) using linear-type traction devices remains controversial for various reasons, including technical limitations. Thus, the purpose of this study was to compare the effects of the newly developed lumbar lordotic curve-controlled traction (L-LCCT) and TT on functional changes in patients and morphological changes in the vertebral disc. Materials and Methods: A total of 40 patients with lumbar intervertebral disc disease at the L4/5 or L5/S1 level as confirmed by magnetic resonance imaging were recruited and divided into two groups (L-LCCT or TT). The comprehensive health status changes of the patients were recorded using pain and functional scores (the visual analogue scale, the Oswestry Disability Index, and the Roland-Morris Disability Questionnaire) and morphological changes (in the lumbar central canal area) before and after traction treatment. Results: Pain scores were significantly decreased after traction in both groups (p < 0.05). However, functional scores and morphological changes improved significantly after treatment in the L-LCCT group only (p < 0.05). Conclusions: We suggest that L-LCCT is a viable option for resolving the technical limitations of TT by maintaining the lumbar lordotic curve in patients with lumbar intervertebral disc disease.

Staged Growing Rods With Preimplantation of Spinal Anchors for Complex Early Onset Scoliosis.

BACKGROUND: Treatment of early onset scoliosis (EOS) with growing rods (GR) can be challenging in patients with significant deformity, hyperkyphosis, or poor bone quality, due to risks of neurological deficit and hardware pull-out. The objective of this study is to report a series of EOS patients managed with a 2-stage GR technique used to minimize these complications. METHODS: Two-stage GR technique was performed in 8 patients at mean age of 5.4 (range, 3.4 to 7.9) years. At stage 1, proximal and distal anchors were implanted with local fusion. At stage 2, the distraction rods were inserted. There were at least 3 months between stages 1 and 2, and halo-gravity traction was used before stage 2 unless contraindicated. Demographic, clinical, and surgical data were retrospectively reviewed with mean 4.9 (range, 2.0 to 9.4) years of follow-up. Radiographic measurements including Cobb and kyphosis angles were evaluated before stage 1, after halo-gravity traction, after stage 2, and at last follow-up. Indications for staging, anchor healing time, and complications were collected and analyzed. RESULTS: Indications for 2-stage surgery were poor bone quality in 5 patients and neurological changes during initial attempt at GR placement in 3 patients. The mean time between stage 1 and 2 was 23 (15 to 45) weeks. Patients have undergone mean 7 (3 to 16) lengthenings. Three patients have been converted to magnetically controlled GR. The major coronal Cobb angle improved from mean 81 degrees (range, 61 to 97) preoperatively to 40 degrees (24 to 50) after stage 2 and remained at 40 degrees (27 to 53) at last follow-up. Kyphosis remained controlled from 45 degrees (10 to 76) preoperatively to 38 degrees (9 to 61) after stage 2 to 41 degrees (17 to 65) at last follow-up. Complications included superficial wound problems (4 patients), broken rods (2 patients), proximal migration (2 patients), and implant prominence (1 patient). At minimum 2-year follow-up, no patients had lingering neurological complications or instrumentation-bone failure of the GR construct. CONCLUSIONS: Two-stage GR technique can effectively be utilized in EOS patients with poor bone quality or in the event of intraoperative neurological changes. Satisfactory deformity correction can be obtained and routine serial lengthenings can take place with minimal complications. LEVEL OF EVIDENCE: Level IV- case series.

Skull traction for cervical spinal injury in Enugu: A 5-year retrospective multicenter analysis of the clinical outcomes of patients treated with two common devices.

BACKGROUND: Treatment of cervical spine injury is the most challenging of all the injuries of the spine, and there is yet no agreement on the best method of care. OBJECTIVE: We studied the complications and outcome of two skull traction devices used to treat cases of cervical spine injury in three centers in Enugu, South East Nigeria. PATIENTS AND METHODS: A retrospective analysis of patients with cervical spine injury managed with skull traction as the definitive treatment using either Crutchfield or Gardner-Wells tongs over a 5-year period (April 2008-March 2013). The traction was applied for 6 weeks, and the patient was subsequently mobilized with either hard cervical collar or Minerva jacket for another 6 weeks. RESULTS: One hundred and five patients with complete records out of 127 cervical spinal injured patients treated were studied. Forty-one had the American Spinal Injury Association (ASIA) Grade A whereas 64 had incomplete cord injury of ASIA Grades B-E. Forty-eight had Crutchfield traction whereas 57 had Gardner-Wells traction. At the end of treatment, no patient improved among those with ASIA Grades A and B. All the 12 cases of mortality were recorded as well among ASIA A (n = 9) and B (n = 3) Grades. Over 50% of ASIA Grades C and D patients improved to Grade E. The complication profile varied significantly between the traction subgroups with those treated using Crutchfield tongs experiencing more events (χ2 = 6.5, df = 1, P< 0.05). However, there was no significant statistical difference in the Association Impairment Scale (AIS) outcome (P = 0.55) as well as mortality rates (χ2 = 0.97, DF = 1, P> 0.05) between those treated with Crutchfield and Gardner-Well traction. CONCLUSION: Crutch field tong traction may be associated with more complications when compared with Gardner-Wells traction. However, from our study, the final American Spinal Injury AIS outcome, as well as the overall mortality rates associated with the two traction techniques, did not vary significantly.

Correlation of obesity with patient-reported outcomes and complications after hip arthroscopy.

PURPOSE: This study aimed to evaluate patient-reported outcomes and complications after hip arthroscopy in an obese population compared with a matched nonobese control group with a minimum 2-year follow-up, using the Modified Harris Hip Score (MHHS) and Nonarthritic Hip Score (NAHS). METHODS: Data were analyzed from 21 consecutive obese patients (body mass index [BMI] ≥ 30) and 18 nonobese patients (BMI < 25) who underwent hip arthroscopy between 2009 and 2012 with a minimum follow-up of 2 years. Data collected included MHHS, NAHS, traction and intraoperative times, and postoperative complications. RESULTS: Traction times were similar between obese and nonobese patients at 48 and 45 minutes (P = .51), respectively. Operative times were also similar at 54 and 51 minutes (P = .79), respectively. Each group had a statistically significant improvement in MHHS from baseline to final follow-up: 45 to 79 (P < .001) in the obese group and 49 to 81 (P < .001) in the nonobese cohort. Similarly, the NAHS showed significant improvement in each group from baseline to final follow-up: 43 to 75 (P < .001) in the obese cohort and 45 to 83 (P < .001) in the nonobese group. There was no difference between groups in MHHS or NAHS data. There were 8 complications in the obese group, most commonly deep vein thrombosis (DVT) and worsened pain, whereas the nonobese cohort had one complication (an instance of heterotopic ossification [HO]). Overall, obese patients had 11.1 times the risk of a complication developing than did nonobese patients (95% confidence interval, 1.2 to 99.7). CONCLUSIONS: Hip arthroscopy in the obese patient population leads to improved short- to mid-term patient-reported outcomes similar to those seen in nonobese patients. Obese patients, however, are at a significantly increased risk of postoperative complications such as DVTs and worsened hip pain. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Outcome of patients with Legg-Calvé-Perthes onset before 6 years of age.

BACKGROUND: The prognosis of Legg-Calvé-Perthes disease (LCPD) in young patients has been accepted as favorable. The purpose of this study was to clarify the outcome of LCPD patients with onset before 6 years of age. METHODS: From 1989 to 2007, of 332 LCPD patients, 114 hips (in 100 patients) were diagnosed before 6 years of age (mean age, 4.5 y old) with subsequent repair of the epiphysis in all cases. Waldenström classification at presentation was initial stage in 76 hips and fragmentation stage in 38 hips. Lateral pillar classification was group A in 17 hips, group B in 22 hips, group B/C in 24 hips, and group C in 51 hips. Treatment methods were observation with restriction of activity alone in 42 hips and several containment treatments in 72 hips. RESULTS: At the mean age of 14, Stulberg classification was class I in 26 hips, II in 46 hips, III in 28 hips, and IV in 14 hips. These data show an acceptable outcome in 72 of 114 hips (63%). Logistic regression analysis revealed that lateral pillar classification (odds ratio, 3.6) and good range of abduction without treatment (odds ratio, 4.0) were prognostic factors. CONCLUSIONS: Poor outcome was observed even in patients before 6 years of age with large necrotic area. Lateral pillar classification and good range of abduction were prognostic factors. LEVEL OF EVIDENCE: Level IV. Therapeutic studies-investigating the results of treatment. Case series.

Femoral Traction Splints in Mountain Rescue Prehospital Care: To Use or Not to Use? That Is the Question.

OBJECTIVES: To determine the incidence of femur fractures in mountain rescue in England and Wales. To investigate the attitudes of rescuers toward the use of femoral traction splints. To review the literature for evidence on the use of traction splints in prehospital medicine and test the hypothesis that femoral traction splints reduce morbidity and mortality in patients with a fractured femur. METHODS: The Mountain Rescue England and Wales database was searched for cases of suspected fractured femur occurring between 2002 and 2012, a questionnaire was sent to all mountain rescue teams in England and Wales, and a literature review was performed. Relevant articles were critically reviewed to identify the evidence base for the use of femoral traction splints. RESULTS: Femur fractures are uncommon in mountain rescue, with an incidence of suspected femur fractures on scene at 9.3 a year. Traction splints are used infrequently; 13% of the suspected femur fractures were treated with traction. However, rescuers have a positive attitude toward traction splints and perceive few disadvantages to their use. No trials demonstrate that traction splints reduce morbidity or mortality, but a number describe complications resulting from their use. CONCLUSIONS: Femur fractures are rare within mountain rescue. Traction splints may be no more effective than other methods of splinting in prehospital care. We failed to identify evidence that supports the hypothesis that traction splints reduce morbidity or mortality. We advocate the use of a femoral traction splints but recognize that other splints may also be appropriate in this environment.

Application of skin traction for surgical treatment of grade IV pressure sore: a clinical report of 160 cases.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To assess the method of primary surgical closure of pressure sores developed by the Ruixin Hospital for burns. SETTING: Nanjing, China. METHODS: The study included 235 grade IV pressure sores of 160 patients, M:F = 119:41. Their age ranged from 19 to 93 years (mean = 47.4, s.d. ± 15.7). The primary disease was spinal cord injury in 141 patients (88.1%). The location of sore spread over ischial, sacrococcygeal and trochanteric regions. The largest pressure sore measured 15 × 25 cm(2). The time from onset of sore to admission ranged from 3 months to 22 years (mean = 35.5 months, s.d. ± 55.8). Local preoperative preparation included external skin traction using adhesive tapes, wound cleaning and change of dressing. General condition was checked and improved by supportive measures. Operation procedures included thorough debridement, excision of hidden minor scars, mobilizing opposing skin flaps and meticulous haemostasis before closure. Skin traction continued after the operation until the wound was healed. RESULTS: All but 10 sores healed primarily. These 10 sores healed after a revision. The length of stay in hospital ranged from 20 to 140 days (mean = 45.1 days, s.d. ± 21.1). Follow-up period was 2-51 months (mean = 22 months, s.d. ± 12.5). Two ischial sores recurred owing to long sitting. They were cured with the same method. Three illustrative cases are presented. CONCLUSION: The method is simple and enjoys a high success rate with a short stay in hospital and hence is cost effective. The recurrence is rare.

Care during the third stage of labour: obstetricians views and practice in an Albanian maternity hospital.

BACKGROUND: Relatively little is known about current practice during the third stage of labour in low and middle income countries. We conducted a survey of attitudes and an audit of practice in a large maternity hospital in Albania. METHODS: Survey of 35 obstetricians and audit of practice during the third stage was conducted in July 2008 at a tertiary referral hospital in Tirana. The survey questionnaire was self completed. Responses were anonymous. For the audit, information collected included time of administration of the uterotonic drug, gestation at birth, position of the baby before cord clamping, cord traction, and need for resuscitation. RESULTS: 77% (27/35) of obstetricians completed the questionnaire, of whom 78% (21/27) reported always or usually using active management, and 22% (6/27) always or usually using physiological care. When using active management: 56% (15/27) gave the uterotonic after cord clamping; intravenous oxytocin was almost always the drug used; and 71% (19/27) clamped the cord within one minute. For physiological care: 42% (8/19) clamped the cord within 20 seconds, and 96% (18/19) within one minute. 93% would randomise women to a trial of early versus late cord clamping.Practice was observed for 156 consecutive births, of which 26% (42/156) were by caesarean section. A prophylactic uterotonic was used for 87% (137/156): this was given after cord clamping for 55% (75/137), although timing of administration was not recorded for 21% (29/137). For 85% of births (132/156) cord clamping was within 20 seconds, and for all babies it was within 50 seconds. Controlled cord traction was used for 49% (76/156) of births. CONCLUSIONS: Most obstetricians reported always or usually using active management for the third stage of labour. For timing and choice of the uterotonic drug, reported practice was similar to actual practice. Although some obstetricians reported they waited longer than one minute before clamping the cord, this was not observed in practice. Controlled cord traction was used for half the births.

A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale.

BACKGROUND: Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery. A period of non-surgical management is recommended for most patients, but there is little evidence to guide non-surgical decision-making. We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The results suggested this approach may be effective, particularly in a more specific sub-group of patients. The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation, and within the pre-defined sub-group. METHODS/DESIGN: The study will recruit 120 patients with low back pain and signs of nerve root irritation. Patients will be randomized to receive an extension-oriented treatment approach, with or without the addition of mechanical traction. Randomization will be stratified based on the presence of the pre-defined sub-grouping criteria. All patients will receive 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments will occur after 6 weeks, 6 months, and 1 year. The primary outcome will be disability measured with a modified Oswestry questionnaire. Secondary outcomes will include self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups, and examine the interaction between treatment and sub-grouping status. DISCUSSION: This trial will provide a methodologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation, and will examine the validity of a pre-defined sub-grouping hypothesis. The results will provide evidence to inform non-surgical decision-making for these patients. TRIAL REGISTRATION: This trial has been registered with http://ClinicalTrials.gov: NCT00942227.

A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction.

The objective of the study was to develop a clinical prediction rule for identifying patients with low back pain, who improved with mechanical lumbar traction. A prospective, cohort study was conducted in a physiotherapy clinic at a local hospital. Patients with low back pain, referred to physiotherapy were included in the study. The intervention was a standardized mechanical lumbar traction program, which comprised three sessions provided within 9 days. Patient demographic information, standard physical examination, numeric pain scale, fear-avoidance beliefs questionnaire and Oswestry low back pain disability index (pre- and post-intervention) were recorded. A total of 129 patients participated in the study and 25 had positive response to the mechanical lumbar traction. A clinical prediction rule with four variables (non-involvement of manual work, low level fear-avoidance beliefs, no neurological deficit and age above 30 years) was identified. The presence of all four variables (positive likelihood ratio = 9.36) increased the probability of response rate with mechanical lumbar traction from 19.4 to 69.2%. It appears that patients with low back pain who were likely to respond to mechanical lumbar traction may be identified.

No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy.

Low back pain (LBP) poses a significant problem to society. Although initial conservative therapy may be beneficial, persisting chronic LBP still frequently leads to expensive invasive intervention. A novel non-invasive therapy that focuses on discogenic LBP is Intervertebral Differential Dynamics Therapy (IDD Therapy, North American Medical Corp. Reg U.S.). IDD Therapy consists of intermittent traction sessions in the Accu-SPINA device (Steadfast Corporation Ltd, Essex, UK), an FDA approved, class II medical device. The intervertebral disc and facet joints are unloaded through axial distraction, positioning and relaxation cycles. The purpose of this study is to investigate the effect of IDD Therapy when added to a standard graded activity program for chronic LBP patients. In a single blind, single centre, randomized controlled trial; 60 consecutive patients were assigned to either the SHAM or the IDD Therapy. All subjects received the standard conservative therapeutic care (graded activity) and 20 sessions in the Accu-SPINA device. The traction weight in the IDD Therapy was systematically increased until 50% of a person's body weight plus 4.45 kg (10 lb) was reached. The SHAM group received a non-therapeutic traction weight of 4.45 kg in all sessions. The main outcome was assessed using a 100-mm visual analogue scale (VAS) for LBP. Secondary outcomes were VAS scores for leg pain, Oswestry Disability Index (ODI), Short-Form 36 (SF-36). All parameters were measured before and 2, 6 and 14 weeks after start of the treatment. Fear of (re)injury due to movement or activities (Tampa Scale for Kinesiophobia), coping strategies (Utrecht Coping List) and use of pain medication were recorded before and at 14 weeks. A repeated measures analysis was performed. The two groups were comparable at baseline in terms of demographic, clinical and psychological characteristics, indicating that the random allocation had succeeded. VAS low back pain improved significantly from 61 (+/-25) to 32 (+/-27) with the IDD protocol and 53 (+/-26) to 36 (+/-27) in the SHAM protocol. Moreover, leg pain, ODI and SF-36 scores improved significantly but in both groups. The use of pain medication decreased significantly, whereas scores for kinesiophobia and coping remained at the same non-pathological level. None of the parameters showed a difference between both protocols. Both treatment regimes had a significant beneficial effect on LBP, leg pain, functional status and quality of life after 14 weeks. The added axial, intermittent, mechanical traction of IDD Therapy to a standard graded activity program has been shown not to be effective.

The timing and influence of MRI on the management of patients with cervical facet dislocations remains highly variable: a survey of members of the Spine Trauma Study Group.

BACKGROUND: Traumatic cervical facet dislocations are potentially devastating injuries. Magnetic resonance imaging (MRI) is an excellent means of assessing ligamentous disruption, disk herniation, and compression of the neural elements. However, despite an improved understanding of these facet dislocations with imaging, treatment remains controversial. PURPOSE: To survey the timing and influence of MRI on the management of patients with traumatic cervical facet dislocations. STUDY DESIGN: Questionnaire study. METHODS: Clinical vignettes, plain radiographs, and computed tomography scans of 10 cases of cervical facet dislocation were presented to 25 fellowship trained spine surgeons. Participants were analyzed as to their next step in diagnosis or treatment: closed reduction, obtaining an MRI, or proceeding directly with open treatment. A revised vignette was then presented; however, on this occasion, an MRI was included with the imaging and had been obtained before a reduction attempt. Participants were then surveyed on their choice of closed or open reduction. Each of the vignettes consisted of 3 different clinical scenarios based on neurologic examination: intact, incomplete, or complete spinal cord injury. RESULTS: The interrater reliability of treatment decisions was very poor, and the reliability after MRI was available and was significantly worse when the patient was considered to have a complete spinal cord injury. After reviewing the MRI, orthopedic surgeons were significantly more likely to choose a closed versus open reduction. Neurosurgeons were significantly more likely than orthopedic surgeons to order an MRI before open or closed treatment. CONCLUSIONS: The timing and utilization of MRI for patients with traumatic cervical facet dislocations remains variable. Further outcome analysis in the form of evidence-based algorithms is necessary to optimize patient management and outcomes.

The Use of Halo Gravity Traction in the Treatment of Severe Early Onset Spinal Deformity.

STUDY DESIGN: Retrospective Review of Prospective cohort. OBJECTIVE: To describe the feasibility of preoperative halo gravity traction (HGT) with subsequent growing rod/guided growth (GR/GG) placement in early onset spinal deformity (EOSD). SUMMARY OF BACKGROUND DATA: In children with severe EOSD, primary implantation of GR/GG constructs is not always possible. We describe a staged protocol with preoperative HGT followed by GR/GG implantation. METHODS: EOSD patients treated with HGT prior to GR/GG implantation were included. HGT used traction up to 50% body weight for 4 to 29 weeks. Pulmonary function tests (PFTs) were performed before and after HGT. Coronal Cobb (CC) and Sagittal Cobb (SC) angles were measured on the Pre-HGT, Post-HGT and 6 week postop x-rays. RESULTS: Thirty patients were included. Average age at GR/GG implantation was 9 years. Most cases (n = 24, 80%) were idiopathic. Most pts had kyphoscoliosis (n = 16, 53.3%). Pre-HGT CC averaged 112 ±â€Š22° and SC averaged 106 ±â€Š26°. CC and SC improved 29% after HGT. There was a significant improvement in body mass index following HGT. CC improved further to 70 ±â€Š14° (36% vs. pre-HGT) and SC to 63 ±â€Š21° (41%) with GR/GG placement. HGT-related complications occurred in nine patients (30%); eight pin site infections, one cranial abscess. Most HGT complications were managed with local pin care and oral antibiotics. Halo revision was required in two pts (6.7%). There was no change in PFTs with HGT (P > 0.05). Averagely, 14 levels were spanned during GR/GG implantation; two patients required vertebral column resection. Surgical complications occurred in nine (30%) patients. At average 16 month follow-up, seven patients (23.3%) required reoperation. CONCLUSION: Preoperative HGT can make severe EOSD curves amenable to GR/GG implantation. HGT results in ∼30% correction with improvement to ∼35-40% following GR/GG. HGT has a 30% complication rate but most are pin-site infections managed with pin-site care and oral antibiotics; 6.7% of patients require revision. LEVEL OF EVIDENCE: 4.

Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks.

AIMS: The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS: National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS: A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION: This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.

Cervical Traction for Managing Neck Pain: A Survey of Physical Therapists in the United States.

Study Design Cross-sectional survey. Objective To examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage. Background Systematic reviews provide little support for traction in managing neck pain. While traction usage among physical therapists in other countries has been described, usage in the United States has not been examined. Methods A random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association were surveyed. Associations among respondents' professional demographics and survey responses were explored with chi-square analyses (α = .05). Results The response rate was 25.5% (n = 1001); 76.6% (n = 767) of respondents reported using traction, and 93.1% reported that they would use traction for a patient presenting with signs of nerve root compression. Common delivery modes included manual methods (92.3%) and mechanical traction tables (88.3%). Using traction is often supplemented with other interventions (exercise, postural education, joint mobilization). A higher proportion of physical therapists with American Board of Physical Therapy Specialties orthopaedic certification reported using traction (88.6%) than did those without specialty certification (73.0%). Conclusion Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Professional demographics (clinical specialist credentialing) were associated with traction usage. J Orthop Sports Phys Ther 2017;47(3):200-208. Epub 30 Oct 2016. doi:10.2519/jospt.2017.6914.

Isolated teres minor atrophy: manifestation of quadrilateral space syndrome or traction injury to the axillary nerve?

This article prospectively determines through magnetic resonance imaging (MRI) the incidence of isolated teres minor atrophy and its gender and age distribution, and documents associated findings related to the rotator cuff, labroligamentous complex, and quadrilateral space. Two hundred seventeen consecutive shoulder MRI examinations performed over a 3-month period were prospectively reviewed and evaluated for isolated teres minor atrophy. Twelve (5.5%) patients had non-compressive isolated teres minor atrophy. Ninety-two percent (n=11) of these patients had rotator cuff or labroligamentous complex tears. No patients had an associated mass within the quadrilateral space. The average patient age was 60 years and 11 of the 12 patients were male. Isolated teres minor atrophy on MRI is most commonly seen in older patients who do not fit the expected clinical presentation of quadrilateral space syndrome. The anatomical relationship of the teres minor nerve to the joint capsule and the frequency of associated shoulder injuries in these patients raises the possibility of an association between humeral decentering and teres minor atrophy. Quadrilateral space syndrome would appear to be a very rare cause of isolated teres minor atrophy.

Lumbar Traction for Managing Low Back Pain: A Survey of Physical Therapists in the United States.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To examine how many physical therapists use traction, the patients for whom traction is used, the preferred delivery modes/parameters of traction, the supplemental interventions used with traction, and whether professional characteristics influence traction usage. BACKGROUND: Several systematic reviews and clinical guidelines have questioned the effectiveness of traction for managing low back pain, yet some patients may benefit from lumbar traction. While traction usage among physical therapists in other countries has been described, usage among physical therapists in the United States has not been examined. METHODS: We surveyed a random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association. Associations among respondents' professional characteristics and survey responses were explored with chi-square analyses (α = .05). RESULTS: The response rate was 25.5% (n = 1001), and 76.6% (n = 767) of respondents reported using traction. Most (58.4%) of the respondents used traction for patients with signs of nerve root compression, though many (31.4%) did not. Common delivery modes included manual methods (68.3%) and mechanical tables (44.9%), most often supplemental to other interventions (eg, stabilization exercises, postural education). Levels of professional preparation (doctoral/masters level versus bachelors/certificate level) were associated with many variables, as was attainment of an orthopaedic specialist certification. CONCLUSION: Most of the orthopaedic physical therapists in the United States who responded to our survey reported that they used lumbar traction, though not necessarily consistent with proposed criteria that identify patients most likely to benefit from traction. They used various traction delivery modes/parameters and used traction within comprehensive plans of care incorporating multiple interventions. Professional characteristics (education levels and clinical specialist credentialing) were associated with traction usage.