Jeffrey S. Shilt

Coping with sports injuries: an examination of the adolescent athlete ☆

Forty-eight injured adolescent athletes completed questionnaires over 3 months after injury to assess psychosocial outcomes. Depressive symptoms decreased over time, and the lack of positive stress and high athletic identity were associated with early depressive symptoms after accounting for injury severity. Increased social support was associated with lower initial depressive symptoms.

The impact of intrathecal baclofen on the natural history of scoliosis in cerebral palsy.

Background: Intrathecal baclofen (ITB) is an effective treatment of spasticity in patients with cerebral palsy. However, several recent reports have raised concerns that the treatment may be associated with a rapid progression of scoliosis. The objective of this study was to further examine the effect of ITB treatment on the progression of scoliosis in patients with cerebral palsy. Methods: Spastic cerebral palsy patients who were ITB candidates were followed radiographically. Baseline Cobb angles of the primary curve were measured during the period of ITB pump insertion and at the most recent follow-up visit. Each patient was matched with a control patient by the diagnosis of cerebral palsy, age, sex, topographic involvement, and initial Cobb angle. The mean rate of change in Cobb angle was compared between ITB and control patients using paired t test. A multiple linear regression model was used to examine the difference, controlling for age, sex, topographic involvement, and initial Cobb angle. Results: Fifty ITB patients and 50 controls were included in the analysis. There was no statistically significant difference between the mean change in Cobb angle in ITB patients (6.6 degrees per year) compared with the matched control patients (5.0 degrees per year, P = 0.39). The results from the multiple regression analysis also failed to show a statistically significant difference (0.92 degrees per year difference between ITB patients and controls, P = 0.56). Conclusions: The progression of scoliosis in cerebral palsy patients with ITB treatment is not significantly different from those without ITB treatment. The findings suggest that patients receiving ITB experience a natural progression of scoliosis similar to the natural history reported in the literature. Level of Evidence: Level III.

Role of vacuum-assisted closure in the treatment of pediatric lawnmower injuries.

Lawnmower injuries in children often present treatment challenges due to complex soft tissue damage. Vacuum-assisted closure (VAC), the application of controlled subatmospheric pressure to a wound surface, has been used to treat complex lacerations in many patients and has been shown to be safe and effective in children. However, VAC treatment of lawnmower injuries in children has not been reported. This study analyzes the outcomes of treatment following the use of VAC in children with lawnmower injuries and compares the results of VAC treatment to historical controls who were treated before VAC was available for wound treatment. The use of VAC demonstrated a trend toward a decrease in revision amputations and an improvement in function after treatment. There were no complications or adverse reactions related to VAC treatment. The VAC system is a safe and effective method of treating soft tissue injuries resulting from lawnmower accidents in children.

Biomechanical analysis of titanium elastic nail fixation in a pediatric femur fracture model.

Background: Increasing weight in relation to total diameter of implanted titanium elastic nails has been found to be significantly associated with increasing sagittal angulation. However, the biomechanical literature has not well established the load at which failure of titanium elastic nails in the sagittal and coronal planes occurs. The purpose of this study was to determine load to failure in sagittal and coronal plane bending of transverse midshaft femur fractures stabilized with titanium elastic nails and correlate this with the maximum patient weight. Methods: Ten synthetic, pediatric-sized femurs 35 cm in length with an intramedullary canal diameter of 9.5 mm were used. Transverse midshaft fracture patterns were created with a handheld saw. Two 4.0-mm titanium elastic nails were then placed in a retrograde fashion through medial and lateral insertion sites in the distal metaphysis of the femur to stabilize the simulated fractures. A 4-point bending load to failure test was performed on each of the femurs. Five femurs were tested in the sagittal plane, and 5 femurs were tested in the coronal plane. Yield load, bending stiffness, and bending moments for both testing configurations were determined. Results: For the sagittal plane bending tests, the yield load was 628 ± 29 N. For the coronal plane bending tests, the yield load was 596 ± 20 N. The resulting bending moments in the sagittal and coronal planes were 20.4 ± 0.9 and 19.4 ± 0.6 Nm, respectively. From these data, we correlated bending moments with in vivo gait data to find a patient weight cutoff of 40 to 45 kg. Clinical Relevance: With the increasing rate of childhood obesity and tendency for sagittal and coronal angulation of femur fractures treated with titanium elastic nails, it is necessary to determine the load at which permanent sagittal and coronal deformation of the nails occurs because this may result in an unfavorable outcome. Conclusions: Our study provides biomechanical evidence that patients weighing more than 40 to 45 kg who undergo stabilization of a transverse midshaft femur fracture with titanium elastic nails are at risk for loss of reduction in the sagittal and coronal planes.

The definition and treatment of pediatric subtrochanteric femur fractures with titanium elastic nails

Purpose: Titanium elastic nailing (TEN) has become more common in the treatment of pediatric femur fractures in many European centers and in North America over the past several years. Prior studies have shown that the use of TEN for midshaft femur fractures results in excellent outcomes with an earlier return to activity, earlier mobilization, and a shortened hospital stay. However, subtrochanteric femur fractures continue to remain a difficult subset of fractures to care for, with loss of reduction and nonunion being significant complications. Studies have differed regarding the definition of pediatric subtrochanteric femur fractures. The purpose of this study is to establish a reproducible method of defining pediatric subtrochanteric fractures and then apply that definition in a retrospective review of 13 patients who sustained subtrochanteric femur fractures treated with TEN at North Carolina Baptist Hospital using a modified technique that allows for improved fracture stability. Methods: Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining subtrochanteric femur fractures treated with TEN from the period of 2000 to 2004 at Wake Forest University. The TEN outcome measures scale was applied to determine their results. Results: TEN allowed rapid mobilization with excellent or satisfactory clinical and radiographic results in all patients. Conclusions: Results suggest that the use of TEN for subtrochanteric femur fractures is a safe and effective method of fixation that benefits patients through early mobilization, shorter hospital stays, and fewer complications. Significance: By applying the definition of subtrochanteric femur fractures described by the authors, results of future studies can be objectively compared and classified. TEN is a safe and effective alternative for treating most pediatric subtrochanteric fractures by decreasing the morbidity that occurs with other treatment modalities.

MW construct in fusion for neuromuscular scoliosis

A retrospective case control review was conducted to determine if the MW construct offers a superior means of correction of Cobb angles and pelvic obliquity in neuromuscular scoliosis. Posterior spinal fusion (PSF) in patients with neuromuscular scoliosis presents a surgical challenge. Particularly difficult is the correction of pelvic obliquity. Numerous instrumentation techniques have sought to address these difficulties. Most recently Arlet et al have introduced the MW construct. (in Eur Spine 8(3):229–231, 1999). They theorize that this construct may allow for superior spinopelvic fixation. Six patients with neuromuscular scoliosis who underwent PSF with the MW construct were compared with six subjects undergoing PSF utilizing the Galveston technique. Subjects were matched on the basis of preoperative Cobb angles and similar amounts of preoperative pelvic obliquity. Individuals who underwent PSF utilizing the MW construct obtained nearly 30% better correction of pelvic obliquity than did those who received a Galveston construct. A trend toward superior correction of Cobb angles with the MW construct was also observed. The MW construct may be a superior construct for curve correction in PSF for neuromuscular scoliosis, particularly those cases with excessive pelvic obliquity.

The effect of increased distraction frequency on soft tissues during limb lengthening in an animal model

The purpose of this study was to compare the effect of distraction frequency on soft tissues. Ten rabbits underwent high-frequency, automated distraction at 1,440 increments per day, whereas five rabbits were manually distracted at a low frequency of three increments per day. The tibias were lengthened approximately 20% at a rate of 1.05 mm/day. The results indicate that all animals had decreased range of motion of the ankle; however, the high-frequency group fared better compared with the low-frequency group (p<0.01). In addition, the P1 latency of the somatosensory evoked potentials did not change in the high-frequency group, but was statistically higher for the low-frequency group (p<0.05). There was no significant difference found in the histologic studies of muscle of either group. Thus increasing the distraction frequency resulted in better range of motion of the ankle joint and maintained normal somatosensory evoked potentials.

Experience with an online prospective database on adolescent idiopathic scoliosis: development and implementation

Considerable variability exists in the surgical treatment and outcomes of adolescent idiopathic scoliosis (AIS). This is due to the lack of evidence-based treatment guidelines and outcome measures. Although clinical trials have been extolled as the highest form of evidence for evaluating treatment efficacy, the disadvantage of cost, time, lack of feasibility, and ethical considerations indicate a need for a new paradigm for evidence based research in this spinal deformity. High quality clinical databases offer an alternative approach for evidence-based research in medicine. So, we developed and established Scolisoft, an international, multidimensional and relational database designed to be a repository of surgical cases for AIS, and an active vehicle for standardized surgical information in a format that would permit qualitative and quantitative research and analysis. Here, we describe and discuss the utility of Scolisoft as a new paradigm for evidence-based research on AIS. Scolisoft was developed using dot.net platform and SQL server from Microsoft. All data is deidentified to protect patient privacy. Scolisoft can be accessed at www.scolisoft.org. Collection of high quality data on surgical cases of AIS is a priority and processes continue to improve the database quality. The database currently has 67 registered users from 21 countries. To date, Scolisoft has 200 detailed surgical cases with pre, post, and follow up data. Scolisoft provides a structured process and practical information for surgeons to benchmark their treatment methods against other like treatments. Scolisoft is multifaceted and its use extends to education of health care providers in training, patients, ability to mine important data to stimulate research and quality improvement initiatives of healthcare organizations.

Neuromuscular recovery after distraction osteogenesis at different frequencies in a rabbit model.

Abstract: The muscle and nerve responses to stresses applied during distraction osteogenesis have not been clearly defined. This study hypothesized that distraction resulting in 30% lengthening decreases muscle force generation of the lengthened muscle and increasing the frequency of distraction attenuates the decrease of force generation accompanying lengthening. This study investigated the effects of different distraction frequencies on neuromuscular recovery in a rabbit model. Animals were assigned into group 1 (low-frequency distraction) and group 2 (high-frequency distraction). Distraction was continued until a 30% increase in the original tibial length was achieved. After consolidation of the osteotomy, knee and ankle range of motion, muscle force generation, and neuromuscular junction parameters were evaluated. Lengthening of 30% resulted in significantly decreased range of motion compared with the control leg (P < 0.05). Lengthening of 30% also substantially decreased force generation of the peroneus longus muscle. However, force generation of the peroneus longus muscle in the high-frequency group was 70.5% ± 6.5% of the control side, significantly higher than that in the low-frequency distraction group (49.7% ± 4.8% of the control side, P < 0.05). There was no statistical difference between the 2 groups in neuromuscular junction morphology, although an abnormal shape of the postsynaptic neuromuscular junction was observed after distraction. The use of a high-frequency distraction technique during limb lengthening may result in a reduction in impairment of knee and ankle range of motion and improved muscle function compared with that observed with the use of low-frequency distraction. Repeated microtrauma to the soft tissues associated with high-frequency distraction may facilitate the regenerative capacity of the soft tissues and result in an improved outcome of muscle and nerve function.

Effect of intra-articular pressurization associated with arthroscopy on the immature physis: investigation in an animal model.

Background Despite the increased use of arthroscopy in pediatric orthopaedics, there is a paucity of data regarding the potential long-term effects of this procedure on the immature physis. The purpose of this study was to test the hypothesis that elevated intra-articular pressures used during arthroscopic surgery do not result in growth disturbances or morphologic alterations in the epiphyseal plate. Methods Twenty-seven 6-week-old skeletally immature New Zealand white rabbits were divided into experimental (n=21) and control groups (n=6). In the experimental group, a hydraulic pump was used to pressurize 1 randomly assigned knee joint per rabbit to intra-articular pressures of 120 mm Hg for 2 hours. In the control group, rabbits received a sham intervention. All rabbits were killed at 6 months of age (skeletal maturity), and their tissues were evaluated grossly, radiographically, and histologically. Data collection included gross measurements (femur and tibia lengths, evaluation of varus/valgus angulation, and knee joint range of motion) and histologic analyses to determine whether morphologic changes were present in the articular cartilage or physis. Confidence intervals were used to test for statistical equivalence. Results The pressurized and control groups had statistically equivalent gross measurements. No significant articular cartilage or physeal lesions were identified in histologic sections or radiographic studies. Conclusion This study provided no evidence that arthroscopic pressurization of the knee joint to 120 mm Hg for 2 hours significantly affected physeal growth in a skeletally immature rabbit model. Clinical Relevance This study provides the first direct evidence that arthroscopic pressurization of immature joints has no clinically significant adverse long-term effects. Therefore, novel uses of arthroscopy in pediatric patients should be explored without undue concern with regard to premature physeal closure.