Ernest L. Sink

Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types.

The purpose of this study was to analyze complications seen in children with femur fractures stabilized with titanium elastic nails, comparing their use in stable and unstable fracture patterns. A retrospective review was performed on 39 consecutive children with femur fractures treated with titanium elastic nails. Patients with comminuted or long oblique fractures were classified as having “length-unstable” fractures. Patients were analyzed qualitatively for any predictive factors or treatment variables that increased the risk of complications. There were 24 patients with complications (62%). Eight patients (21%) underwent unplanned surgery prior to complete fracture union. Six of the eight requiring unplanned surgery were treated for “length-unstable” fractures. The complications that required unplanned surgery for either prominent nails or loss of reduction occurred more commonly in unstable non-transverse fracture patterns. The authors conclude that in patients with “length-unstable” femur fractures, consideration should be given to methods of treatment other than titanium flexible intramedullary nails.

Multicenter study of complications following surgical dislocation of the hip

BACKGROUNDnSurgical hip dislocation enables complete exposure of the hip joint for treatment of various hip disorders.There is limited information regarding the complications associated with this procedure. Our purpose is to report the incidence of complications associated with surgical dislocation of the hip in a large, multicenter patient cohort.nnnMETHODSnA retrospective, multicenter analysis of patients who had undergone surgical hip dislocation was performed.Patients who had undergone a simultaneous osteotomy were excluded. Complications were recorded, with specific assessment for osteonecrosis, trochanteric nonunion, femoral neck fracture, nerve injury, heterotopic ossification, and thromboembolic disease. We graded complications with a validated classification scheme that includes five grades based on the treatment required to manage the complication and any long-term morbidity. With this classification, a Grade-I complication is one that requires no change in the routine postoperative course, Grade II requires a change in outpatient management, Grade III requires invasive surgical or radiologic management, Grade IV is associated with long-term morbidity or is life-threatening,and Grade V results in death.nnnRESULTSnThe study included 334 hips in 302 patients seen at eight different North American centers. There were eighteen complications (5.4%) that were classified as Grade I (not clinically relevant and required no deviation from routine postoperative care). There were six complications (1.8%) classified as Grade II (treated on an outpatient basis or with close observation and resolved). There were nine complications (2.7%) classified as Grade III (treatable and resolved with surgery or inpatient management). There was one complication (0.3%) classified as Grade IV (resulting in a long-term deficit). A total of thirty hips had one or more complications, for an overall incidence of 9%. Excluding heterotopic ossification, the complication rate was sixteen (4.8%) of 334.nnnCONCLUSIONSnSurgical hip dislocation is a safe procedure with a low complication rate. Many of the complications were clinically unimportant heterotopic ossification. There were no cases of femoral head osteonecrosis or femoral neck fracture, and, with the exception of one sciatic neurapraxia that partially resolved, no other complication resulted in long-term morbidity.

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.

Clinical presentation of femoroacetabular impingement in adolescents.

Femoroacetabular impingement (FAI) is a recently recognized hip disorder resulting from an abnormal morphology of the proximal femur and acetabulum. This morphology results in increased hip contact forces with hip motion, specifically flexion. This may lead to labral-cartilage injury and pain. The purpose of this study is to describe the clinical presentation and diagnosis of FAI as a cause of hip pain in adolescents. Thirty-five patients with FAI as the etiology of chronic hip pain from one institution were reviewed. The common symptoms, physical examination, and radiographic findings were analyzed. The age range was 13 to 18 years. There were 30 girls and 5 boys. All patients complained of anterior groin pain. All patients performed a sport/activity that contributed to the symptoms such as dancing. Patients had decreased flexion and limited internal rotation on physical examination. All patients had a positive impingement test. Fifteen patients (43%) had primarily pincer impingement with a crossover sign or acetabular retroversion. Cam impingement was the primary type in 2 patients (6%). There were findings of cam and pincer in 18 patients (51%). Sixteen of 28 patients had a positive labral tear on magnetic resonance imaging (57%). Femoroacetabular impingement is a cause of hip pain in the adolescent population. The diagnosis can be derived from reproducible history, physical examination, and radiographic findings. It is more common in female adolescents, and pincer type is more prevalent.

Acetabular Cartilage and Labral Damage Observed During Surgical Hip Dislocation for Stable Slipped Capital Femoral Epiphysis

Background Surgical hip dislocation allows the surgeon full visualization of the proximal femur and acetabulum. It also makes it possible to directly observe the pathologic relationship between the proximal femur and acetabular rim with hip motion. The purpose of this study is to classify acetabular cartilage and labral damage that is present at the time of surgical hip dislocation for the treatment of symptomatic stable slipped capital femoral epiphysis (SCFE) hips. Methods A retrospective study was performed at 2 North American centers on patients with a stable SCFE who had a surgical hip dislocation for chronic symptoms. The severity of SCFE (slip angle) was measured as mild (0-30 degrees), moderate (30-60 degrees), and severe (60-90 degrees). The degree of acetabular and labral damage was classified in each patient according to the Beck classification used for femoroacetabular impingement. Results Thirty-nine hips in 36 patients that underwent open surgical dislocation for diagnosis of stable SCFE were included. The breakdown of the radiographic severity of the SCFE was 8 mild, 20 moderate, and 11 severe. Labral injury was observed in 34 of 39 hips. Using the Beck classification for labral injury, there were 21 type 1 injuries, 9 type 2 injuries, and 4 type 3 injuries. Cartilage injury was present in 33 of 39 hips. Using Beck classification for cartilage damage, there were 6 grade 0, 5 grade 1, 10 grade 2, 4 grade 3, 10 grade 4, and 4 grade 5 injuries. The average depth of cartilage damage was 5u2009mm (range, 2-10u2009mm). Conclusions In this study, significant chondromalacia and labral injury was observed in hips afflicted with SCFE. Surgical hip dislocation allowed direct confirmation of the impingement of the prominent metaphysis on the acetabular labrum and cartilage.

Efficacy of perioperative halo-gravity traction in the treatment of severe scoliosis in children.

Perioperative halo traction was used in the treatment of severe scoliosis in 19 children. Diagnoses included neuromuscular, idiopathic, and congenital scoliosis. Traction was transferable between the bed and a walker or wheelchair. Thirteen patients had prior spinal surgery, and most required osteotomy. Traction was used for 6 to 21 weeks. All patients underwent spinal fusion surgery after traction, with instrumentation used in 15 patients. Improvement was achieved in all patients. The Cobb angle improved 35% from an average 84° before traction (range 63°–100°) to 55° preceding fusion. Trunk decompensation improved in all patients. Trunk height increased 5.3 cm in traction. Response to traction did not correlate with diagnosis, patient age, or prior surgery. There were no neurologic complications. Perioperative halo-gravity traction improves trunk balance and frontal and sagittal alignment in children with severe spinal deformity. Surgical fusion was enhanced by the improved alignment, and neurologic injury was avoided.

Treatment of pediatric diaphyseal femur fractures.

Methods of treating pediatric diaphyseal femur fractures are dictated by patient age, fracture characteristics, and family social situation. The recent trend has been away from nonsurgical treatment and toward surgical stabilization. The clinical practice guideline on pediatric diaphyseal femur fractures was undertaken to determine the best evidence regarding a number of different options for surgical stabilization. The recommendations address treatments that include Pavlik harness, spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, submuscular plating, and pain management. The guideline authors conclude that controversy and lack of conclusive evidence remain regarding the different treatment options for pediatric femur fractures and that the quality of scientific evidence could be improved for the revised guideline.

Decreased Complications of Pediatric Femur Fractures With a Change in Management

Background Elastic intramedullary nails are commonly the preferred treatment option for operative stabilization of pediatric diaphyseal femur fractures. Increased complication rates have been reported in unstable fractures and older patients treated with TENs (titanium elastic nails). The reported complications have led to a change in management at our institution: limiting the use of TENs and using submuscular plating and trochanteric entry nails as alternatives. The purpose of this study is to analyze whether this change in management has improved outcomes defined by a decrease in complications between 2 time periods. Methods This retrospective study compared 2 cohorts of femur fractures: those treated from January 2001 to January 2003 versus those treated from January 2003 to December 2006. Patients age, weight, fracture type (stable or unstable), operative fixation technique, and complications were compared. Outcomes were measured by major or minor complications that occurred after operative treatment. Results Period I consisted of 46 patients and Period II of 95 patients. There was a significant decrease in TEN use in unstable fractures in Period II versus Period I. Submuscular plating increased from 9% in Period I to 28% in Period II. All complications decreased from 52% in Period I to 23% in Period II. Major complications decreased from 22% to 5%, and minor complications decreased from 30% to 18%. Complications in unstable fractures decreased from 57% to 26% and in stable fractures from 48% to 22%. Conclusions Outcomes of pediatric femur fractures are improved with limiting the use of TENs to stable fractures. Complications resulting from unstable femur fracture management have decreased with other methods of stabilization such as submuscular plating or trochanteric entry nails.

Selective anterior fusion of thoracolumbar/lumbar curves in adolescents: when can the associated thoracic curve be left unfused?

Study Design. A retrospective multicenter study was conducted to investigate patients with a major thoracolumbar/lumbar adolescent idiopathic scoliosis and an associated minor thoracic curve treated with an anterior instrumentation and fusion of the lower curve. Objective. To establish criteria for determining when such curves can be successfully treated by an anterior only procedure of the lower curve with acceptable spinal balance and residual thoracic curve. Summary of Background Data. Anterior spinal instrumentation techniques have been proved effective for the management of isolated thoracolumbar/lumbar scoliosis with small compensatory thoracic curves. The success of a selective anterior fusion when the associated thoracic curve had some structural changes in a small preliminary study was variable and was the stimulus for this study. Methods. A multicenter study involved 49 adolescent patients with a major thoracolumbar/lumbar curve in which the associated minor thoracic curve measured between 30° and 55°. In all the patients, the apical vertebra of the lower curve lay outside the midsacral line, and the thoracic apical vertebra fell outside a line dropped from the center of C7. Multiple radiographic parameters were evaluated. The Risser sign, height, weight, onset of menses, and closure of the triradiate cartilages were studied to access the patients’ maturity. All the patients were observed at least 2 years. Patients were considered to have a satisfactory result if the thoracic curve at the final follow-up assessment measured 40° or less, if balance and sagittal alignment were reasonable, and if additional procedures were not required. Results. At final follow-up assessment, two groups emerged. Group 1 (n = 43) had satisfactory results. The preoperative thoracic curve in this group averaged 40°and 26° after surgery. The lumbar curve averaged 56° before surgery and 22° after surgery. Group 2 (n = 6) had unsatisfactory results. The average thoracic curve was 49° before surgery 54° after surgery, whereas the lumbar curve averaged 59° before surgery and 27° after surgery. Three of these patients underwent posterior thoracic instrumentation and fusion. Conclusions. Statistical analysis showed that a successful surgical outcome was dependent on both the structural changes in the thoracic curve and the patient’s maturity. The thoracolumbar/lumbar–thoracic (TL/L:T) Cobb ratio in combination with the degree of the thoracic curve on lateral bending was the best predictor among the structural indexes. Of 44 patients with a TL/L:T Cobb ratio of 1.25 or greater and/or a thoracic curve, which bent out to 20° or less, 42 had a satisfactory result. The best predictor among the maturity indexes was closure of the triradiate cartilages. Of 43 patients in whom the triradiate cartilages were closed, 42 had satisfactory results. When this data is combined, the outcome for the thoracic curve can be reasonably predicted.

Maintenance of sagittal plane alignment after surgical correction of spinal deformity in patients with cerebral palsy.

Study Design. A case series of patients with cerebral palsy treated for spinal deformity using Luque–Galveston instrumentation was retrospectively analyzed. Objective. To analyze the incidence and risk factors for postoperative loss of sagittal plane correction initially obtained with Luque–Galveston instrumentation in patients with cerebral palsy. Summary of Background Data. The Luque–Galveston instrumentation technique has been widely adopted in the treatment of neuromuscular spinal deformity. Although the results in the coronal plane have been generally satisfactory, problems in maintaining sagittal plane correction have been noted. Methods. For this study, 41 patients with spastic quadriplegia who underwent surgical correction of spinal deformity between 1990 and 1998 were reviewed with attention given to the maintenance of sagittal plane correction. Preoperative, initial postoperative, and most recent radiographs were measured to determine the sagittal Cobb angle from T5 to T12, T12 to L2, and L1 to S1. On the basis of the preoperative sagittal alignment, patients were separated into two groups: those with preoperative hyperkyphosis (T5–T12 ≥ 50°, T12–L2 ≥ 20°, or L1–S1 ≥ 0°) and those with normal or decreased kyphosis. The radiographs were assessed for proximal hardware failure/pullout or junctional kyphosis (>20°), and for backing out of the Galveston rods distally. Results. Of the 41 patients, 29 underwent correction of their deformity with Luque–Galveston instrumentation alone. In 21 of these patients anterior release–fusion preceded the posterior procedure. Additional anterior lumbar instrumentation was used in 12 patients. Proximal loss of correction or implant failure occurred in 13 patients (32%). In four of these patients junctional kyphosis developed at the cephalad extent of the instrumentation, and nine patients had proximal hardware failure/pullout. Posterior migration of the distal end of the Galveston rods occurred in five patients (12%). Four of these five patients had anterior release and fusion without instrumentation. There were no distal failures in patients for whom anterior lumbar instrumentation was used. All of the patients with distal failure and 11 of 13 patients with proximal failure were considered hyperkyphotic before surgery. The region of hyperkyphosis in the patients that lost distal fixation was most often in the thoracolumbar junction. Conclusions. Preoperative hyperkyphosis in the thoracic, thoracolumbar, or lumbar spine was associated with an increased incidence of proximal and distal loss of sagittal plane correction in patients with spastic quadriplegic cerebral palsy treated with Luque–Galveston instrumentation alone. An anterior lumbar release and fusion without instrumentation in a patient with thoracolumbar or lumbar kyphosis increased the risk for posterior pullout of the Galveston rods from the pelvis.