Jose A. Herrera-Soto

The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective.

BACKGROUND The modified Dunn procedure has rapidly gained popularity as a treatment for unstable slipped capital femoral epiphysis (SCFE), but limited data exist regarding its safety and efficacy. The purpose of this study was to present results and complications following this procedure in a large multicenter series. METHODS We reviewed the outcomes of all patients who had been treated with the modified Dunn procedure by five surgeons from separate tertiary-care institutions. All slipped capital femoral epiphyses were defined as unstable according to the Loder criteria. Patients with less than one year of follow-up and those with an underlying endocrinopathy or syndrome were excluded. All surgical procedures were performed by pediatric orthopaedic surgeons who had specific training in the modified Dunn procedure. Operative reports, outpatient records, and follow-up radiographs were used to determine the demographic information, type of fixation, final slip angle, presence of osteonecrosis, and any additional complications. Standardized surveys were administered to determine the pain level (0 to 10 scale), satisfaction (0 to 100 scale), function (modified Harris hip score, 0 to 91 scale), and activity level (UCLA [University of California Los Angeles] activity score, 0 to 10 scale) at time of the most recent follow-up. RESULTS Twenty-seven patients (twenty-seven hips) with a mean of 22.3 months (range, twelve to forty-eight months) of follow-up met the inclusion criteria. Four patients (15%) had broken implants at three to eighteen weeks after surgery and required revision fixation. Seven patients (26%) developed osteonecrosis at a mean of 21.4 weeks (range, ten to thirty-nine weeks), with each surgeon having at least one case of osteonecrosis. The mean slip angle at the time of the most recent follow-up was 6° (95% confidence interval, 2° to 11°). Patients who did not develop osteonecrosis had significantly better clinical results compared with those who developed osteonecrosis, as demonstrated by a lower mean pain score (0.3 compared with 3.1, p = 0.002), higher level of satisfaction (97.1 compared with 65.8, p = 0.001), higher modified Harris hip score (88.0 compared with 60.0, p = 0.001), and higher UCLA activity score (9.3 compared with 5.9, p = 0.031). CONCLUSIONS This largest reported series of unstable slipped capital femoral epiphyses treated with the modified Dunn procedure demonstrated that the procedure is capable of restoring anatomy and preserving function after a slip but that implant complications and osteonecrosis can and do occur postoperatively.

Traumatic hip dislocations in children and adolescents: pitfalls and complications

&NA; Traumatic hip dislocation is an uncommon injury in children. Lack of familiarity with management of the treating physician may lead to complications. Hip dislocation in young children can occur with minor trauma; in adolescents, greater force is required to produce a traumatic complete hip dislocation. Transient hip dislocation with spontaneous but incomplete reduction is a diagnostic pitfall that can occur in adolescents. Any asymmetric widening of the hip joint warrants additional investigation. Most dislocations in children can be reduced with gentle manipulation. Urgent reduction of the hip within 6 hours of injury reduces the risk of osteonecrosis. However, closed reduction in adolescents should be performed with caution because of the risk of displacement of the femoral head during manipulation. Open reduction is indicated when closed reduction fails or when there is interposition of bone or soft tissue following attempted closed reduction. Late complications include osteonecrosis, coxa magna, and osteoarthritis.

Increased Intracapsular Pressures After Unstable Slipped Capital Femoral Epiphysis

Background: Osteonecrosis of the femoral head is the most dreaded complication associated with an unstable slipped capital femoral epiphysis (SCFE). We hypothesize that the hip joint pressure will be increased in unstable slips, confirming that emergent treatment and decompression are warranted. Methods: Thirteen unstable SCFE hips were evaluated. Hip pressure monitoring was performed. Postcapsulotomy measurements were also performed in all of the patients. Five of these under gentle manipulation. Six patients underwent measurement of the hip pressure on the unaffected side. Results: The mean pressure on the affected hip was 48 mm Hg. The mean pressure on the unaffected side was 23 mm Hg. There was a significant increase in intraarticular hip pressure after attempted manipulation (mean, 75 mm Hg). Discussion: Hip pressures are increased in unstable SCFE to levels higher for those of a compartment syndrome probably causing a tamponade effect. There is a need to perform a capsulotomy if manipulation is performed.

Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann's kyphosis

Study Design. Retrospective. Objectives. To determine whether anterior endoscopic release and posterior spinal fusion could achieve stable correction in Scheuermann’s kyphosis. Summary of Background Data. The initial treatment of choice of Scheuermann’s kyphosis is thoracic hyperextension and postural exercises and/or Milwaukee brace. Milwaukee bracing is most efficacious in the early stages when the curvature is flexible and in the skeletally immature. However, it is known that larger curves, vertebral wedging greater than 10°, and skeletally mature patients will not usually respond to this treatment. Surgery is indicated in the skeletally immature with severe deformity where brace treatment has failed to prevent progression. Posterior spinal instrumentation can achieve adequate correction in the less rigid curves. However, the more rigid curves have been shown to be resistant to posterior spinal fusion alone, therefore needing anterior spinal release. Methods. Between 1995 and 2001, 19 patients underwent video-assisted thoracoscopic surgery and posterior spinal fusion for the treatment of Scheuermann’s kyphosis. The average age was 17.4 years with closed triradiate cartilage in all. Average follow-up was 2.7 years. An average of 8.3 discs were released anteriorly; an average of 13 levels were fused posteriorly. Results. Average preoperative kyphosis was 84.8°. Average postoperative kyphosis was 43.7°. Average kyphosis at follow-up was 45.3°. Only 1.6° of correction loss was noted. No junctional kyphosis was present. Two patients developed pleural effusion; one required thoracocentesis. Two patients developed pneumothorax. One patient underwent revision surgery for inferior hook pullout. One required mechanical ventilation. Conclusions. Combined video-assisted thoracoscopic surgery release and posterior spinal fusion for the treatment of Scheuermann’s kyphosis is a viable option for the treatment of the more severe and rigid curves.

Retrospective study on the development of spinal deformities following sternotomy for congenital heart disease.

Study Design. Retrospective review with a minimum of 3 years of follow-up. Objective. We hypothesize that following median sternotomy there may be an increase incidence of both sagittal and coronal spinal deformity. We also think that heart size and a cyanotic cardiac condition are also risk factors for development of spinal deformity. The purpose of this study was to determine the incidence and characteristics of spinal deformity in patients following sternotomy for congenital heart disease. Summary of Background Data. Patients with congenital heart disease are at an increased risk to develop scoliosis. Methods. A total of 108 patients underwent a median sternotomy for the treatment of congenital heart disease and met inclusion criteria. The medical record was reviewed to gather demographic data and medical and surgical history. Serial chest and spine radiographs were reviewed. Results. Scoliosis developed in 28% of the patients (10 males, 20 females). The mean follow-up was 13 years (range, 3–26 years). The mean coronal Cobb angle was 25° (range, 11°–88°). Of these, 7 patients presented with curves of ≥30°. The mean age at diagnosis of scoliosis was 14 years (range, 2–33 years). A kyphotic deformity developed in 22% (24 patients). In patients with scoliosis, the mean sagittal kyphosis was 34° (range, 2°–73°). Patients with a cyanotic cardiac condition had a trend toward severe scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, gender, or heart size. Conclusion. The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or kyphosis, were found in 34% of the patients. The sagittal alignment in scoliosis patients tends toward kyphosis.

Mortality and morbidity in early-onset scoliosis surgery.

Study Design. Retrospective chart review. Objective. To accurately determine complication rates, particularly mortality rates, in surgically treated early-onset scoliosis. Summary of Background Data. The advent of modern segmental instrumentation for spinal fusion surgery in adolescent scoliosis has allowed for application of similar nonsegmental unfused techniques aimed at controlling scoliosis in the very young child. The dismal prognosis for these children without repeated spinal lengthening procedures is unquestioned, although no controlled trials exist. Many, if not most, of these children need surgery; however, the surgical complication rate is very high. Methods. During the study period, all surgically treated children with early-onset scoliosis seen at our institution were identified. Any patient who presented to our clinic with early-onset scoliosis that was surgically managed was included. The total number of procedures, type of implants, number and type of complications, geographic origin of the cases, and final outcomes were all assessed. Results. A total of 165 surgical procedures on 28 patients accrued during the study time period, including index implantation of instrumentation, lengthening, and definitive fusion, as well as operations performed for complications such as wound debridement and revision of failed implants. Clinical diagnoses included congenital scoliosis, syndromic and chromosomal abnormalities, cerebral palsy, and spinal muscular atrophy. There was a complication rate of 84% overall with a mortality rate of almost 18%. The only patients with no complications were those whose entire surgical course had been at our institution only. The mortality rate was equal in patients whose treatment was performed elsewhere versus exclusively in our center. Conclusion. This study underlines the grave severity of these scolioses particularly in syndromic children. The high mortality rate is alarming, suggesting that further study is needed in this area.

Fractures of the fifth metatarsal in children and adolescents.

Objective: Fractures of the fifth metatarsal are the most common metatarsal fractures in children. Their treatment is based on the adult literature. The purpose of our study was to identify the different types of fifth metatarsal fractures, to determine the mean time to healing, and to examine whether current adult recommendations can be extrapolated to children and adolescents. Methods: A total of 103 patients met the inclusion criteria. The fractures were classified according to location. Type I represented an apophyseal injury. Type II represented tubercle fractures with intra-articular extension. Type III injuries represented Jones fracture. Metatarsal neck and shaft fractures were included separately. Results: Apophyseal fractures did well with a short-leg walking cast for 3 to 6 weeks. Displaced intraarticular fractures had a significant delay in healing versus nondisplaced ones. Jones fractures had delays in healing if not treated surgically. Neck and shaft fractures did well with casting. Conclusions: Most fractures of the fifth metatarsal in the pediatric population do well clinically after a course of walking cast, unless the fracture is an intra-articular displaced fracture type or the fracture occurs in the proximal diaphyseal area. Fixation of Jones fractures in active adolescents should be considered to allow faster return to regular activities and prevent refracture. We recommend non-weight bearing casts for all angulated or displaced intra-articular injuries to avoid delays in healing and angulation. From our series, it is evident that most pediatric fifth metatarsal fractures behave as those found in adults and can be treated similarly.

Proximal Femoral Epiphysiolysis During Reduction of Hip Dislocation in Adolescents

Abstract: Traumatic hip dislocation is an uncommon injury in children. The urgency of closed reduction to prevent possible osteonecrosis may present some pitfalls. Adolescents with open proximal femoral physis may have sustained trauma to the physis at the time of dislocation that can lead to displacement of the epiphysis during the reduction maneuver. The purpose of this study is to report 5 cases with this complication and discuss potential etiology and management. All of the 5 patients were between 12 and 16 years old and underwent closed reduction under conscious sedation. Epiphysiolysis of the femoral head was diagnosed after reduction in all 5 patients. Every patient underwent emergent open reduction and internal fixation of the femur and open hip reduction. Avascular necrosis was identified in all 5 patients within 3 to 15 months postinjury. If there is any suspicion of associated physeal injury or if there is any physeal instability noted under fluoroscopy, an open reduction is recommended in the operating room under radiograph guidance to prevent displacement.

Outcomes after salvage procedures for the painful dislocated hip in cerebral palsy.

Background: The painful dislocated hip in the setting of cerebral palsy is a challenging problem. Many surgical procedures have been reported to treat this condition with varying success rates. The purpose of this study is to retrospectively evaluate and compare the outcomes of 3 different surgical procedures performed at our institution for pain relief in patients with spastic quadriplegic cerebral palsy and painful dislocated hips. Methods: A retrospective chart review of the surgical procedures performed by 5 surgeons for spastic, painful dislocated hips from 1997 to 2010 was performed. The procedures identified were (1) proximal femoral resection arthroplasty (PFRA); (2) subtrochanteric valgus osteotomy (SVO) with femoral head resection; and (3) proximal femur prosthetic interposition arthroplasty (PFIA) using a humeral prosthesis. Outcomes based on pain and range of motion were determined to be excellent, good, fair, or poor by predetermined criteria. Results: Forty-four index surgeries and 14 revision surgeries in 33 patients with an average follow-up of 49 months met the inclusion criteria. Of the index surgeries, 12 hips were treated with a PFRA, 21 with a SVO, and 11 with a PFIA. An excellent or good result was noted in 67% of PFRAs, 67% of SVOs, and 73% of PFIAs. No statistical significance between these procedures was achieved. The 14 revisions were performed because of a poor result from previous surgery, demonstrating a 24% reoperation rate overall. No patients classified as having a fair result underwent revision surgery. All patients receiving revision surgery were eventually classified as having an excellent or good result. Conclusions: Surgical treatment for the painful, dislocated hip in the setting of spastic quadriplegic cerebral palsy remains unsettled. There continue to be a large percentage of failures despite the variety of surgical techniques designed to treat this problem. These failures can be managed, however, and eventually resulted in a good outcome. We demonstrated a trend toward better outcomes with a PFIA, but further study should be conducted to prove statistical significance. Level of Evidence: III.

Usefulness of electromyography compared to computed tomography scans in pedicle screw placement.

Study Design. This is a retrospective analysis of 30 pediatric deformity surgeries. Objective. The purpose of this study was to evaluate the accuracy of neuromonitoring in comparison to postoperative computed tomography scans for pedicle screw position. Summary of Background Data. Triggered electromyography potentials in aiding the placement of lumbar pedicle screws are considered useful; however, this method is less accepted in thoracic screw placement. Methods. Thirty pediatric deformity surgeries were reviewed. All screws were placed using fluoroscopic assistance. Electromyography data were obtained on all screws. Every patient underwent postoperative computed tomography scanning. Computed tomography scans were assessed by all authors, and each screw was classified. Sensitivity, specificity, negative predictive value, and likelihood ratios were determined for the cut-off value of an electromyography ≥6 mA. Results. A total of 329 screws were reviewed. No complications occurred. An overall accuracy of 93% was obtained. No retained screw had greater than 2 mm medial pedicle wall breach. Nine screws were removed intraoperatively due to medial breach. The mean electromyography potential for all classes of screws was not statistically different (P > 0.1). The negative predictive value of the test was 0.92 in the thoracic spine and 0.93 in the lumbar spine. The negative likelihood ratios were 0.96 and 0.35 for the thoracic and lumbar spines respectively, and the positive likelihood ratio was 1.4 for the thoracic spine and 12.5 for the lumbar spine. Conclusion. Thoracic and lumbar pedicle screws are safe surgical options in the treatment of pediatric scoliosis. Comparison of electromyography potentials and postoperative computed tomography scans showed no statistically significant difference for all classes of screws. The likelihood ratio for electromyography testing was more clinically significant in the lumbar spine. A triggered electromyography value greater than or equal to 6 mA has a high likelihood of that screw being in the “safe zone.” However, there is no true electromyography cut-off value that guarantees accurate placement and avoidance of neurologic injury.