Daniel Hedequist

Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial.

BACKGROUND Closed reduction and percutaneous pin fixation is the treatment of choice for completely displaced (type-III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. METHODS This prospective, randomized clinical trial had sufficient power to detect a 10% difference in the rate of loss of reduction between the two groups. The techniques of lateral entry and medial and lateral entry pin fixation were standardized in terms of the pin location, the pin size, the incision and position of the elbow used for medial pin placement, and the postoperative course. The primary study end points were a major loss of reduction and iatrogenic ulnar nerve injury. Secondary study end points included radiographic measurements, clinical alignment, Flynn grade, elbow range of motion, function, and complications. RESULTS The lateral entry group (twenty-eight patients) and the medial and lateral entry group (twenty-four patients) were similar in terms of mean age, sex distribution, and preoperative displacement, comminution, and associated neurovascular status. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and one of the twenty-four treated with medial and lateral entry (p = 0.107). There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences (p > 0.05) between groups with respect to the Baumann angle, change in the Baumann angle, humerocapitellar angle, change in the humerocapitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications. CONCLUSIONS With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Results and technique of unstable pediatric femoral fractures treated with submuscular bridge plating.

Abstract: Twenty-seven patients underwent submuscular bridge plating for unstable pediatric femoral fractures with contraindications to fixation with flexible intramedullary nails. This report discusses the technique and results. A precontoured plate was tunneled proximally through a small distal incision in the subvastus plane to bridge the fracture. The plate was secured to the femur, with screws placed percutaneously proximal and distal to the fracture to reduce and stabilize the fracture. A retrospective review of radiographs and clinical follow-up was analyzed for postoperative alignment, any change in alignment or instrumentation failure, bony union, clinical exam, and complications. There were no intraoperative or postoperative complications. There has been no instrumentation failure or loss of reduction. Early callus was seen by 6 to 8 weeks and stable bony union by 12 weeks in all patients. Submuscular plating is a reasonable option for operative stabilization of comminuted and unstable pediatric femoral fractures.

Failure of attempted implant retention in spinal deformity delayed surgical site infections.

Study Design. A retrospective case series. Objective. To determine if implant retention is possible in spinal deformity cases which present as a delayed (greater than 3 months) surgical site infection. Summary of Background Data. The retention of spinal implants in deformity surgery is possible with an acute surgical site infection. Currently, the decision whether or not to retain implants in a delayed surgical site infection is unclear. Methods. A retrospective review of 26 cases of delayed surgical site infections after spinal deformity surgery. Data and information was recorded regarding the initial management of the surgical site infection, the number of operations performed related to the infection, and whether or not the infection could be cleared with implant retention. The number of operations, hospital days, and charges related to the treatment of the infection were recorded. Results. In this series, no patient was able to clear their infection without spinal implant removal. The number of operations required to clear the infection, length of hospitalization, and financial charges were proportionate to the timing of implant removal. Conclusion. Delayed surgical site infections after spinal instrumentation for deformity need to be treated with implant removal to clear the surgical site infection. Patients may require to undergo repeat instrumentation and fusion at a later date if they develop progressive deformity or symptomatic pseudarthrosis after implant removal.

The safety and efficacy of spinal instrumentation in children with congenital spine deformities.

Study Design. A retrospective radiographic and chart review of patients who underwent operative treatment with the use of reduced size spinal instrumentation for congenital spine deformities Objective. To assess the safety and efficacy of spinal instrumentation in young patients who were operated on for a congenital spine deformity. Summary of Background Data. The use of spinal instrumentation has been shown to improve curve correction and arthrodesis rates in spinal deformity surgery. The advent of reduced-size implants has allowed surgeons to expand the use of instrumentation in pediatric patients. The use of reduced-size spinal instrumentation in children with congenital spine deformities has not been well documented. Methods. We retrospectively investigated the use of spinal instrumentation in 40 patients younger than 8 years with a congenital spine deformity. The review of radiographs and medical records was performed to assess the complications associated with instrumentation, the curve correction, and the arthrodesis rate in this patient population. Results. The complications associated with the use of instrumentation in this group of patients were infrequent. Curve correction was excellent, and the sagittal profile was maintained in all patients at an average follow-up of greater than 3 years. All patients obtained a solid arthrodesis. Conclusions. The use of reduced-size spinal instrumentation in young patients is safe and efficacious. Curve correction, length of immobilization, and fusion rate are improved compared to similar patients in the literature treated without instrumentation.

Locking plate fixation for pediatric femur fractures.

Background: The use of locking plates for pediatric femur fractures has not been studied. Locking plate applications for fractures associated with comminution, osteopenia, or minimal bone available for purchase have been well studied in the adult trauma population. Methods: We conducted a retrospective review of children at our institution treated with a locking plate for a femur fracture. We identified 32 patients treated at an average age of 11 years (6-15 years of age). Locking plates were chosen for comminution in 13 patients, nonmalignant pathologic fracture in 9 patients, fracture location in 7 patients, and osteopenia in 3 patients. All patients were treated with a locking plate and followed up until definitive radiologic union. Results: There were no intraoperative complications related to this technology. All patients were healed with near-anatomic alignment with the exception of 1 patient who had valgus malalignment of 12 degrees, which was of no clinical concern and required no intervention. Seven patients had the plates removed with no noted complications. Conclusions: Locking plates are a safe and effective treatment for children and adolescents with femur fractures that may not be amenable to other current means of stabilization. Level of Evidence: Level IV.

Early versus delayed stabilization of pediatric femur fractures: Analysis of 387 patients

OBJECTIVES To assess the effect of timing of femur fracture stabilization on pulmonary complication rates in pediatric trauma patients. DESIGN Retrospective review. SETTING Level I trauma center. PATIENTS Three hundred eighty-seven previously healthy patients from zero to fifteen years of age with traumatic diaphyseal femur fractures. INTERVENTION Femur fracture stabilization: early (less than twenty-four hours after injury) in 213 patients and late in 174 patients. MAIN OUTCOME MEASUREMENTS Age, sex, GCS (Glasgow Coma Score), AIS/ISS (Abbreviated Injury Score/Injury Severity Score), timing of fracture stabilization, duration of mechanical ventilation, intensive care unit stay, and hospital stay were recorded. Pulmonary complications, including pneumonia, respiratory distress syndrome, and pulmonary embolus, were recorded. RESULTS Thirteen patients developed pulmonary complications. Twelve of these had severe head injuries (GCS < or = 8). One had sustained an upper cervical spine fracture that resulted in quadriplegia. Statistical analysis revealed GCS, GCS < or = 8, ISS, and head and neck AIS to be significant predictors of pulmonary complications. Early stabilization of femur fractures had no apparent effect on the pulmonary complication rate. CONCLUSIONS Pulmonary complications are rare in pediatric femur fracture patients. Patients with severe head injuries (GCS < or = 8) or cervical spinal cord injuries are at high risk for pulmonary complications. The timing of femur fracture stabilization does not appear to affect the prevalence of pulmonary complications in these patients.

Modern Cervical Spine Instrumentation in Children

Study Design. A retrospective case series. Objective. To determine the safety, efficacy, and feasibility of using modern segmental cervical spine instrumentation in children. Summary of Background Data. With the exception of transarticular screws, there are currently no series in the literature looking at the use of modern cervical spine implants in children. In the adult population, these implants have been shown to be biomechanically superior to traditional wiring methods. These constructs may also decrease the need for postoperative halo immobilization, while at the same time improving arthrodesis rates. Methods. A retrospective review of 25 pediatric patients greater than 6 years of age treated at our institution with modern segmental instrumentation of the cervical spine. Computed tomography scans were evaluated to determine containment of screws. Radiographic and chart review was done to determine the clinical outcome with respect to fusion and any complications related to surgery. Results. There were no implant related complications in this series. All screws (n = 112) evaluated by computed tomography scan were fully contained. All patients obtained union and there were no reoperations related to the spinal implants. Complications included: 1 deep infection, 1 superficial infection, and 1 transient radiculopathy. Conclusion. Modern cervical spine instrumentation is safe and feasible to use in children older than 6 years of age. The clinical union rate in our series was 100% with no implant related complications.

Surgical site infection after pediatric spinal deformity surgery

The incidence of surgical site infection (SSI) after spinal deformity surgery for adolescent idiopathic scoliosis ranges from 0.5–6.7%. The risk of infection following spinal fusion in patients with neuromuscular scoliosis is greater, with reported rates of 6.1–15.2% for cerebral palsy and 8–41.7% for myelodysplasia. SSIs result in increased patient morbidity, multiple operations, prolonged hospital stays, and significant financial costs. Recent literature has focused on elucidating the most common organisms involved in SSIs, as well as identifying modifiable risk factors and prevention strategies that may decrease the rates of infection. These include malnutrition, positive urine cultures, antibiotic prophylaxis, surgical site antisepsis, antibiotic-loaded allograft, local application of antibiotics, and irrigation solutions. Acute and delayed SSIs are managed differently. Removal of instrumentation is required for effective treatment of delayed SSIs. This review article examines the current literature on the prevention and management of SSIs after pediatric spinal deformity surgery.

Hemivertebra excision in children via simultaneous anterior and posterior exposures.

This study evaluates the effectiveness of hemivertebra excision in children via simultaneous anterior and posterior operative exposures. This study was a retrospective review of patients treated with this technique over a 5-year period with minimum 2-year follow-up. Eighteen patients were studied, all of whom had undergone hemivertebra excision and deformity correction using unilateral compression instrumentation. The average age of the patients at the time of operation was 3 years 2 months and the average preoperative coronal curve measured 40°. There were no neurologic complications. At an average follow-up of 35 months all patients had obtained bony fusion; the average coronal curve measured 11° for an average percentage correction of 71%. Hemivertebra excision by simultaneous exposure is an effective and safe way of managing congenital hemivertebra, and the correction is similar to staged anterior-posterior procedures or posterior-only procedures.

Use of an abduction brace for developmental dysplasia of the hip after failure of Pavlik harness use.

The authors reviewed the records of 15 infants who were treated with an abduction brace after Pavlik harness use for developmental dysplasia of the hip (DDH) failed. Failure was defined as persistent dislocation or instability of the hip. Thirteen of these 15 patients had resolution of DDH with the use of an abduction brace. The median time spent in the brace before stabilization of examination findings was 24 days; the median time in the brace before normalization of ultrasound parameters was 46 days. There were no complications with regard to use of the abduction orthosis. At final follow-up of an average of 3 years and 7 months, no patient had undergone surgery and no patient had residual dysplasia or avascular necrosis of the hip. The two patients in whom both the Pavlik harness and abduction brace failed went on to successful closed reduction and spica cast application.