Jonathan H. Phillips

Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures.

Background: The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants. Methods: Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups. Results: Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN. Conclusions: Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP. Level of Evidence: Level III, therapeutic study.

Digital radiography in pediatric orthopaedics: a prospective, controlled, and randomized trial.

A prospective, controlled, and randomized trial of digital radiography was conducted to evaluate its advantages in children. Matched pairs of radiographs of the feet were taken in 20 children, and pelvic radiographs were taken in another 20 children. Each pair comprised a digital and conventional film. Half of the digital films were made with a 50% radiation dose reduction. The films were scored for quality. Statistically significant advantages were seen for the digital radiographs as compared with the conventional technique. Visualization of soft tissue and bony detail was enhanced in both foot and pelvic radiographs. This was true even with a 50% dose reduction in many of the parameters scored. We conclude that digital radiography offers advantages over conventional radiography, and recommend its use.

Bilateral Unstable Slipped Capital Femoral Epiphysis: A Look at Risk Factors

Unstable slipped capital femoral epiphysis can have disastrous complications including osteonecrosis and chondrolysis. It has been shown that 20% to 80% of patients may develop a contralateral slip ≤18 months after diagnosis. The purpose of this article is to report and characterize patients who developed bilateral unstable slips. After Institutional Review Board approval, the patients included were only those with bilateral unstable slipped capital femoral epiphyses. A minimum 2-year follow-up was required. Seven patients, all female, were included in the study, with an average age of 11.4 years at the time of their first slips. The interval between slips averaged 127 days (range, 0-245 days). All but 1 patient presented with a severe slip. The second slip was also severe in 3 patients and less severe in 4 patients. The triradiate cartilage was open in 3 patients. Two patients required corrective osteotomies. Chondrolysis developed in 2 patients with no osteonecrosis reported. The incidence of bilateral unstable slips ranged from 4% to 20% of all unstable slipped capital femoral epiphyses based on our findings. Skeletal immaturity was not a risk factor. The surgeon must be vigilant for the possibility of bilateral slips. The family must be instructed on precautions patients must take while recuperating from unstable slipped capital femoral epiphyses. Contralateral fixation of the unaffected side may be warranted in patients with initial severe unstable slipped capital femoral epiphyses to prevent this condition.

Spinal Cord Monitoring in Pediatric Cervical Spine Surgery

The role of sensory and motor, intraoperative, and neurophysiological monitoring of spinal cord physiology at multiple, neural levels has become an established routine. The chapter Spinal cord monitoring in pediatric cervical spine surgery is a review of the principles and concepts that need further study in this very specialized area of pediatric cervical spine surgery. This is a discussion of the basic science and clinical application, including practical concerns and protocols. A thorough understanding of the current thinking in this area is germane to surgery of the child’s cervical spine and generalizable to any children’s spinal surgery. The response to alarm criteria is discussed in both a proactive and reactive way. The conclusion is that the principles of neurophysiological monitoring of the spinal cord during orthopedic and neurosurgical procedures are well established and should be followed in the management of disorders of the child’s cervical spine.

Embryology and Anatomy of the Child’s Cervical Spine

The process of the embryological development of the child’s cervical spine shows unique variations from other spinal levels. An understanding of this anatomy and embryology is fundamental to safe surgical approaches in this area.

Radiology of the Growing Cervical Spine

The evaluation of the developing pediatric cervical spine presents certain diagnostic dilemmas that are not encountered in adults. There are several well-documented radiographic pitfalls that can lead physicians to misinterpret normal anatomical variations for true pathologic changes. Physeal variations, unique vertebral architecture, incomplete ossification, and hypermobility of the cervical spine may all cause uncertainty when interpreting radiographs of a child with a history of trauma, pain, or stiffness. There are various radiographic measurements that can be utilized to differentiate true pathology from normal variants; however knowledge of the embryological development and postnatal ossification patterns of the cervical spine is paramount in recognizing traumatic spinal injuries in children. Although cervical spine injuries in children are rare, they are associated with high morbidity and mortality. Therefore understanding the normal appearance of the developing pediatric cervical spine as well as the presentation of pathological changes on plain films, CT, and MRI is essential in ensuring early and accurate diagnosis.

The Fate of the Neuromuscular Hip After Spinal Fusion.

Background: The goals of treatment of neuromuscular scoliosis are to achieve a balanced spine and level pelvis with most constructs including pelvic fixation. However, the pelvis can become a stiff “end vertebra” that prevents compensatory mechanisms to adjust to hip deformities in this patient population. The purpose of this study is to determine the frequency of hip pathology and surgery after spinal fusion in this patient population. Methods: We performed a retrospective chart and radiographic review of cerebral palsy patients who underwent posterior spinal fusion (PSF) at our institution from 2005 to 2011. We collected radiographic data of preoperative and postoperative pelvic obliquity and hip reduction status and position (up, level, down). We further evaluated patients requiring hip surgery (containment or salvage). Results: Of 47 patients with an average follow-up of 3.5 years after spinal fusion, 21 (45%) underwent a hip procedure. Thirty-eight patients (81%) demonstrated or developed hip subluxation/dislocation. Hip pathology occurred more often in the up hip, but the pathologic down hip more often underwent a hip surgery. Eight new hip subluxation/dislocations occurred after spine surgery. Three (38%) of the new postoperative subluxation/dislocations required hip surgery; all had pelvic obliquity <6 degrees. Eleven patients underwent hip surgery before PSF, 7 were varus femoral osteotomies for subluxation, whereas 5 hips required salvage. In follow-up after PSF, none of these had a new dislocation. Ten patients required hip surgery after PSF at a mean of 1.6 years after PSF. Eight patients had a salvage procedure for painful hip and 2 varus femoral osteotomies for subluxations. Conclusions: In our cerebral palsy patients who underwent PSF, 45% of these patients required a hip procedure. In the patients who had containment before PSF, the hips maintained reduction after spinal fixation. After correction of pelvic obliquity, 17% of patients had new-onset hip subluxation/dislocation after PSF. Postoperative subluxation/dislocation was not dependent on whether the hip was up or down preoperatively. Level of Evidence: IV, Retrospective.

Carbon Coated Implants as a New Solution for Metal Allergy in Early-Onset Scoliosis: A Case Report and Review of the Literature

STUDY DESIGNnRetrospective case report.nnnOBJECTIVEnTo report the first known case of immunological camouflage of a metal spinal implant with carbon coating.nnnSUMMARY OF BACKGROUND DATAnMetal sensitivity is common and is a consideration when choosing orthopedic implants in susceptible individuals. The sensitivity often is to nickel, cobalt, or chromium, and titanium is used as a safe alternative. However, when the allergy is also to titanium, solutions may be much more difficult. This case describes an innovative solution to a complex metal allergy that includes titanium in a child requiring spinal instrumentation for early-onset scoliosis.nnnMETHODSnAt age 6 years 7 months, the patient underwent an uncomplicated placement of bilateral posterior Vertical Expandable Prosthetic Titanium Ribs (VEPTRs; Synthes, Inc., West Chester, PA). At that time, there were no known metal allergies. At 3 weeks, the right side had become erythematous and had serosanguineous drainage. It briefly improved after each of 2 surgical debridements and a course of intravenous antibiotics, but within 6 weeks of the index procedure, the pain was still worsening. A titanium allergy was suspected and blood was sent for allergy testing. A test confirmed hypersensitivity to titanium, niobium, molybdenum, iron, and aluminum, among others. The remaining rod was removed. An inxa0vivo trial for tolerance to high-grade stainless-steel implants was done. The implant was removed after 2 weeks because of systemic symptoms that occurred.nnnRESULTSnA plasma-spray, carbon-coated VEPTR rod was designed. A rod sample was inserted into the patients forearm for trial. After 3 months, there was no appreciable reaction. Carbon-coated VEPTRs were placed without complications. The patient has undergone multiple lengthening using the carbon-coated VEPTRs.nnnCONCLUSIONSnIn the rare patient with multiple allergies, choosing orthopedic implants can be challenging. An innovative carbon coating was applied by plasma spray to the VEPTR system, with good results.