Kelly L. Vanderhave

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.

Magnetic resonance imaging of acute patellar dislocation in children: patterns of injury and risk factors for recurrence

Background: Acute patellar dislocation is a common traumatic condition of the knee seen in the active adolescent. The patterns of injury to the ligamentous and chondral surfaces following dislocation have not been well defined in the pediatric population. The purpose of this study was to characterize the patterns of medial patellofemoral ligament (MPFL), vastus medialis obliqus (VMO), and osteochondral injury on magnetic resonance imaging (MRI) following first-time acute lateral patellar dislocation in pediatric patients. Methods: Following approval by the Institutional Review Board, a radiology query was performed to identify all patients between the ages of 11 and 18 years who underwent MRI following an acute first-time patellar dislocation over a 10-year period. The presence and location of injury to the MPFL, VMO, and chondral surfaces were evaluated on MRI images. A retrospective review of the patient’s chart was conducted to confirm that clinical history was consistent with an acute patellar dislocation. Demographic data, including age at the time of injury, sex, knee affected, mechanism of injury, and recurrence of dislocation, were retrieved from the chart. The data were analyzed as a single cohort. Results: One hundred and eleven patients, including 56 males and 46 females with a mean age of 14.9 years (range, 11 to 18 y), were included. MRI demonstrated MPFL injury in 87 patients (78.4%). MPFL injury was present at an isolated patellar insertion in 34 patients (31%) and an isolated femoral insertion in 16 patients (14%). MPFL injury at more than one location was present in 37 patients (33%). VMO edema was present in 62 patients (56%), consistent with sprain or tear. Osteochondral fracture was identified in 38 knees (34%), with 25 from the medial patellar facet, 5 from the lateral femoral condyle, and 8 from both locations. Conclusions: Acute patellar dislocations remain a common injury in pediatric patients. The pattern of injury to the MPFL and VMO on MRI has not been described in a pediatric population. The triad of injury to the MPFL, VMO, and chondral surfaces should be recognized and understood, particularly when surgical reconstruction is necessary. Level of Evidence: Level III.

Meniscus tears in the young athlete: results of arthroscopic repair.

Background The purpose of this study was to evaluate the results of arthroscopic repair of the meniscus in children and young athletes. Methods Arthroscopic meniscus repairs performed on 49 knees in 31 male and 14 female patients <18 years old were reviewed. All repairs were done using an inside-out technique, and 31 patients required concomitant anterior cruciate ligament (ACL) reconstruction. Age at time of injury, time to surgery, and the extent, type, and location of meniscus tear were noted. All patients underwent postoperative rehabilitation and clinical evaluation. The level of activity at follow-up and postoperative outcomes scores was determined. Analysis included t tests, Wilcoxon tests, &khgr;2 tests, and Fisher exact tests, with a level of significance of P≥0.05. Results Excellent clinical outcomes were noted in 43 of 45 patients, with mean length of follow-up of 27 months. Between the groups with and without ACL tears, there were no significant differences in mean age at the time of injury or surgery, or in the distribution of open versus closed physes, medial versus lateral repairs, or level-of-activity at follow-up. However, patients with ACL reconstruction had significantly longer return-to-activity times (mean 8.23 mo vs. 5.56 mo) and significantly lower Tegner scores (mean 6.8 vs. 8.0) than patients without simultaneous reconstruction. Conclusions The clinical results after arthroscopic meniscus repair in the adolescent were excellent, despite long average time from injury to surgery and a high number of tears in poorly vascularized areas. Meniscal tears in skeletally immature athletes may have greater reparative potential, with and without simultaneous ligament reconstruction. Attempts at repair regardless of time from injury or location of tear should be strongly considered in this age group. Level of Evidence Level III retrospective cohort series.

Osteochondral injury after acute patellar dislocation in children and adolescents.

Background: Acute patellar dislocation (APD) is a common injury in the pediatric patient population and may be associated with a spectrum of soft tissue and osteochondral injuries. This study describes the incidence of osteochondral fracture and associated injury patterns in a pediatric population after first-time APD and assesses functional outcomes after treatment. Methods: One hundred twenty-two patients, aged 11 to 18 years, who were evaluated after first-time APD over a 10-year period were identified, 46 of whom had confirmed osteochondral injury on magnetic resonance imaging (MRI). Demographic data, including knee affected, mechanism of injury, recurrent dislocation, operations performed, and condition at last follow-up, were retrieved from the medical record. Operative reports and MRI were used to characterize the location of osteochondral injury. The functional outcome of each patient with an osteochondral fracture was assessed using the Pedi-IKDC questionnaire. Results: Forty-six patients, mean age 14.6 years (range, 11 to 18 y), were included. Osteochondral fracture occurred at the patella in 35 patients (76%), the lateral femoral condyle in 11 patients (24%), and at both locations in 3 patients (6.5%). In 21 patients (44%), MRI confirmed osteochondral injury despite the plain radiograph interpretation as negative for fracture. Twenty-six patients (68%) subsequently underwent surgery after injury. Injury to the medial patellofemoral ligament was identified on MRI in 97.8% of patients (45/46). Fifteen patients (32.6%) underwent a concomitant medial repair at the time of surgery. Osteochondral injury to the distal femur on average had a lower International Knee Documentation Committee score than patellar injuries (72.3±18 vs. 91.1±10.2, P<0.003). Femoral osteochondral injury involving the weight-bearing surface (75.27±18.19) scored lower than non–weight-bearing surface injuries (93.22±7.47; P<0.001). Conclusions: The incidence of osteochondral injury associated with APD is high. Osteochondral fractures may initially go unrecognized on plain radiographs. Patients with weight-bearing lateral femoral condyle injuries had lower short-term functional scores, suggesting that outcomes depend on location of injury. Level of Evidence: Level IV, diagnostic and therapeutic study.

Vertical expandable prosthetic titanium rib device insertion: Does it improve pulmonary function?

PURPOSE Vertical expandable prosthetic titanium rib (VEPTR) insertion and expansion has been advocated to increase thoracic volume and pulmonary function in patients with thoracic insufficiency syndrome. We reviewed our experience with VEPTR implantation to determine if lung function and growth is augmented, to determine the childrens functional status, and if the scoliosis is controlled. METHODS From 2006 to 2010, 29 insertions and 57 expansions were performed in 26 patients at our institution. Demographic data were reviewed in conjunction with complications, scoliosis angles, pulmonary function tests (PFTs), and computed tomography-guided 3D reconstructions to determine lung volumes; and quality of life scores were determined using a modified Scoliosis Research Society (SRS) questionnaire preoperatively and postoperatively. The groups were also stratified by age (because of lung growth potential), disease (congenital or infantile scoliosis, Jeune syndrome, neuromuscular, other structural thoracic disorders), and sex. Analyses using SPSS (SPSS, Chicago, Ill) were performed with P < .05 considered significant. RESULTS Each patient underwent 3.03 ± 1.8 surgeries, spending 0.97 ± 1.8 days in the intensive care unit and 4.41 ± 6 days in the hospital for each procedure. Mean age was 90.7 ± 41 months. Of the 36 complications, most were because of infection (12), half requiring operative repair (hardware removal). The average PFT percent predicted values for forced expiratory volume in 1 second, forced vital capacity, and RV were 54.6 ± 22, 58.1 ± 24, and 145.3 ± 112, respectively, preoperatively and 51.8 ± 20, 55.9 ± 20, and 105.6 ± 31, respectively, postoperatively. The lung volumes measured by computed tomography when corrected for age do not increase significantly postoperatively. The mean Cobb measurement for the preoperative major curves was 64.7° and postoperatively was 46.1° for those curves measured preoperatively, for a 29% curve improvement. All postoperative curves had a mean of 56.4° and 58.1° at final follow-up, a 3% curve increase. The SRS scores for patients remained unchanged and no statistical difference was seen from preoperative to postoperative values. No statistically significant difference was seen in complications, PFT (forced expiratory volume in 1 second, forced vital capacity, RV), lung volumes, scoliosis angles, and SRS scores between sex, age, and disease categories. CONCLUSION There was mild improvement in scoliosis angles but no improvement in lung function and volume. Scoliosis Research Society scores indicate that the children have near normal function both before and after VEPTR placement. Pulmonary function, lung volume, and patient subjective assessments did not increase dramatically after VEPTR placement, although scoliosis angles improved.

Utility of electrodiagnostic testing and computed tomography myelography in the preoperative evaluation of neonatal brachial plexus palsy

OBJECT The rate of neonatal brachial plexus palsy (NBPP) remains 0.4%-4% despite improvements in perinatal care. Among affected children, the extent of brachial plexus palsy differs greatly, as does the prognosis. Controversial elements in management include indications and timing of nerve repair as well as type of reconstruction in patients in whom function will ultimately not be recovered without surgical intervention. Differentiating preganglionic (avulsion) from postganglionic (rupture) lesions is critical because preganglionic lesions cannot spontaneously recover motor function. Distinguishing between these lesions at initial presentation based on clinical examination alone can be difficult in infants. The purpose of the present study was to determine the sensitivity of preoperative electrodiagnostic studies (EDSs) and CT myelography (CTM) in determining the presence of nerve root rupture and avulsions in infants with NBPP. METHODS After receiving institutional review board approval, the authors conducted a retrospective review of patients referred to the Neonatal Brachial Plexus Program between 2007 and 2010. Inclusion criteria included children who underwent brachial plexus exploration following preoperative EDSs and CTM. The CTM scans were interpreted by a staff neuroradiologist, EDSs were conducted by a single physiatrist, and intraoperative findings were recorded by the operating neurosurgeon. The findings from the preoperative EDSs and CTM were then compared with intraoperative findings. The sensitivities and 95% confidence intervals were determined to evaluate performance accuracy of each preoperative measure. RESULTS Twenty-one patients (8 male amd 13 female) met inclusion criteria for this study. The sensitivity of EDSs and CTM for detecting a postganglionic rupture was 92.8% (CI 0.841-0.969) and 58.3% (CI 0.420-0.729), respectively. The sensitivity for EDSs and CTM for preganglionic nerve root avulsion was 27.8% (CI 0.125-0.509) and 72.2% (CI 0.491-0.875), respectively. In cases in which both CTM and EDSs gave concordant results, the sensitivity for both modalities combined was 50.0% (CI 0.237-0.763) for avulsion and 80.8% (CI 0.621-0.915) for rupture. Overall, EDSs were most useful in identifying ruptures, particularly in the upper plexus, whereas CTM was most sensitive in identifying avulsions in the lower plexus. CONCLUSIONS Knowledge of the spinal nerve integrity is critical for early management of patients with NBPP. Surgical management, in the form of nerve repair/reconstruction, and optimal prognostication of NBPP depend on the accurate diagnosis of the level and type of lesion. Both EDSs and CTM scans must always be interpreted in the context of a comprehensive evaluation of the patient. They provide supplemental information (in addition to the physical examination) for early detection of nerve root rupture and avulsion injuries, aiding surgical decision making and preoperative planning for NBPP. Continued advances in imaging, EDSs, and microsurgical nerve repair techniques will allow surgeons to achieve greater success for functional recovery in management of NBPP.

Obesity and its effects on pediatric supracondylar humeral fractures.

BACKGROUND This study evaluates the effects of childhood obesity on fracture complexity and associated injuries in pediatric supracondylar humeral fractures. METHODS A billing query identified all patients who were two to eleven years of age and had undergone operative treatment for extension-type supracondylar humeral fractures over a 12.5-year period. Records were reviewed for demographic data, body mass index percentile, and injury data. Complex fractures were defined as type-3 supracondylar humeral fractures, supracondylar humeral fractures with intercondylar extension, or supracondylar humeral fractures with ipsilateral upper-extremity fractures. Logistic regression analyses were used to test relationships among body mass index subgroups, fracture complexity, elbow motion, preoperative and postoperative neurovascular status, and complications. RESULTS Three hundred and fifty-four patients met our inclusion criteria. Forty-one children were underweight (BMI in the <5th percentile), 182 were normal weight (BMI in the 5th to 85th percentile), sixty-three were overweight (BMI in the >85th to 95th percentile), and sixty-eight were obese (BMI in the >95th percentile). There were 149 patients, eleven of whom were obese, with isolated type-2 fractures and 205 patients, fifty-seven of whom were obese, with complex fractures. Thirty-two patients had preoperative nerve palsies and twenty-eight patients had postoperative nerve palsies. Using logistic regression, obesity was associated with complex fractures (odds ratio, 9.19 [95% confidence interval, 4.25 to 19.92]; p < 0.001), preoperative nerve palsies (odds ratio, 2.69 [95% confidence interval, 1.15 to 6.29]; p = 0.02), postoperative nerve palsies (odds ratio, 7.69 [95% confidence interval, 2.66 to 22.31]; p < 0.001), and postoperative complications (odds ratio, 4.03 [95% confidence interval, 1.72 to 9.46]; p < 0.001). Additionally, obese patients were more likely to sustain complex fractures from a fall on an outstretched hand than normal-weight patients (odds ratio, 13.00 [95% confidence interval, 3.44 to 49.19]; p < 0.001). CONCLUSIONS Obesity is associated with more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. To our knowledge, this study is the first to assess the implications of obesity on supracondylar humeral fracture complexity and associated injuries and it validates public health efforts in combating childhood obesity.

Lyme Disease Presenting as Popliteal Cyst in Children

Lyme disease is the most common tick-borne disease in North America. Our review of the literature found few reports of Lyme disease presented in the orthopaedic literature. However, Lyme disease presenting as a popliteal cyst, with or without rupture, is rarely reported. We present 4 cases of Lyme disease that initially presented to our pediatric orthopaedic clinic for treatment of a popliteal cyst. The early diagnosis and treatment of Lyme disease may help prevent the often-devastating long-term sequelae of Lyme disease. The goal of this article is to increase the awareness of Lyme disease presenting in children as a popliteal cyst.

Outcomes following removal of instrumentation after posterior spinal fusion.

Background: Although there is good evidence to support the removal of instrumentation for infection following posterior spine fusion, there are few studies that report outcomes following removal for late operative site pain. The purpose of this study was 3-fold: (1) to determine whether removal of instrumentation following posterior spinal fusion resolves preoperative pain, (2) to determine whether indolent infection not detected before removal of instrumentation is related to late operative site pain, and (3) to determine whether curve progression differs when spinal hardware is removed for infection versus late operative site pain. Methods: A retrospective study of consecutive patients aged 10 to 21 years, who underwent removal of instrumentation after posterior spinal fusion over a 10-year-period was conducted. Patient demographics, preoperative and postoperative imaging results, laboratory studies, and operative findings were reviewed. All patients had a minimum 2-year follow-up. Statistical analysis was performed using 2-sample t test, bivariate analysis, and multivariate logistic regression models. Results: Seventy-five patients were included. Indications for removal of spinal instrumentation were pain (57%), infection (28%), hardware failure (8%), and prominent hardware (7%). The mean time from index procedure to hardware removal was 2.8 years. The average loss of curve correction following complete hardware removal was 23.1 degrees. Patients who underwent removal of hardware because of infection had bigger changes in their curves than those without infection (mean, 33.8 degrees vs. 18.8 degrees). Of the 43 patients with pain, only 40% reported relief of their symptoms following removal of hardware. Sixteen of the 43 patients were found to have indolent infection confirmed by positive intraoperative culture results. Conclusions: Patients should be cautioned that hardware removal after posterior spinal fusion may not provide complete pain relief. Furthermore, there is risk for curve progression following removal of instrumentation, particularly in the setting of infection. Back pain may be an indicator of infection, and intraoperative cultures should be taken at the time of implant removal. Level of Evidence: Level IV; retrospective case series.

Postoperative spine and VEPTR infections in children: a case-control study.

Background: Surgical site infection (SSI) after pediatric scoliosis surgery is a major cause of morbidity. We compared the odds ratios of various potential risk factors for infection among patients who developed a deep SSI following spinal deformity surgery and those who remained infection free. Methods: This was a case-control study, not a matched study. More noninfection cases (50) than infection cases (20) were selected because more were available. Twenty children with a deep SSI after scoliosis surgery were compared with 50 similar children who did not develop a deep SSI. Fourteen perioperative factors were examined in both the groups. Results: Of the 20 patients who had a deep SSI, 14 had neuromuscular scoliosis. In the infected group, 6 patients had undergone vertical expandable prosthetic titanium rib placement, 2 had undergone growing rod insertion, and 12 had undergone posterior spinal fusion. Eighteen patients developed a SSI within 1 year of the operation and 2 patients presented with a SSI >1 year after surgery. Sixteen patients had positive cultures. Majority were skin flora: coagulase-negative Staphylococcus (8) and Propionibacterium acnes (4). Both patients with tracheostomies had Enterococcus faecalis infections. When comparing the 20 patients with deep SSI to the 50 controls, increased preoperative Cobb angle (P=0.011), increased postoperative Cobb angle (P=0.0043), nonambulatory status (P=0.0002), and increased length of stay (P=0.015) were associated with significantly increased odds of infection. Conclusions: Our study shows that patients with neuromuscular scoliosis are at higher risk of developing a deep SSI after spinal deformity surgery. Skin flora is a common cause of deep SSI. We have now instituted a standard skin preparation protocol to include alcohol and chlorhexidine washes the night before and the morning of surgery. We have altered our prophylactic antibiotic regimen to cover skin flora in all patients and gastrointestinal flora in patients with a tracheostomy. We have counseled the families of nonambulatory children with large neuromuscular curves regarding the significantly increased odds of postoperative deep SSI. Level of Evidence: Level III.