Jeffrey E. Martus

A prospective multicenter study of Legg-Calvé-Perthes disease: functional and radiographic outcomes of nonoperative treatment at a mean follow-up of twenty years.

BACKGROUND Long-term studies have indicated good outcomes for most patients with Legg-Calvé-Perthes disease. However, clinical experience suggests that less favorable outcomes are common. We sought to prospectively document pain and function in a cohort of adults who had previously been treated nonoperatively for Legg-Calvé-Perthes disease. METHODS Patients in our region with Legg-Calvé-Perthes disease were enrolled between 1984 and 1991 as part of a multicenter prospective trial and were treated with hip range-of-motion exercises or bracing. Patients returned for physical examination, radiographs, and completion of outcome measures including the Nonarthritic Hip Score (NAHS) and the Iowa Hip Score (IHS). RESULTS Fifty-six patients (fifty-eight hips) were examined at a mean of 20.4 years (range, 16.3 to 24.5 years) after enrollment. The mean NAHS was 79 (range, 35 to 100), and the mean IHS was 74 (range, 43 to 100). Three patients had required hip arthroplasty and one patient had required a pelvic osteotomy. Fourteen (26%) of the remaining hips had no hip osteoarthritis, sixteen (30%) had mild osteoarthritis (Tönnis grade 1), and twenty-four (44%) had moderate or severe osteoarthritic changes on radiographs (grade 2 or 3). Femoroacetabular impingement indicated by physical examination was associated with pain and with poorer outcomes on the IHS and the NAHS (p = 0.0004, 0.0014, and 0.0007, respectively). The Stulberg classification was significantly associated with impingement on physical examination (p = 0.0495), the NAHS (p = 0.003), and the Tönnis grade (p = 0.012). Multivariate logistic regression showed that only the Stulberg classification was significantly associated with the NAHS (p = 0.0032); the odds ratio for a Stulberg type of I or II compared with IV or V in patients with a fair or poor NAHS was 0.101 (95% confidence interval, 0.018 to 0.573). CONCLUSIONS Pain, arthritis, and ongoing hip dysfunction are common in patients with Legg-Calvé-Perthes disease that was treated nonoperatively. Hips rated as Stulberg type III or IV more frequently had poor or fair outcomes on the IHS and NAHS (61% and 72% for type III and 77% and 60% for type IV). Patients with a lateral pillar type of B, B/C, or C frequently had pain and radiographic evidence of osteoarthritis. Clinical signs of femoroacetabular impingement were associated with pain and with lower functional scores. This prospective study establishes a modern benchmark for outcomes following nonoperative, weight-bearing treatment of Legg-Calvé-Perthes disease.

Safety of topical vancomycin for pediatric spinal deformity: nontoxic serum levels with supratherapeutic drain levels.

Study Design. Retrospective cohort analysis. Objective. To establish if drain levels exceed the minimum inhibitory concentrations for common pathogens (methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and Propionibacterium acnes—2 &mgr;g/mL; Staphylococcus epidermidis, Enterococcus faecalis—4 &mgr;g/mL). Evaluate the safety of topical vancomycin in pediatric patients undergoing spinal deformity surgery and determine if postoperative serum levels approach toxicity (25 &mgr;g/mL). Summary of Background Data. The application of topical vancomycin powder has decreased postoperative wound infections in retrospective analyses in the adult population with minimal local and systemic risks. The safety and efficacy of vancomycin powder has not been completely evaluated in the pediatric population after deformity surgery. Methods. Topical vancomycin powder (1 g) was applied during wound closure after instrumented posterior spinal fusion. All patients received intravenous perioperative antibiotics and a subfascial drain was used. Serum and drain vancomycin levels were collected immediately postoperatively and during the first 2 postoperative days (PODs). Complications were recorded. Results. The study population consisted of 25 patients with a mean age of 13.5 years (9.5–17.1 yr) and mean ± standard deviation body weight of 44.5 ± 18 kg. Underlying diagnoses included: adolescent idiopathic scoliosis (12), neuromuscular scoliosis (10), and kyphosis (3). Mean serum vancomycin levels trended downward from 2.5 &mgr;g/mL (POD 0) to 1.9 &mgr;g/mL (POD 1) to 1.1 &mgr;g/mL (POD 2). Mean drain levels also trended downward from 403 &mgr;g/mL (POD 0) to 251 &mgr;g/mL (POD 1) to 115 &mgr;g/mL (POD 2). No vancomycin toxicity or deep wound infections were observed. One patient with neuromuscular scoliosis developed a superficial wound dehiscence that was managed with dressing changes. Conclusion. Topical application of vancomycin powder in pediatric spinal deformity surgery produced local levels well above the minimum inhibitory concentration for common pathogens and serum levels below the toxicity threshold (25 &mgr;g/mL). There were no deep wound or antibiotic related complications. Level of Evidence: 3

Complications and outcomes of diaphyseal forearm fracture intramedullary nailing: a comparison of pediatric and adolescent age groups.

Background: Flexible intramedullary nailing (IMN) has become a popular technique for the management of unstable or open forearm fractures. Recent publications have suggested an increased incidence of delayed union and poor outcomes in older children and adolescents. The objective of this study was to review forearm fractures treated with IMN, comparing the rate of complications and outcomes between the 2 age groups. Our hypothesis was that IMN is an effective technique with a similar rate of complications in both age groups. Methods: An Institutional Review Board-approved retrospective review was conducted of pediatric forearm fractures treated from 1998 to 2008 at a single institution. Over the study time period, 4161 pediatric forearm fractures were managed nonoperatively (92%) and 353 were treated operatively with plate, cross-pin, or intramedullary fixation (8%). Patients with inadequate follow-up, cross-pin, or plate fixation were excluded. Medical records were reviewed for indications and complications. Complications were graded with a modification of the Clavien-Dindo classification. Outcomes were judged by a new grading system. Results: A total of 205 forearm fractures treated with IMN in 203 patients were identified. The mean age was 9.7 years (range, 1.7 to 16.2 y) and mean follow-up was 42 weeks. Operative indications were failure of closed treatment in 165 (80%) and open fracture in 40 (20%). Mean time from injury to IMN was 5.9 days (range, 0 to 25 d). Single bone IMN was performed in 40 of 185 both bone fractures (26%); there were 20 single-bone forearm fractures treated with IMN. Open reduction was required in 61/165 (37%) of closed fractures. Asymptomatic delayed union (grade 1 complication) was observed in 9 fractures (4%). More severe complications were noted in 17% (grade 2 to 4 complications). Postoperative compartment syndrome occurred in 3 isolated forearm fractures with a significant younger mean age (6.0 vs. 10 y, P=0.031). Overall, complications were significantly more frequent in children older than 10 years of age (25/101) as compared with younger children (13/104, P=0.031). In particular, delayed union was more common in children over the age of 10 years (9/101 vs. 1/104, OR=9.99, P=0.009). Outcomes were good or excellent in 91% of fractures. There was no statistical association of patient age with a fair or poor outcome. Conclusions: IMN is an effective technique for pediatric forearm fractures with good to excellent outcomes in 91%. Complications are not infrequent with this technique, with complications of grade 2 to 4 severity in 17%. There was a 2-fold increase in the rate of complications in children over the age of 10 years. Compartment syndrome was more common in younger children. Patients and families should be counseled about the risks preoperatively. Level of Evidence: Level III—retrospective comparative study.

Immediate Spica Casting of Pediatric Femoral Fractures in the Operating Room Versus the Emergency Department: Comparison of Reduction, Complications, and Hospital Charges

Background Immediate spica casting for pediatric femur fractures is well described as a standard treatment in the literature. The purpose of this study is to evaluate the application of a spica cast in the emergency department (ED) versus the operating room (OR) with regard to quality of reduction, complications, and hospital charges at an academic institution. Methods An institutional review board-approved retrospective review identified 100 children aged 6 months to 5 years between January 2003 and October 2008 with an isolated femur fracture treated with a hip spica cast. Patients were compared based on the setting of spica cast application. Results There were 79 patients in the ED cohort and 21 patients in the OR cohort. There were no significant differences in age, weight, sex, fracture pattern, prereduction shortening, injury mechanism, duration of spica treatment, time to heal, or length of follow-up between cohorts. There were no significant differences in the rate of loss of reduction requiring revision casting or operative treatment (6.3% vs. 4.8%), the need for cast wedging (8.9% vs. 14.3%), or minor skin breakdown (12.7% vs. 14.3%). There were no sedation or anesthetic complications in either group. There were no significant differences in the quality of reduction or the rate of complications between the 2 groups. Spica casting in the OR delayed the time from presentation to cast placement as compared with the ED cohort (11.5 h vs. 3.8 h, P<0.0001) and lengthened the hospital stay (30.5 h vs. 16.9 h, P=0.0002). The average hospital charges of spica cast application in the OR was 3 times higher than the cost of casting in the ED (

Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis

15,983 vs.

Spica MRI after closed reduction for developmental dysplasia of the hip.

5150, P<0.0001). Conclusions Immediate spica casting in the ED and OR provide similar results in terms of reduction and complications. With the significantly higher hospital charges for spica casting in the OR, alternative settings should be considered. Level of Evidence III—Retrospective comparative study.

Accessory Anterolateral Facet of the Pediatric Talus: An Anatomic Study

OBJECTIVE The purpose of our study was to evaluate the diagnostic efficacy and impact of emergent MRI after recent intervention in children with suspected osteomyelitis or septic arthritis. MATERIALS AND METHODS This retrospective case-control study in children with suspected osteomyelitis or septic arthritis consisted of 34 study subjects (mean age, 5.3 years) who underwent MRI after intervention and 96 control subjects (mean age, 8.7 years) who underwent MRI without prior intervention. Final diagnosis and management were abstracted from medical records. Consensus MRI review of the study group was performed to evaluate whether objective MRI criteria of osteomyelitis can be applied to patients who have undergone prior intervention. RESULTS For the study and control groups, no difference was seen in the final diagnosis of osteomyelitis (26.5% [9/34] and 29.2% [28/96], p = 0.76), osteomyelitis or septic arthritis (41.2% [14/34] and 37.5% [36/96], p = 0.70), cellulitis or pyomyositis (20.6% [7/34] and 34.4% [33/96], p = 0.13), and noninfectious conditions (23.5% [8/34] and 13.5% [13/96], p = 0.17). Objective MRI criteria for osteomyelitis were present in all nine patients with a final diagnosis of osteomyelitis and were not present in the remaining 25 who did not have a final diagnosis of osteomyelitis despite recent intervention. Repeat interventions were necessary in the study group at a rate not significantly different from single interventions in the control group (29.4% [10/34] and 27.1% [26/96], p = 0.79). CONCLUSION Iatrogenic soft-tissue and bone edema related to recent intervention in children with suspected osteomyelitis or septic arthritis does not affect the diagnostic efficacy of MRI. Performing MRI before intervention adds efficacy to patient management, prevents unnecessary interventions, and guides surgical procedures when indicated.

Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients

Spica MRI is a fast and effective tool to assess morphology after closed reduction for developmental dysplasia of the hip (DDH) without the need for sedation. The multiplanar capabilities allow depiction of coronal and axial reduction of the hips. Due to MRI’s inherent ability to delineate soft tissue structures, both intrinsic and extrinsic obstacles to failed reduction may be identified. Technical and interpretative challenges of spica MRI are discussed.

Rigid Instrumentation for Neuromuscular Scoliosis Improves Deformity Correction Without Increasing Complications.

BACKGROUND The accessory anterolateral talar facet may be associated with talocalcaneal impingement in the painful flatfoot. We performed an anatomic study to identify this accessory facet and its associated osteologic features. METHODS Within the Hamann-Todd Human Osteological Collection, seventy-nine paired tali and calcanei were identified among forty-three skeletons from individuals who had had an average age of 13.4 years at the time of death. Each specimen was surveyed for an accessory anterolateral talar facet, a calcaneal neck anterior extension facet, a dorsal talar beak, and the talocalcaneal facet pattern. Measurements included the angle of Gissane, posterior facet inclination, calcaneal neck length, posterior facet length, overall calcaneal and talar lengths, and accessory facet dimensions. Lateral radiographs of specimens with accessory facets were made in neutral and everted subtalar alignment. RESULTS An accessory anterolateral talar facet was identified in twenty-seven (34%) of the seventy-nine specimens and was large in two (2.5%). Of the thirty-six skeletons with paired specimens, fifteen had an accessory facet and, of those, ten had the finding bilaterally. Degenerative changes or tarsal coalitions were not observed. Lateral radiographs demonstrated that subtalar eversion obscured observation of the facet. The accessory facet was associated with greater mean age (16.7 compared with 10.9 years; p < 0.0001), male sex (63% compared with 21%; p = 0.011), and a smaller mean angle of Gissane (116.2 degrees compared with 122.2 degrees; p = 0.018). Relative accessory facet volume was positively correlated with increased relative calcaneal posterior facet length (r = 0.53, p = 0.029). The accessory facet was significantly associated with dorsal talar beaking (29% compared with 4%; p = 0.028). CONCLUSIONS An accessory anterolateral talar facet was found in 34% of the specimens in a pediatric osteologic collection. The facet was associated with male sex, a smaller angle of Gissane, and dorsal talar beaking.

Hemiepiphysiodesis Implants for Late-onset Tibia Vara: A Comparison of Cost, Surgical Success, and Implant Failure.

BACKGROUND Debate exists over the safety of rigid intramedullary nailing of femoral shaft fractures in skeletally immature patients. The goal of this study was to describe functional outcomes and complication rates of rigid intramedullary nailing in pediatric patients. METHODS A retrospective review was performed of femoral shaft fractures in skeletally immature patients treated with trochanteric rigid intramedullary nailing from 1987 to 2009. Radiographs made at initial injury, immediately postoperatively, and at the latest follow-up were reviewed. Patients were administered the Nonarthritic Hip Score and a survey. RESULTS The study population of 241 patients with 246 fractures was primarily male (75%) with a mean age of 12.9 years (range, eight to seventeen years). The majority of fractures were closed (92%) and associated injuries were common (45%). The mean operative time was 119 minutes, and the mean estimated blood loss was 202 mL. The mean clinical follow-up time was 16.2 months (range, three to seventy-nine months), and there were ninety-three patients with a minimum two-year clinical and radiographic follow-up. An increase of articulotrochanteric distance of >5 mm was noted in 15.1% (fourteen of ninety-three patients) at a minimum two-year follow-up; however, clinically relevant growth disturbance was only observed in two patients (2.2%) with the development of asymptomatic coxa valga. There was no femoral head osteonecrosis. Among the 246 fractures, twenty-four complications (9.8%) occurred. At the time of the latest follow-up, 1.7% (four of 241 patients) reported pain. The average Nonarthritic Hip Score was 92.4 points (range, 51 to 100 points), and 100% of patients reported satisfaction with their treatment. CONCLUSIONS Rigid intramedullary nailing is an effective technique for treatment of femoral shaft fractures in pediatric patients with an acceptable rate of complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.