Aaron G. Littleton

Complications of Intrathecal Baclofen Pump Therapy in Pediatric Patients

Background The aim of this study was to investigate and evaluate complications of intrathecal baclofen (ITB) pump implantation and maintenance in children with cerebral palsy. Methods We reviewed our entire consecutive series of pediatric patients treated with ITB between 1997 and 2006 at our hospital. There were 174 patients with a diagnosis of cerebral palsy, 8 with mixed dystonia, 2 with athetosis, and 3 with pure dystonia. During follow-up, 8 deaths occurred with no evidence of pump or catheter malfunction in any way contributing to the cause of death. Acute infection within 60 days of the surgery and late infection rates were calculated on the basis of number of incidents and incidents/follow-up patient years, respectively. Independently, a blinded caregiver phone questionnaire was completed in 92 cases. Results There were 316 surgical procedures; 161 were initial ITB pump implants at our institution. The average age at initial implant was 12 years, with an average follow-up of 3 years, 2 months. There were 80 planned replacement procedures (46 battery expirations and 3 planned pump replacements during posterior spinal fusion, 26 catheter replacements for posterior spinal fusion, and 5 reinsertions). There were 78 procedures in 57 patients related to complications, and the acute infection rate was 4.0%. The probability of developing a late infection was 1.0% per year of follow-up. On the basis of the follow-up questionnaire, 81% of parents/caregivers were satisfied with the treatment, and 87% would recommend ITB therapy. Conclusions ITB therapy is a safe and effective treatment for severe spasticity in the pediatric population, but does have a 31% rate of complications requiring surgical management over a 3-year treatment period. Parents and caregivers have a high rate of satisfaction and most would recommend the treatment to others.

Antibiotic-loaded allograft decreases the rate of acute deep wound infection after spinal fusion in cerebral palsy.

Study Design. A retrospective matched cohort study with control group. Objective. To compare the infection rate after posterior spinal fusion with unit rod instrumentation with or without gentamicin-impregnated allograft bone in children with cerebral palsy (CP). Summary of Background Data. Previous studies evaluating wound infection rates after spinal fusion surgery in children with CP report an 8.7% to 10% wound infection rate. The concept of using antibiotic-loaded bone graft (AbBGF) to provide local antibiotics has been explored in high risk patients, such as those with osteomyelitis or infected joint arthroplasty. There have been no reports of using AbBGF prophylactically in spine surgery. Methods. After IRB approval, the medical records of 220 children with CP who underwent spinal fusion with unit rod instrumentation for a primary spinal deformity between January 2000 through December 2006 at a single institution were retrospectively reviewed. We evaluated the incidence of postoperative wound infection in patients with AbBGF and those without bone graft (BGF). Results. One hundred fifty-four patients received AbBGF during spinal fusion surgery and 6 patients (3.9%) developed a deep wound infection. Ten (15.2%) of the 66 patients without AbBGF developed a deep wound infection. The difference between groups was statistically different (P = 0.003). The mean age at surgery, preoperative Cobb angle, correction rate, operative time, and estimated blood loss were not statistically different between the 2 groups (P > 0.05). The length of hospital stay was decreased in the AbBGF group (P < 0.05). Conclusion. The incidence of deep wound infection after spinal fusion in 220 children with CP scoliosis decreased from 15% to 4% with the use of prophylactic antibiotics in the corticocancellous allograft bone.

Lateral Acetabular Growth Stimulation Following a Labral Support Procedure in Legg-Calvé-Perthes Disease

BACKGROUND The main goal of containment treatment in cases of Legg-Calvé-Perthes disease is to prevent hip deformity, which leads to arthritis in adulthood. Recently, the shelf arthroplasty (the labral support procedure) has been proposed as a method of containment. The purpose of the present study was to evaluate growth stimulation of the acetabulum in patients with unilateral Legg-Calvé-Perthes disease by measuring acetabular depth and height following treatment with the labral support procedure. Uninvolved, contralateral hips and hips that were treated with proximal femoral varus osteotomy were used to compare growth. METHODS Sixty-five consecutive patients with unilateral Legg-Calvé-Perthes disease that had been treated with the labral support procedure (forty-nine) or a proximal femoral varus osteotomy (sixteen) were evaluated on the basis of radiographic and clinical data that had been obtained at the time of surgery as well as at one, three, and five years after surgery. Acetabular dimensions (depth, height, and total depth with shelf) were measured and, to eliminate radiographic magnification error, the data were expressed in ratios between the involved and uninvolved sides. RESULTS Preoperatively, both surgical groups were comparable. Acetabular depth indexes at the time of surgery were not different between the groups (p = 0.46). At one, three, and five years postoperatively, the mean depth indexes in the labral support group were significantly higher than those in the proximal femoral varus osteotomy group (F = 5.417, p = 0.001), and trend analysis showed a significant quadratic effect over time in the labral support procedure group (F = 13.132, p = 0.001). The acetabular height indexes at the time of surgery were not different between groups and showed 11% to 13% acetabular overgrowth. The acetabular height indexes in both groups remained unchanged at the time of follow-up (F = 2.82, p = 0.1). The total depth index showed decreasing linear trend values over the period studied (F = 35.115, p = 0.001). CONCLUSIONS Overgrowth of the acetabulum occurs naturally and early in the course of Legg-Calvé-Perthes disease and is more pronounced in terms of height. The labral support procedure induces additional lateral growth of the true acetabulum (excluding the shelf) for three years following surgery, whereas a proximal femoral varus osteotomy does not. Thus, beneficial effects of the labral support procedure are lateral acetabular growth stimulation, prevention of subluxation, and shelf resolution after femoral epiphyseal reossification. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Difficult thoracic pedicle screw placement in adolescent idiopathic scoliosis.

Study Design Retrospective radiographic and clinical consecutive case series. Objective The objective of this study was to identify patients treated with posterior spinal fusion and pedicle screw instrumentation for adolescent idiopathic scoliosis (AIS) in whom it was not possible to place a planned pedicle screw, and describe the possible difficulties in screw placement. Summary of Background Data Despite the knowledge of anatomic characteristics of upper thoracic spine pedicles and considerable experience in thoracic pedicle screw placement, inserting pedicle screws in some patients with AIS may be difficult. Methods We reviewed 96 patients with AIS in whom the intent was to use an all-screw construct in 2004. Placement of the pedicle screws was usually by the freehand method, with intraoperative fluoroscopy used as needed. If a screw could not be safely placed after multiple attempts, a down-going supralaminar or transverse process hook was placed. Medical records were reviewed and radiographs were measured by one of the authors. Results We identified 17 cases (18%) in which a hook had been placed. All cases had a major thoracic curve (Lenke 1, 2, and 3) and the single hook had always been placed at the most cephalad level of the construct on the patients right side. The most common levels for hook placement were T3 and T4; these pedicles were noted to be sclerotic, narrow, and have a moderate amount of rotation on the preoperative posterior-anterior and side bending radiographs. Conclusions Care should be exercised during pedicle screw instrumentation in the apical region of the proximal thoracic curve, whether structural or nonstructural, especially in the concavity. The preoperative radiographs may give helpful clues to intraoperative challenges of pedicle screw insertion at the uppermost level of instrumentation. Hook fixation was satisfactory in this scenario.

Baclofen Pump Implantation and Spinal Fusion in Children: Techniques and Complications

Study Design. Retrospective clinical and radiographic review of complications related to intrathecal baclofen therapy (ITB) and posterior spine fusion (PSF) in patients with cerebral palsy. Objective. To report the technical considerations and complications associated with ITB in patients undergoing PSF. Summary of Background Data. A common treatment for spasticity in children with cerebral palsy is ITB. This population also has a high incidence of severe spinal deformities requiring PSF. Methods. There were 4 groups: A, 26 patients with PSF before ITB; B, 11 patients who underwent PSF and ITB concurrently; C, 25 patients with PSF after ITB; and D, the control group: 103 patients with ITB only. Complications and infections were tabulated from a retrospective chart review and ongoing surveillance data. Multiple &khgr;2 analyses were used to compare the number of patients who experienced complications and infections among the groups. The operative sequence and catheter management techniques for the various scenarios are described in detail in the text. Results. The outcome by group was as follows: group A had 5 catheter malfunctions and 2 infections at the pump site, group B had 2 catheter malfunctions, 1 hypermobile pump and 1 infection at the spinal site, group C had 3 catheter malfunctions, 1 infection at the pump site and 1 infection at the spinal site. The control group had 23 catheter malfunctions, 5 pump failures, 8 infections at the pump site, and 1 infection at the spinal site. Multiple &khgr;2 analyses showed no difference in the number of infection or device/catheter complications among any of the groups. Conclusion. The rate of ITB therapy complications is not increased despite PSF in any order of the procedures. There are technical details in each situation that require attention. With understanding of the appropriate techniques of catheter management, ITB pumps can be implanted and managed without an increased complication rate before, during or after spinal fusion surgery.

Efficacy and safety of percutaneous epiphysiodesis.

Background: The aims of this study were to evaluate outcomes of percutaneous epiphysiodesis, as described by Bowen, in 97 patients and to assess complications and determine whether the effect of the epiphysiodesis will accurately follow the Moseley chart predictions. Methods: A total of 97 patients were reviewed retrospectively. Fifty-six girls and 41 boys, with a mean skeletal age of 12.6 years (range, 10-16 years) at the time of operation, were followed up until skeletal maturity, a mean of 3.8 years (range, 1-10 years). Results: The mean residual leg length discrepancy (LLD) in 88 patients at maturity was 1.3 cm (range, 0-3.5 cm). In 9 patients, the epiphysiodesis was combined with a femoral lengthening or femoral shortening. The residual leg length discrepancy in these 9 patients was 3.3 cm at maturity (range, 0-6.5 cm). Minor complications including knee effusion (n = 2), superficial wound infection (n = 1), and exostosis (n = 3) occurred in 6 patients. Failure of the epiphysiodesis was the only major complication seen (n = 3). Conclusions: This study shows that complications are infrequent when performing percutaneous epiphysiodesis and that the Moseley straight-line method accurately and efficaciously predicted the timing for percutaneous epiphysiodesis in all but one patient who had unpredictable growth from hemihypertrophy secondary to a hemangiomatosis.

Electronic monitoring of scoliosis brace wear compliance.

PurposeAccurate evaluation of patient compliance with scoliosis brace usage has been a challenge for physicians treating patients with adolescent idiopathic scoliosis. This inability to accurately measure compliance has resulted in difficulty in determining brace treatment efficacy. This prospective study was performed to demonstrate the efficacy of using a new electronic brace compliance monitor, the Cricket.MethodsThe Cricket is a small encased circuit that can be attached to the brace and, by means of a temperature sensor, can record brace wear times. This study included ten subjects with adolescent idiopathic scoliosis who were prescribed the Wilmington scoliosis brace (thoraco-lumbo-sacral orthosis) into which the Cricket sensor was incorporated. Subjects kept a diary of brace wear times.ResultsComparisons of data for the Cricket, subject diaries, and prescribed brace wear were evaluated. The mean error between the diary times and Cricket recording was 2%. Patient compliance was 78%.ConclusionsThe Cricket is a reliable, accurate, and sensitive device to determine patient compliance with scoliosis brace usage.

Associations Among Slipped Capital Femoral Epiphysis, Tibia Vara, and Type 2 Juvenile Diabetes

Background: Clinical consequences of obesity are numerous and include slipped capital epiphysis of the femur, tibia vara, impaired mobility, insufficient muscle strength, glucose intolerance, type 2 diabetes, hyperlipidemia, nonalcoholic fatty liver disease, cholelithiasis, hypertension, sleep apnea, polycystic ovary disease, increased cardiorespiratory effort, and pseudotumor cerebri, among others. Because slipped capital femoral epiphysis, tibia vara, and type 2 diabetes are observed commonly in obese children, a degree of multiple disease occurrence in a patient would be anticipated; however, the senior author has never observed an obese adolescent who presented at the initial diagnosis with a coexistence of slipped capital femora epiphysis, tibia vara, or type 2 diabetes, so, possibly, these constellations of comorbidities may represent unique obesity phenotypes. Methods: We reviewed the population consisting of all consecutive patients with newly diagnosed slipped capital femoral epiphysis or tibia vara from 2000 to 2006 and a selected group of patients with type 2 diabetes treated at the Alfred I. duPont Hospital for Children, Wilmington, DE. Results: There were 57 cases of slipped capital femoral epiphysis, 41 cases of tibia vara, and 53 cases of type 2 diabetes. The tibia vara group had the highest body mass index (BMI; 40.81 [13.01]); the diabetes group (BMI, 35.76 [7.04]) and the slipped capital femoral epiphysis group (BMI, 29.08 [7.07]) had the lowest BMI. There was no significant difference in age at the disease onset and height between groups. There was no overlap of disease at initial presentation among slipped capital femoral epiphysis, adolescent tibia vara, and type 2 diabetes. Conclusions: We observed 3 separate obesity-related phenotypes in adolescents with no overlap of disease at initial presentation among slipped capital femoral epiphysis, adolescent tibia vara, and type 2 diabetes.

Intrauterine gangrene of the lower extremity in the newborn: a report of two cases.

We describe 2 cases of intrauterine gangrene involving the lower extremity in 2 unrelated neonates. Both cases were complicated by prematurity, and 1 case was complicated by an intrauterine distal femur fracture and twin-twin transfusion syndrome. Both cases resulted in profound ischemic necrosis from the knee to the foot, requiring knee disarticulation. In both cases, a follow-up period of 7 years is now completed, and no further medical or surgical complications have arisen.

Postoperative radiographs after pinning of supracondylar humerus fractures: are they necessary?

Background: The purpose of this study was to evaluate the necessity of early postoperative radiographs after pinning of supracondylar humerus fractures by determining both the percentage of patients who displayed change in fracture fixation and whether these changes affected their outcome. Methods: A series of 643 consecutive patients who underwent operative management of Gartland type II and III fractures at our institution between January 2002 and December 2010 were reviewed. Demographic data were obtained through chart review, including age, sex, extremity, fracture type, and mechanism. Intraoperative fluoroscopic images were compared with postoperative radiographs to identify changes in fracture alignment and pin placement. Results: A total of 643 patients (320 females, 323 males) with a mean age of 6.1 years (range, 1.1 to 16.0) were reviewed. Fifty-seven percent of fractures were classified as type II and 43% were type III. The overall complication rate was 8.8% (57/643). Pin backout or fracture translation was seen in 32 patients (4.9%) at the first postoperative visit. All of these patients sustained type III fractures. One of these patients required further operative management. Patients with changes in pin or fracture alignment did not demonstrate a statistically significant difference in time to first postoperative visit (P=0.23), days to pin removal (P=0.07), or average follow-up time (P=0.10). Fracture severity did not correlate with change in alignment (P=0.952). No postoperative neurological complications were observed in patients with alignment changes. Conclusions: Mild alignment changes and pin migration observed in postoperative radiographs after pinning of supracondylar humerus fractures have little effect on clinical management parameters or long-term sequelae. Radiographs can therefore be deferred until the time of pin removal provided adequate intraoperative stability was obtained. Level of Evidence: Level IV.