Effect of Antibiotic Prophylaxis on Infection Rates in Pediatric Supracondylar Humerus Fractures Treated with Closed Reduction and Percutaneous Pinning: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

Supracondylar humerus fractures (SCHFs) are the most common elbow fracture in the pediatric population. In the case of displaced fractures, closed reduction and percutaneous Kirschner wire pinning (CRPP) is commonly performed. Infection rates are between 0 and 7%; however, retrospective studies have shown no benefit of preoperative antibiotics. There continues to be notable variability in antibiotic usage based on surgeon preference and local institutional policy. We conducted a double-blinded, randomized controlled trial to evaluate whether antibiotic prophylaxis reduces the risk of infection in pediatric SCHF patients treated with CRPP.

METHODS

Pediatric patients with displaced SCHF who presented to a pediatric hospital were enrolled and randomized into two groups. Group I received one dose of prophylactic antibiotics (25 mg/kg cefazolin IV up to 1g or clindamycin 10 mg/kg up to 600 mg/kg IV in the case of cefazolin allergy). Group II received placebo (10-mL prefilled syringe of normal saline). All patients underwent CRPP and casting followed by pin removal 3 to 6 weeks after the initial procedure. The presence of pin-site infection, erythema, drainage, septic arthritis, and osteomyelitis was recorded.

RESULTS

One hundred sixty patients were enrolled in the study. Eighty-two patients were randomized to receive antibiotics, and 78 patients were randomized to placebo. No difference was seen in the rate of infection between the treatment groups (1.2% in the antibiotic group versus 1.3% in the placebo group; P = 1.00). Presence of purulent drainage (0.0% versus 1.3%; P = 0.49), septic arthritis (0.0% versus 0.0%; P = 1.00), and osteomyelitis (1.2% versus 0.0%; P = 1.00) was similar in both groups. No difference in the need for additional antibiotics (1.2% versus 1.3%; P = 1.00) or additional surgery (1.2% versus 0.0%; P = 1.00) was found between groups.

DISCUSSION

The use of antibiotic prophylaxis did not affect the risk of infection in pediatric patients who underwent CRPP for displaced SCHF.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03261830.

LEVEL OF EVIDENCE

Therapeutic Level I.

Incidence of Tether Breakage in Anterior Vertebral Body Tethering

BACKGROUND

Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively.

METHODS

All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts.

RESULTS

In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002).

CONCLUSIONS

The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively.

LEVEL OF EVIDENCE

Level IV.

Bilateral vertebral body tethering: identifying key factors associated with successful outcomes

PURPOSE

The treatment of operative double major pediatric spinal deformities (e.g., Lenke 3 or 6) with bilateral vertebral body tethering (VBT) can be significantly more challenging when compared to other deformity patterns (e.g., Lenke 1) or treatment with a posterior spinal fusion. We aimed to identify preoperative and perioperative characteristics that were associated with successful postoperative outcomes in patients treated with both a thoracic and thoracolumbar (e.g., bilateral) tether.

METHODS

We retrospectively assessed radiographic and clinical data from patients enrolled in a large multi-center study who had a minimum postoperative follow-up of two years. Standard radiographic parameters were extracted from standing spine and left hand-wrist radiographs at various timepoints. We classified patients based on their preoperative deformity pattern (Primary Thoracic [TP] vs. Primary Thoracolumbar [TLP]) and assessed: (1) deformity balance, (2) tilt of the transitional vertebra, and (3) postoperative success.

RESULTS

We analyzed data from thirty-six patients (TP: 19 and TLP: 17). We observed no relationship between deformity balance at first erect and postoperative success (p = 0.354). Patients with a horizontal transitional vertebra at first erect were significantly (p = 0.001) more likely to exhibit a successful outcome when compared to those who exhibited a tilted transitional vertebra (83% vs. 62%). Patients who had TLP were also more likely to exhibit a successful outcome when compared to patients who exhibited TP (76% vs. 50%).

CONCLUSION

These data indicate that double major deformities can be successfully treated with VBT, particularly for those who exhibit TLP.

Automated extraction of biplanar stereo-radiographic image measurements: Mizzou 3D SPinE

PURPOSE

Although several studies have reported on the application of biplanar stereo-radiographic technology in pediatric clinical practice, few have performed large-scale analyses. The manual extraction of these types of data is time-consuming, which often precludes physicians and scientists from effectively utilizing these valuable measurements. To fill the critical gap between clinical assessments and large-scale evidence-based research, we have addressed one of the primary hurdles in using data derived from these types of imaging modalities in pediatric clinical practice by developing an application to automatically transcribe and aggregate three-dimensional measurements in a manner that facilitates statistical analyses.

METHODS

Mizzou 3D SPinE was developed using R software; the application, instructions, and process were beta tested with four separate testers. We compared 1309 manually compiled three-dimensional deformity measurements derived from thirty-five biplanar three-dimensional reconstructions (image sets) from ten pediatric patients to those derived from Mizzou 3D SPinE. We assessed the difference between manually entered values and extracted values using a Fisher's exact test.

RESULTS

Mizzou 3D SPinE significantly reduced the duration of data entry (95.8%) while retaining 100% accuracy. Manually compiled data resulted in an error rate of 1.58%, however, the magnitude of errors ranged from 5.97 to 2681.82% significantly increased the transcription accuracy (p value < 0.0001) while also significantly reducing transcription time (0.33 vs. 8.08 min).

CONCLUSION

Mizzou 3D SPinE is an essential component in improving evidence-based patient care by allowing clinicians and scientists to quickly compile three-dimensional data at regular intervals in an automated, efficient manner without transcription errors.

Once-weekly TransCon CNP (navepegritide) in children with achondroplasia (ACcomplisH): a phase 2, multicentre, randomised, double-blind, placebo-controlled, dose-escalation trial

Background

TransCon CNP (navepegritide) is an investigational prodrug of C-type natriuretic peptide (CNP) designed to allow for continuous CNP exposure with once-weekly dosing. This 52-week phase 2 (ACcomplisH) trial assessed the safety and efficacy of TransCon CNP in children with achondroplasia.

Methods

ACcomplisH is a global, randomised, double-blind, placebo-controlled, dose-escalation trial. Study participants were recruited between June 10, 2020, and September 24, 2021. Eligible participants were prepubertal, aged 2-10 years, with genetically confirmed achondroplasia, and randomised 3:1 to once-weekly subcutaneous injections of TransCon CNP (6, 20, 50, or 100 μg CNP/kg/week) or placebo for 52 weeks. Primary objectives were safety and annualised growth velocity (AGV). ACcomplisH is registered with ClinicalTrials.gov (NCT04085523) and Eudra (CT 2019-002754-22).

Findings

Forty-two participants received TransCon CNP at doses of 6 μg (n = 10; 7 female), 20 μg (n = 11; 3 female), 50 μg (n = 10; 3 female), or 100 μg (n = 11; 6 female) CNP/kg/week, with 15 receiving placebo (5 female). Treatment-emergent adverse events (TEAEs) were mild or moderate with no grade 3/4 events reported. There were 2 serious TEAEs that were assessed as not related to TransCon CNP. Eleven injection site reactions occurred in 8 participants receiving TransCon CNP and no symptomatic hypotension occurred. TransCon CNP demonstrated a dose-dependent improvement in AGV. At 52 weeks, TransCon CNP 100 μg CNP/kg/week significantly improved AGV vs placebo (least squares mean [95% CI] 5.42 [4.74-6.11] vs 4.35 [3.75-4.94] cm/year; p = 0.0218), and improved achondroplasia-specific height SDS from baseline (least squares mean [95% CI] 0.22 [0.02-0·41] vs -0·08 [-0.25 to 0.10]; p = 0.0283). All participants completed the randomised period and continued in the ongoing open-label extension period receiving TransCon CNP 100 μg CNP/kg/week.

Interpretation

This phase 2 trial suggests that TransCon CNP is effective, safe, with low injection site reaction frequency, and may provide a novel, once-weekly treatment option for children with achondroplasia. These results support TransCon CNP at 100 μg CNP/kg/week in the ongoing pivotal trial.

Funding

Ascendis Pharma, A/S.

Outcomes of vertebral body tethering in the lumbar spine

PURPOSE

The use of vertebral body tethering (VBT) for the treatment of main thoracic deformities in adolescent idiopathic scoliosis patients is becoming increasingly more common, but limited data exist on its safety and efficacy in thoracolumbar deformities. We aimed to evaluate the postoperative outcomes of patients with thoracolumbar (TL) deformities that were treated with VBT.

METHODS

We assessed clinical and radiographic data from twenty-eight consecutive patients that were surgically managed with VBT, all of whom exhibited a TL deformity with at least two years (mean: 44.7 ± 14.5 months) of postoperative follow-up. Standard radiographic parameters were extracted from left hand wrist and standing posterior-anterior and lateral spine radiographs at various timepoints. Outcome variables were assessed based on preoperative Lenke Classification and included: deformity measures, complications, surgical revisions, and postoperative success.

RESULTS

The mean age at the time of instrumentation was 13.4 ± 1.3 years, with an average preoperative Sanders Stage of 4.6 ± 1.4. A significant reduction in preoperative deformities was observed at most postoperative timepoints. A perioperative complication was observed in three patients and surgical revision was required in another four patients. A suspected broken tether was observed in sixteen patients, most of which occurred at the apex of the lumbar deformity. Only one patient required surgical revision due to a suspected broken tether. We observed an overall success rate of 57%, regardless of Lenke Classification.

CONCLUSIONS

These data indicate that VBT can successfully correct TL deformity patterns in 57% of patients without an increase in the rate of perioperative complications, suspected broken tethers, or surgical revisions.

Household Income and Parental Educational Level Affect Post-Operative Opioid Usage in Pediatric Orthopaedic Patients

Opioid medications are commonly prescribed after pediatric orthopaedic surgery, but there is a critical need to optimize prescribing practice. This study identifies socio-economic characteristics, surgical characteristics, and patient reported psychological factors influencing postoperative opioid use in this population and found that post-operative opioid use in this pediatric orthopaedic population is multifactorial. Physicians should consider implementing protocols for initial opioid prescriptions to cover two to three days following common orthopaedic surgeries for most pediatric patients.

Anterior Vertebral Body Tethering Compared with Posterior Spinal Fusion for Major Thoracic Curves

BACKGROUND

Anterior vertebral body tethering (AVBT) is an alternative to posterior spinal fusion (PSF) for the surgical treatment of scoliosis. The present study utilized a large, multicenter database and propensity matching to compare outcomes of AVBT to PSF in patients with idiopathic scoliosis.

METHODS

Patients with thoracic idiopathic scoliosis who underwent AVBT with a minimum 2-year follow-up retrospectively underwent 2 methods of propensity-guided matching to PSF patients from an idiopathic scoliosis registry. Radiographic, clinical, and Scoliosis Research Society 22-Item Questionnaire (SRS-22) data were compared preoperatively and at the ≥2-year follow-up.

RESULTS

A total of 237 AVBT patients were matched with 237 PSF patients. In the AVBT group, the mean age was 12.1 ± 1.6 years, the mean follow-up was 2.2 ± 0.5 years, 84% of patients were female, and 79% of patients had a Risser sign of 0 or 1, compared with 13.4 ± 1.4 years, 2.3 ± 0.5 years, 84% female, and 43% Risser 0 or 1 in the PSF group. The AVBT group was younger (p < 0.001), had a smaller mean thoracic curve preoperatively (48 ± 9°; range, 30° to 74°; compared with 53 ± 8°; range, 40° to 78° in the PSF group; p < 0.001), and had less initial correction (41% ± 16% correction to 28° ± 9° compared with 70% ± 11% correction to 16° ± 6° in the PSF group; p < 0.001). Thoracic deformity at the time of the latest follow-up was 27° ± 12° (range, 1° to 61°) for AVBT compared with 20° ± 7° (range, 3° to 42°) for PSF (p < 0.001). A total of 76% of AVBT patients had a thoracic curve of <35° at the latest follow-up compared with 97.4% of PSF patients (p < 0.001). A residual curve of >50° was present in 7 AVBT patients (3%), 3 of whom underwent subsequent PSF, and in 0 PSF patients (0%). Forty-six subsequent procedures were performed in 38 AVBT patients (16%), including 17 conversions to PSF and 16 revisions for excessive correction, compared with 4 revision procedures in 3 PSF patients (1.3%; p < 0.01). AVBT patients had lower median preoperative SRS-22 mental-health component scores (p < 0.01) and less improvement in the pain and self-image scores between preoperatively and the ≥2-year follow-up (p < 0.05). In the more strictly matched analysis (n = 108 each), 10% of patients in the AVBT group and 2% of patients in the PSF group required a subsequent surgical procedure.

CONCLUSIONS

At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent AVBT had a residual curve of <35° compared with 97.4% of patients who underwent PSF. A total of 16% of cases in the AVBT group required a subsequent surgical procedure compared with 1.3% in the PSF group. An additional 4 cases (1.3%) in the AVBT group had a residual curve of >50° that may require revision or conversion to PSF.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Physeal fusion status and lesion size are more important than patient age for healing of juvenile osteochodritis dessicans lesions of the distal femur

PURPOSE

The purpose of the study was to evaluate the effect of skeletal age and lesion size, location, and grade on the success of nonoperative treatment for juvenile osteochondritis dissecans (OCD). It is hypothesized that skeletal maturity, including a combination of maturation phenotypes, correlates with nonoperative lesion healing.

METHODS

The clinical and radiographic data on 52 patients aged 7-20 years treated for OCD of the distal femur between 2010 and 2019 were retrospectively reviewed. Knee radiographs were assessed for number of lesions present and lesion location, size, and stage. Assessments of skeletal maturation were performed on all antero-posterior knee radiographs using the Roche, Wainer, and Thissen (RWT) method. Patients were categorized as healed if they demonstrated no pain on clinical examination. The relationship between skeletal maturity and nonoperative lesion healing was determined using Spearman rank correlations on available variables.

RESULTS

Neither chronological nor skeletal age was associated with surgical status (Rho = 0.03, n.s., and Rho = 0.13, n.s., respectively) or the healing status of nonoperatively treated OCD lesions (Rho = 0.44, n.s., and Rho = 0.03, n.s., respectively). Epiphyseal fusion status of the distal femoral physis was moderately correlated with nonoperative healing, but was not statistically significant (lateral femoral physis: Rho = 0.43, p = 0.05; medial femoral physis: Rho = 0.43, n.s.). Lesion length correlated with surgical status (Rho = - 0.38, p = 0.009).

CONCLUSION

The extent of fusion of the distal femoral physis (multi-stage grading) may be more strongly correlated with nonoperative healing than other markers of skeletal maturity or chronological age. Clinicians can use this as an additional radiographic sign when considering nonoperative treatment for juvenile OCD lesions in the distal femur. OCD lesion length and physeal fusion status appear to be more important for healing than patient age.

Spontaneous Lumbar Curve Correction Following Vertebral Body Tethering of Main Thoracic Curves

BACKGROUND

Growth modulation through anterior vertebral body tethering (AVBT) has emerged as a fusionless option for the treatment of progressive scoliosis. When tethering the main thoracic curve, the compensatory thoracolumbar/lumbar curve must correct indirectly as a result. The present study evaluated the response of these lumbar curves following AVBT of the main thoracic curves.

METHODS

Patients who underwent thoracic AVBT and who had a minimum follow-up of 2 years were included. Magnitudes of the thoracic and lumbar curves were recorded preoperatively and at the first-erect and 2-year postoperative visits. Lumbar curves were further stratified according to their lumbar modifier (A, B, or C). Analysis of variance (ANOVA) and repeated-measures ANOVA were performed to compare correction rates, and the Pearson coefficient was utilized to determine the correlation between the tethered thoracic curve and uninstrumented lumbar curve magnitudes.

RESULTS

A total of 218 patients were included. Thoracic curve correction was 40% at the first-erect visit and 43% at 2 years (p = 0.012). Lumbar correction was 30%, 26%, and 18% at the first-erect visit (p < 0.001 for all compared with preoperatively) and minimally changed at 31%, 26%, and 24% at 2 years for lumbar modifiers A, B, and C, respectively. A total of 118 patients (54%) showed thoracic curve improvement between the first-erect and 2-year visits. In a subgroup analysis, these patients had a correction in lumbar curve magnitude from preoperatively to the first-erect visit of 30%, 22%, and 16% for lumbar modifiers A, B, C, respectively, that increased to 42%, 34%, and 31% at 2 years, with strong correlation to thoracic correction at 2-year follow-up (r = 0.557, p < 0.001).

CONCLUSIONS

Although there was immediate lumbar correction following AVBT of a main thoracic curve, further improvement following initial correction was only observed among patients with growth modulation of the thoracic curve. Considering all patients, the uninstrumented lumbar curve corrected 30% at 2 years and the instrumented thoracic curve corrected 40%. As indications for AVBT are refined, these data will provide insight into the response of the uninstrumented lumbar curve.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

When successful, anterior vertebral body tethering (VBT) induces differential segmental growth of vertebrae: an in vivo study of 51 patients and 764 vertebrae

PURPOSE

This study aimed to determine (1) does vertebral body tethering (VBT) produce differential growth modulation in individual vertebrae in patients with idiopathic scoliosis, (2) does VBT change disc shape, and (3) does VBT affect total spine length?

METHODS

Patients with idiopathic scoliosis treated with VBT of the main thoracic curve and minimum 2-year follow-up were included. Vertebrae and discs were categorized as uninstrumented proximal thoracic, instrumented main thoracic, or uninstrumented thoracolumbar-lumbar. The left- and right-sided heights of each vertebra and disc were measured on subsequent radiographs to assess for differential growth. T1-T12 thoracic and T1-S1 thoracolumbar growth velocities were compared with standardized reference data.

RESULTS

Fifty-one patients (764 vertebrae and 807 discs) were analyzed. The average major curve magnitude improved from 46° ± 11° to 17° ± 11° at 2-year follow-up. Differential growth was observed in MT vertebrae, in which the left/concave side grew 2.0 ± 2.2 mm compared with 1.5 ± 2.3 mm on the right/convex (tethered) side (p < 0.001). Differential height changes were observed for all discs, but were most pronounced in instrumented MT discs, in which the right/convex sides decreased by an average of 1.2 mm each, compared with no significant height change on the left/concave side. Total spinal growth velocities were not significantly different from standard reference data.

CONCLUSION

Vertebral body tethering limits convex spinal growth as designed while permitting concave growth. Curve correction results from differential vertebral growth and decreased convex disc height. Overall spinal growth continues at the expected rate.

LEVEL OF EVIDENCE

Level IV case series.

Team Integrated Enhanced Recovery (TIGER) Protocol after Adolescent Idiopathic Scoliosis Correction Lowers Direct Cost and Length of Stay While Increasing Daily Contribution Margins

INTRODUCTION

Posterior spinal fusion (PSF) is the gold standard procedure for curve correction in Adolescent Idiopathic Scoliosis (AIS). Enhanced recovery protocols (ERPs) have been found to decrease pain and hospital length of stay (LOS) resulting in decreased total hospital charges.

METHODS

We identified all adolescent idiopathic scoliosis patients treated with a posterior spinal fusion at our children's hospital between 2015-2019. Length of stay, pain scores, and hospital direct costs were calculated to determine the pathway's efficacy.

RESULTS

Hospital LOS was reduced by 26% and post-op pain scores did not significantly change when using the Team Integrated Enhanced Recovery (TIGER) protocol (P<0.05). Total hospital costs decreased by 7.9%, daily contribution margins increased 7.9%, and daily net income increased 10.6% after TIGER protocol implementation.

CONCLUSION

TIGER protocol resulted in decreased hospital LOS as well as direct costs for the hospital without increasing postoperative pain scores.

As Vertebral Body Tethering Impacts Missouri, New Technology Grows in the Right Direction

All eleven-year-old girls want to do is play and be active like every other child her age. Yet, the ability to have a normal childhood for one of our patients became a concern when she and her parents noticed an abnormal lateral curvature in her spine, which was later diagnosed as adolescent idiopathic scoliosis. In February 2014, she presented with a 45° thoracic deformity with a high risk of progression. At that time, the gold standard for the treatment of her deformity was a posterior spinal fusion - a surgical treatment she nor her parents were interested in pursuing. After their initial appointment, her parents scoured the internet and discovered a new non-fusion surgical technique, known as vertebral body tethering, that might correct their daughter's deformity without the need for titanium rods in her spine. In April 2014, that same eleven-year-old girl underwent vertebral body tethering of her main thoracic deformity from T5 to L1 under the care and management of Dr. Daniel Hoernschemeyer, a pediatric orthopaedic surgeon, with the University of Missouri's Department of Orthopaedic Surgery. Today, she is a healthy young adult who is thinking more about prom than about her scoliosis.

Vertebral Body Tethering: Rationale, Results, and Revision

Vertebral body tethering is a nonfusion technique for the surgical correction of adolescent idiopathic scoliosis. For skeletally immature patients for whom vertebral body tethering is indicated, it is an alternative option to the gold standard posterior spinal fusion (PSF) and may at least partially preserve motion in instrumented segments of the spine. Benefits of the procedure include the possibility of avoiding the long-term sequelae of PSF such as adjacent segment disease and proximal junctional kyphosis. Recent retrospective case series of vertebral body tethering have shown promising results with correction rates up to 70% but greater variability in outcomes compared with PSF. The complication profile of the procedure also appears to differ from PSF with tether breakage and overcorrection as primary concerns in addition to approach-related complications. Although early outcomes have been promising, additional studies to optimize surgical timing, long-term outcomes, and the possible role of tethering in the more skeletally mature patient are required.

Treatment of femoral fractures in children aged two to six

Aims

Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group.

Methods

Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years.

Results

All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia.

Conclusion

Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061.

Anterior Vertebral Body Tethering for Adolescent Scoliosis with Growth Remaining: A Retrospective Review of 2 to 5-Year Postoperative Results

BACKGROUND

Anterior vertebral body tethering (VBT) is an early treatment option for progressive scoliosis in pediatric patients, allowing for continued deformity correction during normal growth. We report postoperative radiographic and clinical outcomes for patients treated with VBT.

METHODS

This clinical and radiographic retrospective review of 31 consecutive patients included an analysis of preoperative, perioperative, and postoperative details, including the Lenke classification; Cobb angle measurements of the proximal thoracic, main thoracic, and lumbar curves; the sagittal profile; and skeletal maturity. Successful outcomes were defined by a residual curve of ≤30° in skeletally mature patients who did not undergo a posterior spinal fusion (PSF).

RESULTS

Of the 31 patients treated, 29 met the inclusion criteria, and 2 were lost to follow-up. The mean patient age (and standard deviation) at the time of the surgical procedure was 12.7 ± 1.5 years (range, 10.2 to 16.7 years), with most patients classified as Risser grade 0 or 1 (52%) and Sanders stage 3 (32%). A mean of 7.2 ± 1.4 vertebral levels were instrumented, with a minimum preoperative Cobb angle of 42°. At the latest follow-up, 27 patients had reached skeletal maturity (Sanders stage ≥7) and 20 patients exhibited a curve magnitude ≤30°, for a success rate of 74%. A suspected broken tether occurred at ≥1 level in 14 patients (48%). Two patients underwent PSF and 4 had tether revision. The overall revision rate was 21% (6 of 29).

CONCLUSIONS

This study shows the success and revision rates as well as the impact of a suspected broken tether on the procedural success of VBT. Despite our patient population being slightly more mature at the time of the surgical procedure compared with previous studies, we had a higher success rate and a lower revision rate. A PSF was avoided in 93% of patients, indicating that VBT may be a reliable treatment option for adolescent scoliosis in skeletally immature individuals.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Analysis of the s2 alar-iliac screw as compared with the traditional iliac screw: does it increase stability with sacroiliac fixation of the spine?

BACKGROUND CONTEXT

Arthrodesis of the lumbosacral junction continues to be a challenge in pediatric and adult spinal deformity surgery.

PURPOSE

To evaluate the biomechanical rigidity of two types of lumbosacral fixation. Our hypothesis was that the use of S2 alar-iliac (S2AI) fixation will result in statistically similar biomechanical fixation as compared with use of an iliac screw with a 95% confidence interval.

STUDY SETTING

Controlled biomechanical laboratory METHODS: Ten human cadaveric lumbosacral specimens were separated into two test groups: (1) S2AI (n=5) and (2) iliac screw (n=5). S2AI and iliac screws were placed according to current clinical practice techniques. Specimens were mounted in an unconstrained dual leg stance configuration for testing in flexion, extension, lateral bending, and axial rotation. These loads were induced by moving the offset loading arm 10 mm in the respective direction from the point of neutral motion with displacement control up to a 10 N-m moment, except axial rotation which used a 4 N-m moment. Optical tracking was used to monitor motion of the vertebra, pelvis, and fixation instrumentation during testing. Specimens were tested in intact and instrumented states. The stiffness values between S2AI and iliac screw configurations were compared.

DISCLOSURE

The present study received external research support (>$50,000 -<$75,000) from Stryker Spine (Allendale, NJ, USA).

RESULTS

There was a consistent trend of increased construct stiffness for all S2AI samples compared with the iliac screw group. However, none of the groups tested reached statistical significance for a 95% confidence interval.

CONCLUSIONS

S2AI screws are just as stable as iliac screws with biomechanical testing in flexion, extension, rotation, lateral bending, and axial rotation. Given the similarities of biomechanical testing to human movements, these findings support S2AI screws as a viable option for lumbosacral fixation.

Discoid Meniscus Associated With Achondroplasia

Achondroplasia is the most common skeletal dysplasia. This form of dwarfism is caused by a point mutation in the fibroblast growth factor receptor 3 (FGFR3) gene, leading to inhibition of endochondral ossification for these patients. This results in a normal trunk height but shortened limbs. The discoid meniscus may be an important associated finding to better understand the common complaints of leg pain for these patients. Although the incidence for a discoid meniscus is between 3% and 5% for the general population, it is unknown with achondroplasia. This case series includes 4 patients, with ages ranging from adolescence to early adulthood, with symptoms of knee pain that were not attributable to some of the more common findings seen in this patient population. Typically, patients with achondroplasia who experience knee pain are evaluated for more common and well-known etiologies such as genu varum, ligamentous instability, and neurogenic claudication. However, the authors propose that symptomatic discoid lateral meniscus should be added to the differential diagnosis for lower-extremity pain in the achondroplasia population. A thorough history and physical examination, in combination with magnetic resonance imaging, can aid in making the diagnosis. Treatment with arthroscopic debridement, saucerization of the meniscus, and repair for unstable injuries has yielded good outcomes for this patient population. [Orthopedics. 2016; 39(3):e498-e503.].

Use of mineral oil aids scoliosis correction by decreasing implant friction

Adolescent idiopathic scoliosis is commonly corrected through posterior spinal fusion and instrumentation using pedicle screws. One difficulty in performing the correction with this method is the potential for friction at the interface between the rod and each individual point of fixation. The authors have found that the application of mineral oil at these points of contact serves to reduce friction, reducing the need for undue force and increasing the likelihood of effective fixation. The lubrication afforded by the mineral oil is particularly helpful when performing scoliosis correction using the classic derotation of the rod and direct vertebral rotation.

Effects of dexmedetomidine on propofol and remifentanil infusion rates during total intravenous anesthesia for spine surgery in adolescents

INTRODUCTION

Total intravenous anesthesia with propofol and a synthetic opioid is a frequently chosen anesthetic technique for posterior spinal fusion. Despite its utility, adverse effects may occur with high or prolonged propofol dosing regimens including delayed awakening. The current study investigated the propofol-sparing effects of the concomitant administration of the alpha(2)-adrenergic agonist, dexmedetomidine, during spinal fusion surgery in adolescents.

METHODS

The surgical database of the department of orthopedic surgery was searched and patients (12-21 years of age) were identified who had undergone spinal fusion for either idiopathic or neuromuscular scoliosis during the past 24 months. Patients were assigned to two groups. Group 1 included patients anesthetized with propofol and remifentanil and group 2 included patients anesthetized with dexmedetomidine, propofol, and remifentanil. In the latter group, dexmedetomidine was administered as a continuous infusion of 0.5 microg.kg(-1).h(-1) started after the induction of anesthesia without a loading dose. Propofol was adjusted to maintain the bispectral index (BIS) number at 40-50 and remifentanil was adjusted to maintain the mean arterial pressure (MAP) at 50-65 mmHg. Labetolol or hydralazine was used if the MAP could not be maintained at 50-65 mmHg with remifentanil up to a maximum dose of 0.6 microg/kg/min. Statistical analysis included a nonpaired t-test for parametric data (age, weight, remifentanil/propofol infusion requirements, and heart rate/blood pressure values). A nonparametric statistical analysis (Dunn) was used to compare BIS numbers. Parametric data are presented as the mean +/- SD while nonparametric data are presented as the median and the 95th percentile confidence intervals.

RESULTS

Twelve patients received propofol-remifentanil-dexmedetomidine and 24 received propofol-remifentanil. There were no differences in the demographic data, BIS numbers or hemodynamic parameters between the two groups. There was a reduction in the propofol infusion requirements in patients who also received dexmedetomidine (71 +/- 11 microg.kg(-1).min(-1)) compared with those receiving only propofol-remifentanil (101 +/- 33 microg.kg(-1).min(-1), P = 0.0045). No difference was noted in the remifentanil infusion requirements or the use of supplemental agents (hydralazine and labetolol) to maintain controlled hypotension.

CONCLUSION

The concomitant use of dexmedetomidine in patients undergoing spinal fusion reduces propofol infusion requirements when compared with those patients receiving only propofol and remifentanil.

Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents

BACKGROUND

Dexmedetomidine may be a useful agent as an adjunct to an opioid-propofol total intravenous anesthesia (TIVA) technique during posterior spinal fusion (PSF) surgery. There are limited data regarding its effects on somatosensory (SSEPs) and motor evoked potentials (MEPs).

METHODS

The data presented represent a retrospective review of prospectively collected quality assurance data. When the decision was made to incorporate dexmedetomidine into the anesthetic regimen for intraoperative care of patients undergoing PSF, a prospective evaluation of its effects on SSEPs and MEPs was undertaken. SSEPs and MEPs were measured before and after the administration of dexmedetomidine in a cohort of pediatric patients undergoing PSF. Dexmedetomidine (1 microg x kg(-1) over 20 min followed by an infusion of 0.5 microg x kg(-1) x h(-1)) was administered at the completion of the surgical procedure, but prior to wound closure as an adjunct to TIVA which included propofol and remifentanil, adjusted to maintain a constant depth of anesthesia as measured by a BIS of 45-60.

RESULTS

The cohort for the study included nine patients, ranging in age from 12 to 17 years, anesthetized with remifentanil and propofol. In the first patient, dexmedetomidine was administered in conjunction with propofol at 110 microg x kg(-1) x min(-1) which resulted in a decrease in the bispectral index from 58 to 31. Although no significant effect was noted on the SSEPs (amplitude or latency) or the MEP duration, there was a decrease in the MEP amplitude. The protocol was modified so that the propofol infusion was incrementally decreased during the dexmedetomidine infusion to achieve the same depth of anesthesia. In the remaining eight patients, the bispectral index was 52 +/- 6 at the start of the dexmedetomidine loading dose and 49 +/- 4 at its completion (P = NS). There was no statistically significant difference in the MEPs and SSEPs obtained before and at completion of the dexmedetomidine loading dose.

CONCLUSION

Using the above-mentioned protocol, dexmedetomidine can be used as a component of TIVA during PSF without affecting neurophysiological monitoring.

Near-infrared spectroscopy identifies compartment syndrome in an infant

Acute compartment syndrome is a surgical emergency requiring immediate intervention to limit tissue and nerve injury. Although the measurement of compartment pressure is frequently performed, there is controversy regarding the pressure at which fasciotomy should be performed. Near-infrared spectroscopy (NIRS) uses the same technology as pulse oximetry to estimate tissue oxygenation. To date, NIRS is used most commonly to estimate cerebral oxygenation during intraoperative anesthetic care. The authors present a 1-month-old infant who developed an acute compartment syndrome of the right lower extremity after cardiac surgery. In addition to the measurement of compartment pressures, the diagnosis of compartment syndrome was confirmed by NIRS with a value of 15% in the involved leg versus 40% to 50% in the noninvolved contralateral lower extremity. The potential use of this modality in identifying compartment syndrome is reviewed.

Early presentation of spinal stenosis in achondroplasia

One third of patients with achondroplasia develop spinal stenosis requiring surgical intervention. However, this condition rarely develops before the age of 15 years. The goal of the current study was to identify anatomical factors and clinical symptoms associated with early presentation of lumbar stenosis in such patients. The charts of 22 pediatric patients with achondroplasia who developed lumbar spinal stenosis requiring surgery (subjects) were reviewed retrospectively, focusing on clinical presentation, physical examination findings, and radiographic data. These findings were compared with those of a group of patients who had not developed stenotic symptoms (controls). Analysis was performed using chi2 test. Significance was set at P < 0.05. All 22 subjects presented with neurogenic claudication (weakness, pain, and/or numbness), and 77% had bladder incontinence. Compared radiographically with controls, the subjects had a significantly larger average percentage decrease in the transverse interpedicular distance from T12 to L5 (-8% vs -19%, respectively) and a significantly greater thoracolumbar kyphosis angle (24.2-degree angle vs 14.1-degree angle, respectively). These features were associated with an increased likelihood of developing symptomatic stenosis. The study indicated that 6 patients (32%) of the control group had caudal widening of the lumbar spine from T12 to L5.

Delayed Postoperative Paralysis in Adolescent Idiopathic Scoliosis

A delayed spinal epidural hematoma following scoliosis surgery is relatively uncommon but well recognized by clinical and radiographic findings. A 12-year-old girl with scoliosis measuring 80 degrees lower thoracic curve underwent anterior (T6-T12) and posterior fusion with posterior instrumentation from T2 to L1. She developed bilateral leg weakness and progressive left lower leg paralysis 24 hours later. Emergent decompression and partial removal of hardware was performed. Reinsertion of segmental instrumentation and correction of her curve was performed 2 weeks later. The patient had complete recovery of her neurologic deficits, and her correction was maintained at 85% at 4-months follow-up. The authors recognized that there should be no delay in returning the patient to surgery if neurological deficits are noticed. Exploration and decompression of "an occupying lesion" and release of cord tension by partial removal of hardware and re-instrument can achieve appropriate original correction of scoliosis and satisfactory clinical outcome.