Christopher A. Iobst

Limb lengthening with submuscular plate stabilization : A case series and description of the technique

Combining a circular fixator with a percutaneously inserted locking plate has all of the same advantages that lengthening over an intramedullary nail provides but eliminates the concern with regard to creating a deep infection in the medullary canal. It also can be applied to virtually any bone in any age group of patients without any concern with regard to causing avascular necrosis, fat embolism, or physeal injury. The design of the locking plate prevents loss of fixation and protects against bending of the regenerate bone after frame removal. This study represents a description of the surgical technique and a retrospective examination of the first 6 patients treated using this technique. The average age of the patients is 7.6 years, and the average duration of follow-up is 10 months. All 6 patients achieved solid union of the lengthening site and full, unassisted weight bearing with excellent range of motion. The mean lengthening was 3.52 cm, which represents an average of 14.6% of the overall bone length. The mean duration of external fixation was 45 days, and the mean external fixation index was 0.42 mo/cm. The mean distraction rate was 0.85 mm/d. There were 3 serious and 2 severe complications noted. The serious complications included the development of a premature consolidation and a translational deformity of the regenerate in 1 patient, requiring a revision corticotomy, and a fall of a second patient 3 months after fixator removal, causing a fracture at the superior edge of his locking plate. The 2 severe complications were an 11-degree and an 18-degree residual procurvatum deformity that developed during lengthening. In conclusion, lengthening with the assistance of a percutaneously inserted locking plate provides an alternative method to lengthening over an intramedullary nail, applicable to children with open physes.

Nonoperative management of pediatric type I open fractures

The purpose of this study was to examine the results of pediatric patients with type I open fractures managed nonoperatively. A retrospective chart review of all type I open fractures managed nonoperatively from 1998 to 2003 was performed. Forty patients were followed until healing of the fracture clinically and radiologically. One deep infection occurred in this series, producing an overall infection rate of 2.5%. This compares favorably with the literatures infection rate of 1.9% in pediatric type I open fractures treated operatively. There was a 0% infection rate in the 32 upper-extremity type I open fractures and a 0% infection rate in the 23 patients under age 12. These results suggest that nonoperative management of pediatric type I open fractures is safe and effective, especially in children under age 12 with upper-extremity fractures.

Access to Care for Children With Fractures

Background Earlier studies have found that children with fractures and PPO insurance have no access problems to orthopaedic care, but children with Medicaid have problems with access to orthopaedic care. Methods Fifty randomly selected orthopaedic offices in each of the 2 counties served by a childrens hospital were telephoned to seek an appointment for a fictitious 10-year-old boy with a forearm fracture. Each office was called twice, 1 time reporting that the child had PPO insurance and 1 time that he was having Medicaid. In the second arm of the study, data including insurance status were prospectively collected on all patients with fractures seen in the emergency department of childrens hospital. Results Of the 100 offices telephoned, 8 offices gave an appointment within 1 week to the child with Medicaid insurance. Thirty-six of the 100 offices gave an appointment within 1 week to the child with PPO insurance. For the 2210 pediatric fractures seen in the emergency department, the payer mix for patients presenting initially to our facility (1326 patients) was 41% Medicaid, 9% selfpay, and 50% commercial. For the patients presenting to our emergency department after being seen at an outside facility first (884 patients), the payer mix was 47% Medicaid, 13% self-pay, and 40% commercial. The percentages between these two groups were similar but did have a statistically significant difference (P=0.021). Conclusions To the best of our knowledge, this is the first study that reports a majority (64/100) of orthopaedic offices in the region would not care for a child with a fracture regardless of insurance status. Consistent with earlier studies, children with Medicaid have less access to care. The similar insurance status of children sent to the emergency department from other facilities compared with those presenting directly suggests that children in this study are sent to a childrens hospital for specialized care rather than for economic reasons. Level of Evidence Level II.

National access to care for children with fractures.

Background: Access to health care for many pediatric orthopaedic patients is becoming more difficult. In some communities, children with fractures have limited access to care regardless of insurance status. The purpose of this study was to determine the level of difficulty in obtaining access to care for children with fractures nationally and compare our results to the published results of a national survey in 2006. Methods: Five orthopaedic offices were identified in each state using an internet search with Google maps by typing “general orthopedics” under the search heading for each state. Each office was contacted with a scripted phone call describing a fracture in a 10-year-old boy that does not involve the growth plate. The office was then told the patient has Medicaid insurance. If no appointment was given, the reason was recorded and the office was asked to refer us to another orthopaedic surgeon. A second phone call was made to the same office a few days later using the same script but the office was told the patient has a private preferred-provider organization insurance. If no appointment was given, the reason was recorded. Results: Of the 250 (23.6%) offices across the country, 59 would see a pediatric fracture patient with Medicaid. 41.3% (79/191) of the offices refusing the patient stated that they do not accept Medicaid patients. Of the 250, 205 (82%) of the offices across the country would see a pediatric fracture patient with a private preferred-provider organization insurance. The 10 states with lowest Medicaid reimbursement offered an appointment 6% of the time, whereas the 10 best reimbursing states offered an appointment 44% of the time. Discussion and Conclusions: The access to care for children with fractures is becoming more difficult across the country. Compared with the published data in 2006, the number of offices willing to see a child with private insurance has decreased from 92% to 82%. The number of offices willing to see a child with a fracture and Medicaid insurance has decreased from 62% to 23% over the same time span. Level of Evidence: Level II.

Hip arthrodesis: revisited.

Advanced, unilateral hip disease in an active, otherwise healthy, adolescent presents a challenging problem for orthopaedic management. Although arthrodesis of the hip is performed less frequently now than in the past, it remains an effective treatment choice for monoarticular hip disease in young patients. Hip arthrodesis can provide complete pain relief and allow strenuous activity in patients too young for replacement arthroplasty. Unfortunately, temporal and cultural changes, including exposure to people (usually older) who have had excellent outcomes from total hip arthroplasty, have increased the expectations of patients (31). Consequently, hip arthrodesis has become a relatively unpopular treatment choice among patients and surgeons. Despite technical advances in total hip arthroplasty, including the use of noncemented components, hip replacements are not currently known to last without revisions for 30 to 40 years in vigorous, active individuals. Hip arthrodesis, conversely, can provide a durable, functionally satisfying alternative to arthroplasty and allows young patients with severe unilateral hip disease to lead productive lives. Lagrange of France is credited with performing the first hip arthrodesis on a 16-year-old girl in 1886 (6). His attempt at wire fixation failed, and a pseudarthrosis developed (26). Nevertheless, his pioneering approach served, with modifications, as the procedure of choice for half a century for painful conditions of the hip joint, especially at a time when tuberculitic and pyogenic arthritis were prevalent. In 1908, Albee (2) performed the first hip arthrodesis in the United States. Subsequent authors advocated numerous techniques ranging from extraarticular fusion with iliofemoral bone grafts (usually for tuberculous or septic sequelae) to intraarticular fusion with postoperative immobilization in a cast (25). Internal fixation was introduced during the 1930s to 1950s (van Nes, Burns, Watson-Jones, Kuntscher) in an effort to increase stability, decrease the rate of pseudarthrosis, maintain the position of fusion, and mobilize the patient more rapidly (11). All these methods required prolonged immobilization in bed or in a cast, and pseudarthrosis rates remained disturbingly high (6–47%) (11). Farkas, in 1939 (13), first described the addition of a subtrochanteric osteotomy to the arthrodesis in an attempt to decrease the rate of nonunion by eliminating the long femoral lever arm, thereby reducing tension across the fusion site. Charnley (9) attempted to achieve greater bone contact and stability with central dislocation and internal compression fixation in 1953. Modern techniques of hip arthrodesis began with Schneider’s introduction of the Cobra-head plate in 1966 (30). This revolution in internal fixation techniques provided surgeons with a more secure and reliable arthrodesis technique that required minimal external immobilization and allowed earlier patient mobilization. Current techniques using internal or external fixation allow precise positioning of the hip, preservation of bone stock, early weight bearing, and have very low rates (0–10%) of nonunion (26). Numerous surgical techniques of arthrodesis exist today, but the superiority of any particular technique has not been demonstrated. All methods of fixation have the same goals: (a) primary union of the arthrodesis within a reasonable time; (b) avoid postoperative casting; (c) minimize inequality of leg lengths; (d) preserve knee motion; (e) achieve proper position of the fused hip; and (f) facilitate potential future conversion to total hip arthroplasty by retaining the hip abductors (28). Four basic techniques are mentioned in the recent literature. The most commonly described technique uses the Cobrahead plate, which can be placed laterally or anteriorly and follows established principles of stable internal fixation and tension-band compression at the site of hip arthrodesis (18,24). Its major advantages are that it allows precise positioning of the hip, has high rates of union, and diminishes the need for postoperative immobilization. Critics of the Cobra plate note the necessity of extensive soft tissue dissection, especially the detachment of the abductor muscles, which may have an adverse effect on later conversion to a total hip arthroplasty (29). Murrell and Fitch (26) described a technique that reattaches the greater trochanter to the Cobra plate in an effort to preserve the hip abductors. Klemme et al. (18) noted that adolescents at or above the 90th percentile for their age-determined weight were at a significant risk for pseudarthrosis when arthrodesis was attempted with the Cobra plate. The Cobra plate, despite some limitations, remains a reliable choice for achieving a solid, painless fusion in most adolescents (Fig. 1). Address correspondence to Dr. Carl L. Stanitski, Department of Orthopaedic Surgery, Medical University of South Carolina, 96 Jonathan Lucas St., Suite 708, Charleston, SC 29425, U.S.A. From the Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A. Journal of Pediatric Orthopaedics 21:130–134

Pediatric Heelys Injuries

Background: To determine the incidence and severity of injuries caused by Heelys. Methods: A retrospective review of all fractures presenting to an orthopaedic emergency room at a metropolitan childrens hospital during a 90-day period. The type of fracture, mechanism of injury, and management were recorded for each patient. For those injuries related to the use of Heelys, further data were collected including total number of visits, cast changes, and cost. Each Heelys patient/family was contacted and answered a questionnaire detailing their use of Heelys and the events surrounding the injury. Results: A total of 953 patients with fractures were evaluated for 90 days. Sixteen patients with 17 fractures (1.68%) were identified as being related to the use of Heelys. This compares to the incidence of fractures in our sample from basketball (6.19%), bicycle (4.41%), football (4.09%), monkeybars (3.78%), skateboarding (3.25%), soccer (2.62%), baseball (2.52%), and trampoline (2.31%). The average age of each Heelys patient was 8.9 years, and 13 patients were girls. There were 16 upper extremity and 1 lower extremity fracture. No patient needed operative treatment or admission. Average number of follow-up visits was 1.6, with an average of 1.4 casts per patient. Average cost per patient was

Hexapod External Fixation of Tibia Fractures in Children.

1368. Ninety-two percent of the Heelys injuries occurred outdoors. Fifty-four percent of children were being supervised when they fell, but only 31% were wearing any safety equipment. Sixty-two percent of parents were not aware that safety equipment was recommended. All 13 parents indicated that they would not purchase another pair of Heelys, and only 23% of the children wanted to keep using Heelys after the injury. Conclusions: The incidence of Heelys injuries (1.68%) was relatively low compared with other common childhood play activities. The fractures were mostly in the upper extremity, and no fracture required surgical intervention or admission to the hospital. Sixty-two percent of the parents were not aware that safety equipment was recommended, and only 31% of the children were wearing safety equipment. Level of Evidence: Level 2 cohort study.

Correction of Cubitus Varus After Pediatric Supracondylar Elbow Fracture: Alternative Method Using the Taylor Spatial Frame.

Most tibia fractures in children can be treated nonoperatively. For fractures that do require surgery, however, the most common methods of management include plating or flexible nail insertion. Some fracture patterns, such as periphyseal fractures, fractures with bone and/or soft tissue loss, or fractures with delayed presentation, are not easily amenable to these techniques. Hexapod external fixators are especially helpful in these difficult cases. The purpose of this review is to discuss the principles of performing hexapod circular external fixation applied to pediatric tibia fractures. Some of the additional capabilities of the hexapod external fixator will also be highlighted.

The biomechanics of guided growth: does screw size, plate size, or screw configuration matter?

Background: Cubitus varus is a well-reported complication of supracondylar fracture of the humerus potentially resulting in cosmetic problems, impaired function, and malpractice claims. Traditional methods of correcting malunited distal humeral fractures involve complex osteotomies that have a high complication rate, require a large exposure, and challenging fixation. We present a technique of gradual correction using a percutaneous transverse osteotomy and 3 dimensional correction with a Taylor Spatial Frame. Methods: This was a retrospective, IRB-approved study of 12 patients between 2006 and 2010, with cubitus varus after a malunited pediatric supracondylar fracture. The average age at initial injury was 5+8 years. The average age of the patients at surgery was 8+8 years. We measured technical (radiographic parameters and complications), functional (clinical carrying angle, range of motion, QuickDash), and satisfaction domain (questionnaire) outcomes at a minimum follow-up of 6 months. Results: The osteotomy healed in all patients by 10 weeks after the index surgery. The mean external fixator time was 10 weeks. The average preoperative and postoperative humeroulnar angles for the affected elbow were 23 degrees varus and 5.8 degrees valgus, respectively. This was statistically significant (P<0.001). The mean preoperative and postoperative carrying angles were 22 degrees of varus and 5.8 degrees of valgus. This was statistically significant (P<0.001). The results of the QuickDash assessment showed that patients were doing very well with regard to the use of their upper extremity. The mean symptom/disability score was 0.80. No major complications or neurovascular complications were encountered. Overall satisfaction with the procedure was high. Conclusions: The Taylor Spatial Frame as used in this case series provides the experienced surgeon another safe, accurate, and reliable method to correct cubitus varus after pediatric supracondylar fracture. We used in 7 of our 12 cases, a previously unreported pattern of distal humeral pin fixation that allows for a very distal metaphyseal osteotomy, close to the deformity apex. This is a biplanar delta configuration that straddles the olecranon fossa and is appropriate for both children and adults. Level of Evidence: Level IV.

Assessing Quality and Safety in Pediatric Supracondylar Humerus Fracture Care.

Guided growth with the eight-plate is a commonly used technique to correct angular limb deformities in children. However, the optimal combination of plate size, screw size, and screw configuration has not been determined. Using osteotomized femoral sawbones and a rail frame, we developed a growth model to examine the effect of these variables at 6-month, 12-month, and 18-month growth increments. The mean annual coronal plane change was 11.3°. Screw size and plate size were not associated with the rate of angular correction. Screw configuration was important, with parallel screws resulting in optimal correction at all time points compared with divergent screws (P<0.05).