Jennifer M. Weiss

Management of infection after instrumented posterior spine fusion in pediatric scoliosis.

Study Design. Case series retrospective review. Objective. To identify what factors predict successful eradication of infection after I&D of an infected posterior spinal fusion with instrumentation. Summary of Background Data. The treatment of infection of instrumented spine fusions in children has few clear guidelines in the literature. Methods. The medical records of patients who required a surgical irrigation and debridement (I&D) for infection after posterior spinal fusion and instrumentation for scoliosis from 1995 to 2002 were retrospectively reviewed. Results. Fifty-three patients were identified with the following underlying diagnoses: 21 patients (40%) idiopathic scoliosis, 10 patients (23%) cerebral palsy, 3 patients (6%) spina bifida, 1 patient (2%) congenital scoliosis, and 17 patients (32%) other. There were 31 patients (58%) with surgery <6 months from initial fusion, and 22 (42%) patients >6 months. Of the 43 patients with implant retained at the time of the first I&D, 20 patients required a second I&D (47%). Of the 10 patients with complete implant removal, 2 patients required a second I&D (20%). Coagulase-negative Staphylococcus was the most prevalent organism, growing in 25 (47%) of the cultures. Of patients with idiopathic scoliosis, 8 of 21 (38%) required a second I&D; of the patients with other diagnoses, 14 of 32 (44%) required a second I&D, which was not a significant difference (P > 0.05). Conclusion. To the best of our knowledge, this is the largest reported series of spinal implant infections. When children with an infection after posterior spinal fusion with instrumentation undergo irrigation and debridement, there is a nearly 50% chance that the infection will remain if all spinal implants are not removed. As nearly 50% of the infections were caused by coagulase-negative Staphylococcus, we recommend that prophylactic antibiotic coverage for this organism is used at the time of the initial spinal fusion.

The Demographics and Epidemiology of Osteochondritis Dissecans of the Knee in Children and Adolescents

Background: Osteochondritis dissecans (OCD) is a disorder of subchondral bone and articular cartilage whose incidence in children is not clearly known. Purpose: The purpose of this study was to assess the demographics and epidemiology of OCD of the knee in children. Study Design: Descriptive epidemiology study. Methods: A retrospective chart review of an integrated health system was performed on patients with OCD of the knee aged 2 to 19 years from 2007 to 2011, with over 1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. The incidence of OCD was determined for the group as a whole and by sex and age group (2-5 years, 6-11 years, and 12-19 years). Patient differences based on age, sex, and ethnicity were analyzed, and using multivariable logistic regression models, associations between age, sex, ethnicity, and diagnosis of OCD of the knee were evaluated. Results: One hundred ninety-two patients with 206 OCD lesions of the knee fit the inclusion criteria. No OCD lesion of the knee was found in 2- to 5-year-old children. One hundred thirty-one (63.6%) lesions were in the medial femoral condyle, 67 (32.5%) were in the lateral femoral condyle, 96 (50.0%) lesions were right sided, 82 (42.7%) were left sided, and 14 (7.3%) were bilateral. The incidence of patients with OCD of the knee aged 6 to 19 years was 9.5 per 100,000 overall and 15.4 and 3.3 per 100,000 for male and female patients, respectively. Those aged 12 to 19 years represented the vast majority of OCD, with an incidence of 11.2 per 100,000 versus 6.8 per 100,000 for those aged 6 to 11 years. For those aged 6 to 11 and 12 to 19 years, female patients had an incidence of 2.3 and 3.9 per 100,000, respectively, while male patients had an incidence of 11.1 and 18.1 per 100,000, respectively. Multivariable logistic regression analysis revealed a 3.3-fold increased risk of OCD of the knee in patients aged 12 to 19 years compared with those aged 6 to 11 years (P < .001; 95% confidence interval [CI], 2.37-4.48), and male patients had 3.8 times a greater risk of OCD of the knee than female patients (P < .001; 95% CI, 2.71-5.41). Based on race and ethnicity, blacks had the highest odds ratio of OCD of the knee compared with all other ethnic groups. Conclusion: In this population-based cohort study of pediatric OCD of the knee, male patients had a much greater incidence of OCD and almost 4 times the risk of OCD compared with female patients. Also, patients aged 12 to 19 years had 3 times the risk of OCD of the knee as compared with 6- to 11-year-old children.

A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures.

Background The most commonly cited classification system for lateral condyle fractures (Milch) has not been shown to be predictive of outcome or recommend treatment. Purpose To determine whether a classification system and treatment based on fracture displacement and articular congruity correlates with the complication rate after pediatric lateral humeral condyle fractures. Methods A retrospective review of all children with lateral condyle fractures treated operatively at one institution from 1996 to 2003 was performed. All fractures were classified by the following system: A Type I fracture is displaced less than 2 mm. In a Type II fracture there is ≥2 mm of displacement with intact articular cartilage, as demonstrated by arthrogram (65 patients). In a Type III fracture there is ≥2 mm of displacement and the articular surface is not intact (93 patients). The 158 patients with types 2 and 3 fractures underwent surgery and are the focus of this study. Complication rates were compared between groups 2 and 3, and with regard to patient age, length of time between injury and surgery, and duration of casting. Results The overall complication rate was 25% (39 of 158). The most common complications included radiographic and/or clinical bump (16 of 158 or 10%), and infection treated with oral antibiotics (4 of 158 or 2.5%). There were 6% major complications (10 of 158) defined as those with presumptive long-term effects or requiring reoperation, including 1 nonunion (0.6%). There were no acute complications at the time of injury or surgery. If lateral bump is excluded as a complication, then the overall complication rate is 14.6% (23 of 158). The overall complication rates for types 2 and 3 fractures were statistically significantly different (P<0.03): 11% (7 of 65) for type 2 and 34% (32 of 93) for type 3 fractures. Major complication rates were 1.5% (1 of 65) for type 2 fractures and 10% (9 of 93) for type 3 fractures, whereas minor complications occurred in 9% (6 of 65) of type 2 fractures, and 25% (23 of 93) of type 3 fractures (P=0.03). There was no correlation between complication rate and patient age, number of days between fracture and surgery (all patients were treated within 16 d of their fracture), or duration of casting. We found that all 65 patients with Type II fractures had <4 mm of fracture displacement on pre-operative radiographs, and all fractures Type III fractures had ≥4 mm of displacement. This may aid in predicting which fractures can be treated with closed pinning prior to an operative arthrogram. Conclusions This is the largest series of operatively treated lateral condyle fractures reported in the literature. This classification system and treatment based on fracture displacement and articular congruity predicts the risk of complications, which were more than 3 times as likely to occur in type 3 fractures as type 2 fractures.

Orthopaedic conditions in the newborn.

&NA; The occasional consultation on a neonate can be unfamiliar territory for many orthopaedic surgeons. Just as children are not little adults, newborns are not just little children; rather, they have a unique physiology that affects the presentation of their orthopaedic concerns. Careful physical examination with appropriate understanding of neonatal development is essential to making the proper diagnosis. A flail extremity in the newborn is most commonly attributed to fracture or brachial plexus palsy; however, infection must also be considered and ruled out to prevent long‐term morbidity. Metatarsus adductus is the most common foot abnormality, but clubfoot, calcaneovalgus deformity, and congenital vertical talus may also be encountered. Joint contractures that spontaneously improve are normal in the newborn, but it is important to identify and institute proper treatment for early developmental dysplasia of the hip, congenital knee dislocation, and torticollis. Clavicular pseudarthrosis and periosteal reactions may be discovered on radiographic examination. A basic understanding of the relevant conditions will help the orthopaedist with the initial diagnosis and management of orthopaedic issues in the newborn.

Diagnosis and Treatment of Osteochondritis Dissecans

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of osteochondritis dissecans of the knee. None of the 16 recommendations made by the work group is graded as strong; most are graded inconclusive; two are graded weak; and four are consensus statements. Both of the weak recommendations are related to imaging evaluation. For patients with knee symptoms, radiographs of the joint may be obtained to identify the lesion. For patients with radiographically apparent lesions, MRI may be used to further characterize the osteochondritis dissecans lesion or identify other knee pathology.

Osteochondritis dissecans of the knee: pathoanatomy, epidemiology, and diagnosis.

Although several hypotheses have been described to explain the cause of osteochondritis dissecans, no single hypothesis has been accepted in the orthopedic community. Given its increased incidence among athletes, most in the sports medicine community agree that repetitive microtrauma plays at least some role in its development. Knowledge regarding the epidemiology and pathoanatomy of osteochondritis dissecans has helped the understanding of osteochondritis dissecans; however, much is still to be learned about this condition and its cause. This article reviews the history of osteochondritis as it pertains to the current understanding of its pathoanatomy, epidemiology, and diagnostic features.

Clinical outcomes as a function of meniscal stability in the discoid meniscus: a preliminary report.

Background: Current treatment for discoid meniscus includes arthroscopic saucerization, with meniscal stabilization additionally performed in patients with demonstrated instability. It is thought that unstable discoid menisci represent a more severe variant and are therefore at risk for poorer clinical outcomes. Our hypothesis was that there is no difference in clinical outcomes between patients undergoing discoid meniscal saucerization alone and those who additionally require stabilization. Methods: A retrospective chart review was performed for all patients presenting to a single pediatric center for treatment of a symptomatic discoid meniscus. Data collected included sex, age, affected side(s), preoperative and postoperative range of motion (ROM), type of surgery, and the presence of postoperative complications. In addition, a subset of these patients was enrolled prospectively. These patients completed 3 self-assessment tools—the International Knee Documentation Committee questionnaire, Lysholm Knee Score, and Tegner Activity Scale—before and after surgical intervention. Outcomes measures included objective criteria (ROM and surgical complications) and subjective criteria (patient-reported functional outcomes). For all outcomes measures, the Fisher exact test was used to determine whether significant differences existed between the patients who had undergone saucerization only and those who had also required surgical stabilization. Results: Fifty-seven knees in 51 patients were included in the study. Thirty-three patients (58%) underwent saucerization alone and 24 (42%) underwent saucerization and stabilization. Six surgical complications were identified. There was no significant difference between the groups regarding patient-specific factors (sex, age, and affected side) and postoperative outcomes measures (ROM and complication rate). Average patient follow-up was 15 months postoperatively. Seventeen patients (17 knees) additionally completed the 3 self-assessment questionnaires. In this subset of patients followed prospectively, there was no significant difference in self-reported outcomes detected between the meniscal saucerization and meniscal repair groups. Conclusions: Short-term results for patients with symptomatic discoid menisci requiring surgical intervention are favorable. The addition of a meniscal stabilization step to the saucerization procedure does not negatively affect either early clinical outcomes or complication rates in patients with demonstrated meniscal instability. Level of Evidence: Level III: Therapeutic Study, Retrospective, Comparative.

Rotator cuff injuries in adolescent athletes.

The cause of rotator cuff injuries in the young athlete has been described as an overuse injury related to internal impingement. Abduction coupled with external rotation is believed to impinge on the rotator cuff, specifically the supraspinatus, and lead to undersurface tears that can progress to full-thickness tears. This impingement is believed to be worsened with increased range of motion and instability in overhead athletes. A retrospective review of seven patients diagnosed with rotator cuff injuries was performed to better understand this shoulder injury pattern. The type of sport played, a history of trauma, diagnosis, treatment method, and outcome were noted. Six patients were male and one was a female. Baseball was the primary sport for four patients, basketball for one, gymnastics for one, and wrestling for one. The following injury patterns were observed: two patients tore their subscapularis tendon, two sustained avulsion fractures of their lesser tuberosity, one tore his rotator interval, one tore his supraspinatus, and one avulsed his greater tuberosity. Only four patients recalled a specific traumatic event. Three patients were treated with arthroscopic rotator cuff repair, three with miniopen repair, and one was treated with rehabilitation. Six of the seven patients returned to their preinjury level of sport after treatment. Rotator cuff tears are rare in the adolescent age group. The injury patterns suggest that acute trauma likely accounts for many rotator cuff tears and their equivalents in the young patient. Adolescents with rotator cuff tears reliably return to sports after treatment. The possibility of rotator cuff tears in skeletally immature athletes should be considered. The prognosis is very good once this injury is identified and treated.

Osteochondritis Dissecans of the Ankle in Children and Adolescents Demographics and Epidemiology

Background: Osteochondritis dissecans (OCD) of the ankle is a disorder of the talar or distal tibial subchondral bone and articular cartilage whose incidence in children is not clearly known. Purpose: To assess the demographics and epidemiology of OCD of the ankle in children. Study Design: Descriptive epidemiologic study. Methods: A retrospective chart review of an integrated health system was conducted on patients with ankle OCD aged 2 to 19 years from 2007 to 2011, with >1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. Ankle OCD incidence was determined for the group as a whole and by both sex and age group (divided into age groups of 2-5, 6-11, and 12-19 years). The risk for ankle OCD for age group, sex, and ethnicity was assessed using multivariate logistic regression models. Results: A total of 85 patients fit the inclusion criteria, and 71.8% of lesions found were in the medial talus, 56.5% of lesions were right sided, and none were bilateral. No ankle OCD lesions were found in 2- to 5-year-olds. The incidence of ankle OCD in patients aged 6 to 19 years was 4.6 per 100,000 overall and 3.2 and 6.0 per 100,000 for male and female patients, respectively. Patients aged 12 to 19 years represented the vast majority of those with OCD, with an incidence of 6.8 per 100,000 compared with 1.1 per 100,000 in those 6 to 11 years of age. In those aged 6 to 11 and 12 to 19 years, female patients had a respective incidence of 1.5 and 8.9 per 100,000, whereas male patients had a respective incidence of 0.7 and 4.8 per 100,000. The overall female/male ratio of ankle OCD was 1.6:1. Multivariate logistic regression analysis revealed a 6.9 times increased risk for ankle OCD in patients aged 12 to 19 years compared with those aged 6 to 11 years (95% CI, 3.8-12.5; P < .0001), and female patients had a 1.5 times greater risk for ankle OCD than male patients (95% CI, 1.0-2.3; P = .06). On the basis of race and ethnicity, non-Hispanic whites had the highest relative risk for disease and African Americans the lowest risk. Conclusion: In this population‐based cohort study of pediatric ankle OCD, female patients had a greater incidence of OCD and a 1.5 times greater risk for ankle OCD compared with male patients. Teenagers had nearly 7 times the risk for ankle OCD compared with children 6 to 11 years of age.

Preventable childhood injuries

Background: This is a literature review generated from The Committee on Trauma and Prevention of Pediatric Orthopaedic Society of North America to bring to the forefront 4 main areas of preventable injuries in children. Methods: Literature review of pertinent published studies or available information of 4 areas of childhood injury: trampoline and moonbouncers, skateboards, all-terrain vehicles, and lawn mowers. Results: Much literature exists on these injuries. Conclusions: Preventable injuries occur at alarming rates in children. By arming the orthopaedist with a concise account of these injuries, patient education and child safety may be promoted. Level of Evidence: 3.