Video-assisted thoracoscopic surgery in idiopathic scoliosis: evaluation of the learning curve

STUDY DESIGN

Retrospective review of patients with idiopathic scoliosis who underwent same-day or staged anterior and posterior spinal fusion and segmental spinal instrumentation.

OBJECTIVE

Evaluation of our learning curve with video-assisted thoracoscopic surgery (VATS) with respect to operative time, blood loss, and complications in patients with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

VATS is a minimally invasive alternative to thoracotomy in the management of idiopathic scoliosis. An increased or steep learning curve has been described in the initial application of this technique.

METHODS

We began performing VATS in 1998. We compared our first 25 consecutive VATS patients (Group 2) and subsequent 28 consecutive VATS patients (Group 3) to our previous 16 consecutive patients (Group 1) with a thoracotomy (1991-1998) for idiopathic scoliosis. Training at a sponsored regional course was obtained before performing our first VATS procedure.

RESULTS

VATS allowed more disc to be excised in Group 2 (4.5 +/- 1, 5.7 +/- 1, and 4.4 +/- 1 discs in Group 1, Group 2, and Group 3, respectively) and significantly decreased the anterior operative time (215 +/- 33, 260 +/- 56, and 177 +/- 47 minutes) and time per individual disc excision (50 +/- 13, 47 +/- 12, and 41 +/- 12 minutes), while providing comparable correction of the thoracic deformity (67% +/- 12%, 66% +/- 10%, and 70% +/- 13% correction). There was no increase in estimated intraoperative anterior blood loss (228 +/- 213, 183 +/- 136, and 211 +/- 158 mL), estimated blood loss per disc excised (51 +/- 42, 34 +/- 29 and 48 +/- 37 mL), or complications in the VATS groups. Complications were primarily pulmonary and resolved with medical therapy. Postoperative chest tube drainage (855 +/- 397, 462 +/- 249, and 561 +/- 261 mL) and total perioperative anterior blood loss (1083 +/- 507, 647 +/- 309, and 773 +/- 308 mL) were significantly decreased in the VATS groups, but this was attributed to the use of Amicar.

CONCLUSIONS

VATS is an effective procedure for anterior spinal fusion in idiopathic scoliosis. The learning curve is short, provided appropriate training is obtained.

Closed reduction for treatment of development dysplasia of the hip in children

Although many studies have analyzed the success rates of closed reduction and spica casting for the treatment of developmental dysplasia of the hip (DDH) in children, the definition of success for this procedure is not standardized in the literature. We retrospectively reviewed our experience with closed reduction for treatment of DDH in 30 children (35 hips) over an 8-year period to determine the success rates of this procedure on the basis of how success is defined. In only 1 patient (2 hips, 6%) were the hips unable to be concentrically reduced with sufficient stability at the time of closed reduction. In 10 (30%) of the other 33 hips, the acetabulum failed to develop sufficiently after closed reduction, and a secondary surgery was required a mean of 22 months after cast removal. Four (12%) of the 33 hips developed radiographic evidence of avascular necrosis. Therefore, the success rate of closed reduction for DDH varies markedly depending on how success is defined.

Closed reduction for treatment of developmental dysplasia of the hip in children

Although many studies have analyzed the success rates of closed reduction and spica casting for the treatment of developmental dysplasia of the hip (DDH) in children, the definition of success for this procedure is not standardized in the literature. We retrospectively reviewed our experience with closed reduction for treatment of DDH in 30 children (35 hips) over an 8-year period to determine the success rates of this procedure on the basis of how success is defined. In only 1 patient (2 hips, 6%) were the hips unable to be concentrically reduced with sufficient stability at the time of closed reduction. In 10 (30%) of the other 33 hips, the acetabulum failed to develop sufficiently after closed reduction, and a secondary surgery was required a mean of 22 months after cast removal. Four (12%) of the 33 hips developed radiographic evidence of avascular necrosis. Therefore, the success rate of closed reduction for DDH varies markedly depending on how success is defined.

Fibrinogen levels following Amicar in surgery for idiopathic scoliosis

STUDY DESIGN

Prospective evaluation of fibrinogen levels before surgery and after surgery in patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) who received Amicar to decrease perioperative blood loss.

OBJECTIVES

To assess a possible association between postoperative fibrinogen levels and Amicar administration.

SUMMARY OF BACKGROUND DATA

Our previous randomized, double-blind (Amicar and control) study demonstrated a rise in fibrinogen levels on the first postoperative day in the Amicar group, but not in the control group. Fibrinogen levels were not measured on the remaining postoperative days. We subsequently measured fibrinogen levels on all postoperative days in 21 consecutive patients with idiopathic scoliosis and found a dramatic increase throughout the postoperative hospitalization. This study is a continuation of our analysis of postoperative fibrinogen levels.

METHODS

We analyzed fibrinogen levels before surgery and on all postoperative days (4 or 5 days) until discharge in 51 consecutive patients, including our 21 previously reported patients, who received Amicar and underwent a PSF and SSI. We also analyzed the same factors with respect to perioperative blood loss as in our previous Amicar studies.

RESULTS

There were 41 females and 10 males with a mean age at surgery of 14.2 +/- 1.8 years. Their mean hospitalization was 4.6 +/- 0.8 days. Their mean estimated intraoperative blood loss was 766 +/- 308 mL and postoperative suction drainage 532 +/- 186 mL for a total perioperative blood loss of 1297 +/- 311 mL. The perioperative transfusion requirements were 0.5 +/- 0.6 U per patient. The preoperative fibrinogen was 255.5 +/- 58.3 mg/dL, and it rose steadily throughout the postoperative period to 680.9 +/- 111.9 mg/dL on the fifth postoperative day. There were no complications related to the use of Amicar.

CONCLUSIONS

Fibrinogen levels rise steadily throughout the postoperative period. The significance of this increase is unknown. Was it due to the use of Amicar or just the effects of surgery itself? Further investigations will be necessary.

A cadaveric examination of pediatric cervical pedicle morphology

STUDY DESIGN

A retrospective radiographic analysis of 47 intact cadaver pediatric cervical spines at the Hamann-Todd Osteology Collection in Cleveland, Ohio.

OBJECTIVES

Evaluate the morphology of the pediatric cervical spine pedicle, the feasibility of surgical pedicle screw instrumentation, and examine the contribution of growth to the pedicle axis.

SUMMARY OF BACKGROUND DATA

The adult cervical spine has been studied extensively and the morphology of the pedicles well documented. The morphology of the pediatric cervical, thoracic, and thoracolumbar spine has been studied radiographically, but, to our knowledge, no study has specifically examined the cervical spine pedicle, pedicle axis, and their changes with growth.

METHODS

A total of 47 pediatric human cadaver spines with a mean age of 13 years (range 3-18 years at death) from the Hamann-Todd Osteology Collection at the Cleveland Museum of Natural History were analyzed radiographically. There were 25 females and 22 males. The C3-C7 vertebrae were used in this study. The 228 vertebral specimens were evaluated in the axial and sagittal planes. The radiographs were subsequently digitized and measured for 5 parameters on the axial view: pedicle axis length, pedicle length, pedicle width, cervical spinal canal anteroposterior spinal canal diameter, and interpedicular distance.

RESULTS

The pedicle axis length increased with advancing age. The pedicle length remained relatively constant throughout growth, and the pedicle diameter showed a statistically significant increase with growth. Mean pedicle diameter width was 3.0 mm at C3 and 4.2 mm at C7 in the 3-5 year-old group compared to 4.3 mm and 6.1 mm, respectively, at C3 and C7 at 18 years of age. The anteroposterior spinal canal diameter remained relatively constant with increasing age. The interpedicular distance achieved 80% of its adult size by 3-5 years of age. Regarding pedicle axis growth, the 3 components of the pedicle axis (i.e., vertebral body, pedicle, and lateral mass) were analyzed with regards to their contribution to growth. The vertebral body contributed an increasing percentage to overall pedicle axis growth with age, while the pedicle itself contributed a progressively smaller percentage.

CONCLUSIONS

Our results showed an overall increase in the pedicle axis and pedicle width but no significant change in pedicle length. The data in this study indicate that pedicle screws may not be safe for use in the pediatric cervical spine, particularly younger children. The use of lateral mass screws was not specifically addressed in this study. As in the thoracolumbar spine, growth of the pedicles in relation to the spinal canal is lateral to the canal. The vertebral body itself appears to contribute most to overall pedicle axis growth, while the pedicle itself contributes a progressively smaller percentage over time.

Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management

STUDY DESIGN

Literature review.

OBJECTIVE

To establish consistent parameters for future adolescent idiopathic scoliosis bracing studies so that valid and reliable comparisons can be made.

SUMMARY OF BACKGROUND DATA

Current bracing literature lacks consistency for both inclusion criteria and the definitions of brace effectiveness.

METHODS

A total of 32 brace treatment studies and the current bracing in adolescent idiopathic scoliosis proposal were analyzed to: (1) determine inclusion criteria that will best identify those patients most at risk for progression, (2) determine the most appropriate definitions for bracing effectiveness, and (3) identify additional variables that would provide valuable information.

RESULTS

Early brace studies lacked clarity in their inclusion criteria. In more recent studies, inclusion criteria have narrowed considerably to include primarily those patients most at risk for curve progression who may benefit from the use of a brace. Brace effectiveness was usually defined by various degrees of curve progression at maturity. Less frequently, it was defined by the resultant curve magnitude at maturity, whether or not surgical intervention was needed, or if there was change to another brace.

CONCLUSIONS

Optimal inclusion criteria for future adolescent idiopathic scoliosis brace studies consist of: age is 10 years or older when brace is prescribed, Risser 0-2, primary curve angles 25 degrees -40 degrees , no prior treatment, and, if female, either premenarchal or less than 1 year postmenarchal. Assessment of brace effectiveness should include: (1) the percentage of patients who have < or =5 degrees curve progression and the percentage of patients who have > or =6 degrees progression at maturity, (2) the percentage of patients with curves exceeding 45 degrees at maturity and the percentage who have had surgery recommended/undertaken, and (3) 2-year follow-up beyond maturity to determine the percentage of patients who subsequently undergo surgery. All patients, regardless of subjective reports on compliance, should be included in the results (intent to treat). Every study should provide results stratified by curve type and size grouping.

Comparison of single and dual growing rod techniques followed through definitive surgery: a preliminary study

STUDY DESIGN

Retrospective analysis of patients treated with single and dual growing rods who had completed their course of treatment, had definitive fusion, and had a minimum of 2 years follow-up.

OBJECTIVES

To determine which technique was the most effective in the management of severe spinal deformity in young children: control of the spinal deformity, spinal growth, and the incidence of complications.

SUMMARY OF BACKGROUND DATA

Growing rod techniques provide proximal and distal segmental "claw" foundations, but their overall results through definitive fusion have not been clearly determined.

METHODS

A total of 28 consecutive patients who had growing rod procedures followed through definitive spinal fusions were analyzed. There were three patient groups: Group 1 (N = 5), single submuscular rod and short apical fusion; Group 2 (N = 16), single growing rod alone; and Group 3 (N = 7), dual growing rods.

RESULTS

The interval between initial rod insertion and definitive spinal fusion was similar in all three groups. The best overall results occurred in Group 3, whereas the patients in Group 1 had the worse results. Both Groups 2 and 3 provided good initial correction of the spinal deformity and allowed spinal growth. Group 2 had better frontal and sagittal plane balance and the lowest complication rate.

CONCLUSION

The use of growing rods is effective in controlling severe spinal deformities and allowing spinal growth. Dual rods are stronger than single rods and, therefore, provide better initial correction and maintenance of correction. The use of an apical fusion does not appear to be effective over the course of treatment.

The role of amicar in decreasing perioperative blood loss in idiopathic scoliosis

STUDY DESIGN

Four separate studies on the role of Amicar in decreasing perioperative blood loss in idiopathic scoliosis.

OBJECTIVES

To assess the efficacy and possible mechanisms of action for Amicar.

SUMMARY OF BACKGROUND DATA

Preliminary prospective, randomized double-blind and analysis of same-day anterior spinal fusion (ASF), fibrinogen, and posterior spinal fusion (PSF) studies have demonstrated Amicar to be effective in idiopathic scoliosis surgery. Increased fibrinogen secretion is a possible explanation.

METHODS

Amicar is administered at 100 mg/kg over 15 minutes not to exceed 5 g at anesthesia induction. Maintenance is 10 mg/kg per hour until wound closure.

RESULTS

Preliminary study: Amicar (N = 28) was effective compared with a control group (N = 31). Perioperative blood loss and transfusion following PSF were 1,604 +/- 517 mL and 1.1 +/- 1.0 U in the Amicar group compared with 2,312 +/- 994 mL and 2.1 +/- 1.1 U in the control group (P < 0.003). Prospective, randomized double-blind study confirmed this efficacy, although primarily in postoperative suction drainage: 1,391 +/- 212 mL and 1.1 +/- 1.0 U compared with 1,716 +/- 513 mL and 2.1 +/- 1.3 U (P < 0.002). A fibrinogen study (N = 21) demonstrated steady and excessive increase following PSF: before surgery it was 266 +/- 63 mg/dL and on the fifth postoperative day 699 +/- 94 mg/dL. In same-day anterior and posterior spinal surgery, Amicar was again effective, but primarily in decreasing chest tube drainage and during PSF. Group 1 (N = 15, no Amicar) 3,807 +/- 105 mL and 3.1 +/- 1.5 U; Group 2 (N = 27, Amicar for PSF only) 2,080 +/- 659 mL and 1.9 +/- 0.9 U; and Group 3 (N = 16, both ASF and PSF) 2,183 +/- 851 mL and 1.0 +/- 0.8 U.

CONCLUSIONS

Amicar appears highly effective in decreasing perioperative blood loss. This results in less autologous blood donation, blood transfusion, costs, and complications. Its mechanism of action is uncertain but may be related to increased fibrinogen secretion.

Spinal exostoses: analysis of twelve cases and review of the literature

STUDY DESIGN

Retrospective review of spinal exostoses treated at our institution and literature review.

OBJECTIVES

Review of 12 cases of spinal exostoses treated at our institution compared with 165 cases of spinal exostoses reported in the literature.

SUMMARY OF BACKGROUND DATA

Spinal exostoses are uncommon. Most reports consist of 1 to 3 cases. The relationship between solitary exostoses and those associated with multiple hereditary exostoses (MHE), as well as the incidence of intraspinal and extraspinal location, symptoms presentation, and results of treatment are unclear.

METHODS

The medical records, operative reports, and diagnostic imaging of 12 patients with spinal exostoses treated at our institution between 1972 and 2002 were reviewed. The literature was reviewed using MEDLINE search of English literature and bibliographies of published manuscripts.

RESULTS

Solitary spinal exostoses were more common than those associated with MHE. Lesions were most common in the upper cervical spine and originated from the posterior elements. Patients with exostoses associated with MHE were significantly younger and had a higher incidence of symptoms consistent with neural structure compression than patients with solitary exostoses. Complete excision resulted in resolution of preoperative symptoms. Intralesional excision resulted in recurrence in all cases.

CONCLUSIONS

Spinal exostoses are more common than reported previously. Patients with MHE that present with back pain or neurological symptoms should produce a high index of suspicion. Evaluation should include both computed tomography and magnetic resonance imaging to define the origin of the exostosis and the presence of neural structure compression. Surgical excision should be preformed en bloc.

The effect of amicar on perioperative blood loss in idiopathic scoliosis: the results of a prospective, randomized double-blind study

STUDY DESIGN

A prospective, randomized, double-blind Institutional Review Board-approved study evaluating the efficacy of Amicar (epsilon aminocaproic acid), an antifibrinolytic agent, in decreasing perioperative blood loss in idiopathic scoliosis.

OBJECTIVES

To compare the perioperative (intraoperative and postoperative) blood loss and the need for autologous and homologous blood replacement in two groups of essentially identical patients undergoing a posterior spinal fusion for idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Reducing perioperative blood loss and the need for transfusion in patients undergoing spinal surgery is important to orthopedic surgeons. Recently, there has been interest in pharmacologic agents, particularly Amicar and Aprotinin, to assist in decreasing perioperative blood loss. In 2001, in a preliminary study, we demonstrated that Amicar appeared to be effective in reducing perioperative blood loss in patients with idiopathic scoliosis undergoing a posterior spinal fusion and segmental spinal instrumentation. This was a study of 28 consecutive patients receiving Amicar compared to a historical control group of the 31 previous consecutive patients with the same study criteria. The current study was performed to confirm our preliminary findings.

METHODS

We analyzed the perioperative blood loss of 36 patients with idiopathic scoliosis who were blindly randomized by the operating room pharmacy into an Amicar and control group. The criteria to be included in the study was the same as the preliminary study: diagnosis of idiopathic scoliosis, age at surgery 11 to 18 years, posterior spinal fusion and segmental spinal instrumentation only, autogenous iliac crest bone graft or homologous cancellous bone graft, and a signed agreement to participate in the study. The patients in both groups had the same anesthetic technique, intraoperative procedure, instrumentation, postoperative management, and standardized indications for transfusions.

RESULTS

Before surgery, the patients in both groups were essentially identical. The distribution of patients and their results was not known until the completion of the study. Patients in the Amicar group demonstrated a statistically significant decrease in perioperative blood loss and the need for autologous blood transfusion. Interestingly, this decrease was predominantly in the postoperative suction drainage. This may be due to elevated fibrinogen levels induced by Amicar. The patients taking Amicar had no intraoperative or postoperative thromboembolic complications.

CONCLUSIONS

The results of this study confirmed that the use of intraoperative Amicar is a safe, effective, and inexpensive method to significantly reduce perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion and segmental spinal instrumentation. The results have allowed us to reduce our recommendation for perioperative autologous blood donation, thereby further decreasing costs.

Predictive value of pelvic incidence in progression of spondylolisthesis

STUDY DESIGN

Retrospective analysis of pelvic incidence and other radiographic parameters as a predictor of progression of isthmic spondylolisthesis.

OBJECTIVES

To evaluate the predictive value of various radiographic parameters, including pelvic incidence, in determining the risk for progression of lumbosacral isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA Although pelvic incidence has recently been shown to be positively correlated to the severity of spondylolisthesis, it has not been confirmed as a predictor of spondylolisthetic progression.

MATERIALS AND METHODS

Thirty-six patients who have undergone primary posterior lumbosacral fusion for isthmic spondylolisthesis at our institution from 1977 to 2001 were retrospectively analyzed. There were 24 females and 12 males with a mean age of 21.3 +/- 2.0 years (range, 12 to 53 y). Twenty-two patients had high-grade (Meyerding class III, IV, V) and 14 patients had low-grade (Meyerding class I, II) spondylolisthesis, respectively. Factors evaluated included age, gender, neurologic deficits, reason for surgery, and documented evidence of progression. Slip percentage, high-grade or low-grade slip, slip angle, sacral inclination, sacral rounding, trapezoidal L5 vertebra, and pelvic incidence were measured from immediate preoperative standing lateral radiographs. These factors were statistically analyzed for risk of progression. Continuous variables were analyzed using one-way analysis of variance. Nominal variables were analyzed using chi2 test.

RESULTS

Pelvic incidence (P = 0.66) was not predictive of spondylolisthetic progression. Of the other radiographic measurements, slip percentage (P < 0.001), slip angle (P = 0.016), and high-grade spondylolisthesis (P < 0.0001) were highly predictive of progression. Interestingly, sacral inclination (P = 0.33) was not predictive of progression.

CONCLUSIONS

Pelvic incidence cannot adequately predict the probability of spondylolisthetic progression. Analysis of the other clinical and radiographic parameters revealed that slip percentage and high-grade spondylolisthesis remain the most positive predictors of progression.

Second cervical vertebrae pedicle fractures versus synchondrosis in a child

Fractures of the second cervical vertebrae (C2) can be difficult to diagnose in young children. A 17-month-old infant sustained bilateral C2 pedicle fractures after minor trauma. The initial lateral radiograph showed pedicle defects, but even with computed tomography and a bone scan with single photon emission computed tomography this could not be differentiated from a congenital abnormality. One week after injury, repeat radiographs showed spondylolisthesis confirming the defects were fractures. The fractures were treated by closed reduction and a halo vest and healed uneventfully. This child is among a small number of patients with bilateral C2 pedicle fractures that occur predominantly in young children. Diagnosis can be difficult even with a high index of suspicion.

Pelvic fractures in a pediatric level I trauma center

OBJECTIVES

Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures.

SETTING

Urban university pediatric Level I trauma center in a large metropolitan community.

PATIENTS/PARTICIPANTS

Retrospective analysis of 57 consecutive children with 66 pelvic fractures seen between 1993 and 1999.

INTERVENTION

Fifty-two patients were treated nonoperatively, and five patients required operative stabilization (four acetabular fractures and one partial sacroiliac joint disruption).

MAIN OUTCOME MEASURE

Type and cause of pelvic fracture, type of management used, incidence of associated injuries, hemorrhage requiring transfusion, and mortality.

RESULTS

Hemorrhage directly related to the pelvic fracture occurred in only one patient (2%), whereas 11 other patients required transfusions associated with other body-area injuries. Three patients with pelvic fractures died (5%), but deaths were due to other body-area injuries.

CONCLUSIONS

Children with pediatric pelvic fractures require careful evaluation for other body-area injuries, as these are most likely to be related to hemorrhage or mortality.

Sternoclavicular joint ganglion cysts in young children

Ganglion cysts originating from the sternoclavicular joint in children have not been previously reported. In this study, 5 children who presented with a small mass over the anterior aspect of the sternoclavicular joint were evaluated and treated. Only 1 patient was symptomatic. A ganglion cyst was suspected in each case and confirmed by magnetic resonance imaging in 3 patients and ultrasound in one patient. Excisional biopsy was performed in 3 patients and the diagnosis of a ganglion cyst confirmed histopathologically. No patient has had a recurrence. Observation of asymptomatic cystic lesions that arise in the sternoclavicular location is recommended.

Association of bladder exstrophy with congenital pathology of the hip and lumbosacral spine: a long-term follow-up study of 13 patients

The authors evaluated, clinically and radiographically, 13 of 28 patients with bladder exstrophy treated at their institution between 1964 and 1982. All had been treated with bilateral iliac osteotomies and pelvic rami reapproximation to assist in urologic repair. At skeletal maturity, the diastasis had partially recurred and the patients had short stature and were living normal lives. Mild acetabular dysplasia and other pelvic abnormalities were common, as were abnormal radiographic findings in the lumbosacral spine. Despite these findings, most did not affect function. These results support the need for pelvic reconstruction for urologic repair, as well as the need for periodic radiographic evaluation of the pelvis and lumbosacral spine. If present, these have the potential to adversely affect function as an adult.

Submuscular Isola rod with or without limited apical fusion in the management of severe spinal deformities in young children: preliminary report

STUDY DESIGN

Retrospective review of the results of submuscular rod placement with and without limited apical fusion for the treatment of severe spinal deformities in young children.

OBJECTIVES

To determine the success of this method for controlling severe deformities while allowing for spinal growth and to compare this method with previously reported results.

SUMMARY OF BACKGROUND DATA

A variety of methods for controlling scoliosis in young children have been reported, but complications including spontaneous fusion, loss of correction, instrumentation failure, and limited spinal growth are common.

METHODS

The cases of 29 young children with progressive scoliosis or kyphoscoliosis as a result of a variety of diagnoses treated with a submuscular Isola rod and a postoperative orthosis were retrospectively reviewed. Eleven patients also had a short anterior and posterior apical fusion or convex hemiepiphysiodesis to aid in correction and stabilization of their deformity. The remaining 18 patients had a submuscular rod only.

RESULTS

The mean age at surgery was 6.7 years (range, 1-11 years). The initial preoperative mean magnitude of the major curve was 66 degrees (range, 42-112 degrees ). After surgery this decreased to a mean of 38 degrees (range, 16-70 degrees ). The most recent radiographs demonstrated a mean 47 degrees curve (range, 28-79 degrees ). The mean number of lengthenings per patient has been two (range, 0-5). Nine patients have reached a suitable age and have been converted to a posterior spinal fusion and segmental spinal instrumentation. Nine complications have occurred in seven patients (24%). These included five hook displacements and three rod breakages. These were treated by hook reinsertion and rod exchange or sleeve and a repeat lengthening. There was one superficial infection treated medically.

CONCLUSION

This technique is useful in the management of severe spinal deformities in young children who have either failed, or have a contraindication to, orthotic management. Complications are relatively frequent but well tolerated.

A three-dimensional study of calcaneonavicular tarsal coalitions

The authors studied 37 presumed calcaneonavicular tarsal coalitions from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. The anatomy of the coalitions and the associated subtalar and transverse tarsal joints was quite variable. The coalitions in 8 specimens completely spared the anterior facet of the calcaneus and in 7 specimens it was partially replaced by the navicular portion of the coalition, whereas in 22 specimens the anterior calcaneal facet was completely replaced by the navicular portion of the coalition. The authors suggest that the pathoanatomy of calcaneonavicular coalitions is not uniform and may involve the subtalar and transverse tarsal joints. This may have clinical relevance and contribute to the unsatisfactory results in feet undergoing coalition resection and soft tissue interposition.

Child and family functioning 6 and 12 months after a serious pediatric fracture

BACKGROUND

Previous findings indicate that pediatric fractures can have adverse consequences for child adjustment and family functioning immediately after injury. However, longer term effects of the fractures are unknown. The purposes of the present prospective study were to examine the child and family outcomes of pediatric traumatic fractures at 6 months and 1 year after injury, and to identify injury and treatment factors associated with these outcomes.

METHODS

We evaluated 57 children 6 to 12 years of age with traumatic fractures requiring hospitalization. Using standardized measures and parent interview, we obtained measures of pre- and postinjury child and family functioning.

RESULTS

Although outcomes were primarily positive at 1 year after injury, child functional limitations and family stress were observed up to 6 months after injury. Lower extremity fractures had a more negative impact on families across all three assessment points. Children with fracture interventions that involved prolonged immobilization had more functional limitations at 6 months than children who were ambulatory. Family burden was higher at 1 month for the immobilized children, but not at later follow-up.

CONCLUSION

Some children and families experience adverse effects during the year after a serious pediatric fracture, especially if sustained in a lower extremity. Fracture stabilization that allows for greater ambulation may offer some benefits related to functional outcomes and family impact.

The Effect of epsilon-aminocaproic acid on perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: a preliminary prospective study

STUDY DESIGN

A prospective study evaluating the efficacy of epsilon-aminocaproic acid (EACA) in decreasing perioperative blood loss in idiopathic scoliosis.

OBJECTIVES

To compare the perioperative blood loss and need for blood replacement in two groups of patients undergoing surgery for idiopathic scoliosis. One group received intraoperative EACA; the other did not and served as controls.

SUMMARY OF BACKGROUND DATA

Excessive blood loss increases the operative time, risk for blood product disease transmission, postoperative complications, and costs associated with posterior spinal fusion and instrumentation. EACA is an antifibrinolytic agent that has been shown to be effective in reducing perioperative blood loss during pediatric cardiothoracic surgical procedures. We hypothesized that it would also be effective in lowering blood loss during posterior spinal fusion for idiopathic scoliosis.

METHODS

We compared the perioperative blood loss of 28 consecutive pediatric patients with idiopathic scoliosis who underwent posterior spinal fusion and received intraoperative EACA with 31 consecutive patients who did not receive this medication and served as a control group.

RESULTS

The patients in both groups were similar. Patients in the EACA group demonstrated statistically significant decreases in total estimated perioperative blood loss and the need for autologous blood transfusion. The patients in the EACA group had no intraoperative or postoperative complications related to the use of this medication.

CONCLUSIONS

Based on these preliminary findings, we believe that EACA is helpful in decreasing blood loss in patients undergoing posterior spinal fusion and instrumentation, and may decrease the number of autologous units needed to maintain safe perioperative hemoglobin levels, thereby improving safety and lowering cost associated with scoliosis surgery.

Salter-Harris type II fractures of the capital femoral epiphysis

Salter-Harris type II fractures of the capital femoral epiphysis have not been previously documented. The authors have treated three patients who sustained four such fractures. One child had a recurrent fracture two years after the first had healed satisfactorily. Two fractures were treated by spica cast immobilization, one fracture by closed reduction and internal fixation, and the other fracture healed without treatment. No patient developed avascular necrosis or other complications. Two of the children had an association with idiopathic slipped capital femoral epiphysis. An etiologic relationship with slipped capital femoral epiphysis, if any, is uncertain.

The floating knee in the pediatric patient. Nonoperative versus operative stabilization

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weightbearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weightbearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.

The rigid flatfoot. Tarsal coalitions

Tarsal coalitions are the major cause of painful rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalitions are the most common sites. They are often bilateral and may be asymptomatic. They represent a failure of fetal mesenchymal differentiation, and onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilaginous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerized tomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and interposition of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, with arthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions.