A Role for Thyroid Testing in Slipped Capital Femoral Epiphysis? 32% Rate of Abnormal Values in Tested Patients

BACKGROUND

Hypothyroidism is a known risk factor for slipped capital femoral epiphysis (SCFE), and prior studies of hypothyroid-associated SCFE have demonstrated an incidence of up to 6%. However, there is limited evidence and no formal practice guidelines regarding whether patients presenting with SCFE should undergo screening for endocrine disorders. This study aims to investigate the incidence of abnormal thyroid function studies in patients presenting with SCFE.

METHODS

This was a retrospective review of all patients aged 0 to 18 years treated for SCFE at a single pediatric hospital from January 2015 to July 2022. On presentation, patients' BMI, thyroid-stimulating hormone (TSH), free T4, vitamin D, creatinine, BUN, and HbA1c levels were documented. Follow-up and treatment for any identified endocrinopathies were noted. In addition, the chronicity, stability, and severity of their slips were recorded.

RESULTS

Ninety-eight patients with 106 hips were included in this study. TSH was obtained at the time of initial presentation in 66% (n=65/98) of patients. Median TSH was 2.99 (range: 0.02 to 919, std dev: 132.4). The normal reference range for our institution is 0.5 to 4.5 mcIU/mL. Thirty-two percent (n=21/65) of patients with a documented TSH had an abnormal value. Of those patients who had an elevated TSH, 3 were diagnosed with clinical hypothyroidism and went on to treatment with levothyroxine (n=3/19, 16%), 2 patients had been started on levothyroxine before presentation (n=2/19, 11%), and 2 patients were followed in endocrinology clinic until their TSH levels had normalized without further intervention (n=2/19, 11%).

CONCLUSIONS

Screening of our SCFE population revealed a 32% incidence of thyroid abnormalities which affected treatment in 24% of those patients. This is a much higher incidence of hypothyroid-associated SCFE than previously demonstrated in the literature and has prompted us to start including thyroid screening studies as a routine part of our workup for all patients with SCFE.

LEVEL OF EVIDENCE

Level III.

Standardized In-harness Ultrasound Protocol Improves Success Rate of Brace Treatment for Dislocated Hips

OBJECTIVE

Infant hip dislocations benefit from early detection and treatment for optimal outcomes. Prior studies have identified that there remains wide variability in the success rate of bracing between institutions. Although there are standardized methods to screen infants for hip dysplasia, there are no clear guidelines regarding how to image a child being treated for a hip dislocation with a Pavlik harness. As a result, there is substantial variability in how treatment success or failure is monitored between and within institutions. The goal of our study is to determine whether a standardized in-harness imaging protocol improves outcomes and the likelihood of successful treatment for dislocated hips being treated with the Pavlik harness.

METHODS

All patients with hip dislocations and pretreatment ultrasound (US) were included from July 2018 to July 2022. A new institutional US protocol was implemented in July 2020, during which standardized in-harness imaging was obtained for patients with hip dislocations. Patients treated before the implementation of standardized in-harness imaging were categorized as nonstandardized and after implementation as a standardized group. Outcomes were compared between standardized and nonstandardized groups. P<0.05 determined the statistical significance.

RESULTS

One hundred twenty-eight hips met the inclusion criteria (n = 97 patients). The mean age at diagnosis was 41.6 ± 23.4 days and was predominantly female (85.6%). There was no significant difference between the patients' demographics and baseline clinical characteristics between the standardized and nonstandardized groups. Pavlik harness success rate was significantly higher in the standardized group (85% vs 60%, P= 0.0024). Twenty-eight hips in the nonstandardized group remained dislocated and were indicated for surgical treatment, whereas only 8 hips remained dislocated in the standardized group and necessitated closed or open reduction.

CONCLUSIONS

Standardization of in-harness imaging for patients undergoing treatment for developmental hip dislocations can significantly improve the Pavlik harness success rate. These findings emphasize the importance of obtaining images with the hip in flexion and abduction to prevent inadvertent stress during US evaluation for hips that have not yet stabilized, which may lead to premature cessation of the Pavlik harness.

LEVEL OF EVIDENCE

Level III.

Hip Pain in Adolescent Patients

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.

Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial

BACKGROUND

Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures.

METHODS

Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort.

RESULTS

A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort.

CONCLUSIONS

Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure.

LEVEL OF EVIDENCE

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

Intramedullary Ulnar Fixation for the Treatment of Monteggia Fracture

Background

Although many pediatric Monteggia fractures can be treated nonoperatively, the presence of any residual radiocapitellar subluxation following ulnar reduction mandates a more aggressive approach to restore and maintain ulnar length. In younger children, restoration and maintenance of ulna length may be achieved through intramedullary fixation of the ulnar shaft.

Description

A Steinmann pin or flexible intramedullary nail is introduced percutaneously through the olecranon apophysis and advanced within the medullary canal to the ulnar fracture site. If necessary, the ulnar length and alignment are then restored by either a closed reduction or open reduction. The pin or nail is advanced across the fracture site into the distal fracture fragment and then advanced to a point just proximal to the distal ulnar physis. Once restoration of normal radiocapitellar alignment is verified fluoroscopically, the pin is bent and cut outside of the skin and a cast or splint is applied.

Alternatives

Closed reduction and cast immobilization is a well-accepted form of treatment for a Monteggia fracture. If ulnar length and alignment along with an anatomic reduction of the radiocapitellar joint can be achieved in this fashion, surgery can be avoided, but close radiographic follow-up is recommended to assess for loss of alignment with subsequent radial-head subluxation. Open reduction and internal fixation with use of a plate-and-screw construct can achieve similar results to intramedullary fixation and should be considered for length-unstable fractures and those in which an appropriately sized intramedullary implant fails to maintain adequate ulnar alignment. If plastic deformation of the ulna is present with residual radiocapitellar subluxation following reduction of the ulnar diaphysis, consideration should be given to elongating the ulna through the fracture site with use of plate fixation in order to allow reduction of the radial head.

Rationale

Intramedullary fixation provides several benefits over open reduction and plate fixation for these injuries. In general, treatment can be rendered with a shorter anesthetic time, less scarring, and without the concern for symptomatic retained hardware associated with plating along the subcutaneous boarder of the ulna shaft.

Expected Outcomes

Compared with nonoperative treatment, intramedullary fixation of length-stable Monteggia fractures has lower rates of recurrent radial-head subluxation and loss of ulnar alignment requiring subsequent operative treatment¹. If healing is achieved without residual radiocapitellar instability, good elbow function can be expected.

Important Tips

The entry point for the intramedullary implant should be slightly radial to the tip of the olecranon apophysis to compensate for the anatomic varus bow of the proximal aspect of the ulna.Intramedullary fixation is ideal for length-stable ulnar fractures. If a comminuted or long oblique fracture is present, an intramedullary device may not maintain ulnar length, leading to residual or recurrent radiocapitellar instability. For length-unstable fractures, therefore, a plate-and-screw construct should be considered.No more than 3 attempts should be made to pass the intramedullary implant into the distal ulnar segment by closed means in order to limit the risk of iatrogenic compartment syndrome.If anatomic alignment of the radiocapitellar joint is not achieved following an apparent anatomic reduction of the ulna, assess for plastic deformation of the ulna and consider open elongation of the ulna through the fracture site with use of plate fixation.Following fixation and radial-head reduction, immobilize the forearm in the position of maximal radiocapitellar stability (typically in supination).

What's New in Pediatric Hip?

BACKGROUND

Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip.

METHODS

We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

RESULTS

A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information.

CONCLUSIONS

DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions.

LEVEL OF EVIDENCE

Level V.

Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection

BACKGROUND CONTEXT

Although many risk factors are known to contribute to the development of a postoperative surgical site infection (SSI) following spinal surgery, little is known regarding the costs associated with the management of this complication, or the predictors for which patients will require increased resources for the management of SSI.

PURPOSE

The aim of this study was to identify specific risk factors for increased treatment costs and length of stay in the management of a postoperative SSI.

STUDY DESIGN/SETTING

This is a retrospective cohort study of all patients undergoing spine surgery at a single institution for 3 consecutive years.

PATIENT SAMPLE

The study included 90 patients who were required to return to the operating room following spine surgery for postoperative SSI.

OUTCOME MEASURES

The primary outcome measure was length of stay and hospital costs for patients with postoperative SSI following spine surgery at a single institution.

METHODS

A retrospective review of all patients undergoing spine surgery at a single institution for 3 consecutive years was performed to identify patients requiring secondary surgical intervention for SSI. Demographic and financial data from both the index admission and all subsequent readmissions within 2 years of the index procedure were reviewed. Independent variables abstracted from patient records were analyzed to determine the nature and the extent of their associations with total direct hospital costs and length of stay.

RESULTS

A total of 90 patients were identified that resulted in 110 readmissions, and these patients cumulatively underwent 138 irrigation and debridement (I&D) procedures for the management of postoperative spine SSI. The average length of stay for the index operation and secondary readmissions were 6.9 and 9.6 days, respectively. The mean direct cost of the treatment for SSI was $16,242. The length of stay, the number of levels fused, methicillin-resistant Staphylococcus aureus (MRSA), decreased serum albumin on readmission, and the number of I&D procedures required were significantly associated with increased treatment costs.

CONCLUSIONS

Preoperative nutritional status assessment and MRSA colonization screening with targeted prophylaxis represent potentially modifiable risk factors in the treatment of SSI. Further study is needed to investigate the relationship between poor nutrition status and increased length of stay and total costs in the treatment of SSI following spine surgery.

Correlation between shunt series and scoliosis radiographs in children with myelomeningoceles

Object

Over 85% of patients with myelomeningoceles require placement of a ventriculoperitoneal shunt for hydrocephalus, and between 25% and 85% of these patients develop scoliosis. Although most patients undergo repeated shunt series radiography to evaluate for device malfunction, scoliosis radiographs are less consistently obtained. The authors sought to determine if a correlation exists between these 2 radiographic techniques for a given patient, as shunt series are obtained with the patient supine, whereas scoliosis radiographs are acquired with the patient standing upright. The authors also endeavored to study if shunt series radiographs can reliably detect significant scoliosis.

Methods

The authors retrospectively reviewed a single institution's series of 593 patients with myelomeningoceles and identified all patients in whom a shunt series and scoliosis radiographs were obtained within a 6-month period. They reviewed the medical records and radiographs of these patients for demographic and radiographic parameters. They then applied a linear regression model and determined shunt series curve cutoffs to detect scoliotic curves greater than 20° and 50°.

Results

Of the 593 patients identified, 116 did not have radiographs available for interpretation. Of the remaining 477 patients, 201 had radiographic evidence of scoliosis (42%), and 66 had both a shunt series and a scoliosis radiographs acquired within a 6-month interval. In 4 patients, both end vertebrae of the scoliotic curve could not be visualized on a single radiograph. The mean age of the remaining cohort was 10.6 ± 5.2 years and the mean curve magnitude was 58° ± 37°. Using identical end vertebrae, the mean shunt series curve magnitude was 49° ± 35°. The mean interval between both radiographs was 2.3 ± 3.3 months. The regression model showed a strong linear association between shunt series and scoliosis series curves. A curve greater than 19° on shunt series radiographs would detect significant curves of greater than 20° on scoliosis series with 91% sensitivity and 78% specificity. A shunt series curve greater than 37° had 100% sensitivity and 93% specificity in identifying significant scoliotic curves greater than 50°.

Conclusions

Although shunt series radiographs may not precisely depict scoliotic curve magnitude because the impact of gravity is negated, they may be useful in helping to confirm clinical suspicion of scoliosis. The authors' results suggest a strong correlation between both types of radiographs.

Kyphectomy in patients with myelomeningocele treated with pedicle screw-only constructs: case reports and review

OBJECT

Significant lumbar kyphosis is frequently observed in patients with myelomeningocele and has been associated with increasing functional impairment, decreased abdominal volume, respiratory impairment, discomfort, and skin ulcerations overlying the prominent gibbus. Treatment of severe kyphotic deformities can include kyphectomy, with or without ligation of the thecal sac, with posterior spinal fixation. However, most series have reported a high rate of morbidity and complications associated with surgical intervention for correction of kyphosis in patients with myelomeningocele. The authors describe a technique in which pedicle screw (PS)-only constructs are used without transection of the thecal sac to treat severe kyphosis successfully, with minimal morbidity.

METHODS

The authors retrospectively reviewed medical records and radiographic images in 2 patients with myelomeningoceles in whom kyphectomies had been performed at the authors' institution between January 2007 and July 2010. They also reviewed the existing literature for case reports or published series of patients with myelomeningocele treated with kyphectomies, to evaluate the outcomes.

RESULTS

Both patients were male and had thoracic-level myelomeningoceles that had been repaired at birth, with associated paraplegia. Neither patient had any significant scoliotic deformity associated with the kyphosis, and both had fixation from T-9 to the ilium, which was performed using PS constructs, along with L1-2 kyphectomies. The patient in Case 1 was 20 years old and was treated for progressive kyphosis and an ulcerated nonhealing wound over the gibbus. The patient in Case 2 was 10 years old and was treated for progressive pain and functional impairment. The 2 patients had a mean correction of 63%, with a mean correction of kyphotic deformity from 136° to 51°. Neither patient developed any complication in the short term postoperatively, whereas published series have reported high complication rates, including wound infection, poor wound healing, CSF leakage, pseudarthrosis, and shunt malfunction.

CONCLUSIONS

Severe kyphotic deformities in patients with myelomeningocele can be safely treated using PS-only constructs without ligation of the thecal sac. Further evaluation with a larger sample and longer follow-up are needed to detect any associated complications, such as proximal junctional kyphosis. Further evaluation may also validate whether PS-only constructs permit successful outcomes with a shorter construct and fewer instrumented levels.

Effects of doxycycline on articular cartilage GAG release and mechanical properties following impact

The effects of doxycycline were examined on articular cartilage glycosaminoglycan (GAG) release and biphasic mechanical properties following two levels of impact loading at 1 and 2 weeks post-injury. Further, treatment for two continuous weeks was compared to treatment for only the 1st week of a 2-week culture period. Following impact at two levels, articular cartilage explants were cultured for 1 or 2 weeks with 0, 50, or 100 microM doxycycline. Histology, GAG release to the media, and creep indentation biomechanical properties were examined. The "High" (2.8 J) impact level had gross surface damage, whereas "Low" (1.1 J) impact was indiscernible from non-impacted controls. GAG staining decreased after High impact, but doxycycline did not visibly affect staining. High impact resulted in decreased aggregate moduli at both 1 and 2 weeks and increased permeability at 2 weeks, but tissue mechanical properties were not affected by doxycycline treatment. At 1 week, High impact resulted in more GAG release compared to non-impacted controls. However, following High impact, 100 microM doxycycline reduced cumulative GAG release at 1 and 2 weeks by 30% and 38%, respectively, compared to no treatment. Interestingly, there was no difference in GAG release comparing 2 weeks continuous treatment with 1 week on, 1 week off. These results support the hypothesis that doxycycline can mitigate GAG release from articular cartilage following impact loads. However, doxycycline was unable to prevent the loss of tissue stiffness observed post-impact, presumably due to initial matrix damage resulting solely from mechanical trauma.

The Effects of Isolation on Chondrocyte Gene Expression

Tissue engineering of articular cartilage usually requires the isolation and culture of chondrocytes. Previous studies have suggested that enzymatic isolation may alter the metabolic activity and growth rate of chondrocytes. This study examined the effects of 4 common isolation protocols on chondrocyte gene expression, morphology, and total cell yield immediately following the digest (t = 0) and after 2 culture periods (24 h and 1 week). Cartilage explants were digested using 1 of 4 protocols: (1) 6-h collagenase digest, (2) 22-h collagenase digest, (3) 45-min trypsin digest followed by a 3-h collagenase digest, or (4) 1.5-h pronase digest followed by a 3-h collagenase digest. Gene expression levels for glyceraldehyde-3-phosphate dehydrogenase, type I collagen, type II collagen, aggrecan, superficial zone protein, matrix metalloproteinase- 1, and tissue inhibitor of metalloproteinase-1 were measured at t = 0 h, 24 h, and 1 week using quantitative reverse transcriptase-polymerase chain reaction. In this study, cell yield was greatest for the 22-h collagenase and pronase-collagenase digests. However, the data indicate that a 6-h collagenase digest has the fewest gene expression changes compared to native cells. For tissue engineering, data from this study suggest that when cell yield is critical, a 22-h collagenase digest is preferable, but when obtaining cells closest to native chondrocytes is more desired, the 6-h collagenase digest is more beneficial.