Mark C. Lee

Mini-C-Arm Fluoroscopy for Emergency-Department Reduction of Pediatric Forearm Fractures

BACKGROUND Reduction of pediatric forearm fractures with the patient under sedation in the emergency department is a common practice throughout the United States. We hypothesized that the use of a mini-c-arm fluoroscopy device as an alternative to routine radiographs for evaluation of fracture reduction would (1) allow a more anatomic fracture reduction, (2) decrease the number of repeat reductions or subsequent procedures, (3) reduce overall radiation exposure to the patient, and (4) decrease the orthopaedic consultation time in the emergency department. METHODS A retrospective cohort analysis of 279 displaced forearm and wrist fractures treated with closed reduction and casting with the patient under sedation in the emergency department of a level-I pediatric trauma center was performed, and the data were compared with historical controls. One hundred and thirteen fracture reductions were assessed with a mini-c-arm device, and 166 fracture reductions were evaluated with radiographs. All patients had radiographs of the injury. Blinded, independent reviewers graded the quality of reduction for residual angulation and translation of the reduced fracture. Radiation exposure was determined by the average number of radiographs made through either modality. Emergency department and outpatient charts were reviewed to determine the total orthopaedic consultation time and the need for repeat reductions or operative intervention. RESULTS Pediatric forearm fractures undergoing closed reduction with assistance of the mini c-arm had a significant improvement in reduction quality (average angulation [and standard deviation], 6° ± 4° vs. 8 ± 6°; p = 0.02), a decrease in repeat fracture reduction and need for subsequent operative treatment (two [2%] of 113 fractures vs. fourteen [8.4%] of 166 fractures; p = 0.0001), and a decrease in radiation exposure to the patient (mean, 14.0 ± 10.3 mrem vs. 50.0 ± 12.7 mrem). The average orthopaedic consultation time was decreased with use of a mini c-arm (28 ± 12 min vs. 47 ± 19 min, p < 0.001). CONCLUSIONS Use of the mini c-arm to assist in the closed reduction of pediatric forearm and wrist fractures in the emergency department can improve the quality of the reduction, decrease the radiation exposure to the patient, and decrease the need for repeat fracture reduction or additional procedures. Mini-c-arm imaging can also decrease the average orthopaedic consultation time for fracture reduction.

Epiphysiodesis with infusion of stromal cell-derived factor-1 in rabbit growth plates.

BACKGROUND The mechanism of physeal closure is poorly understood, although both mechanical and biological factors may play a role in the process. In this study, we evaluated the effect of the application of a chemokine stromal cell-derived factor-1 (SDF-1) to rabbit physes in vivo with regard to growth inhibition. METHODS A continuous infusion system consisting of a fenestrated catheter and an osmotic pump were implanted into the right proximal tibial physis of twenty six-week-old New Zealand White rabbits. Ten of the pumps were loaded with human recombinant SDF-1alpha, and ten were loaded with phosphate-buffered saline solution (sham treatment). The left leg was used as the uninvolved control. The growth of the tibiae was followed radiographically for eight weeks, and histologic analysis was performed for both the SDF-1-treated rabbits and the sham-treated rabbits at two, four, and eight-week time-points. RESULTS Radiographic evaluation showed a significant growth inhibition in the SDF-1alpha-treated physes (4.5 +/- 3.0 mm; p = 0.007) compared with the sham-treated physes after eight weeks. No difference was noted when the sham-treated leg was compared with the contralateral, control leg (0.2 +/- 2.9 mm; p = 0.465). Histologic evaluation showed marked physeal disorganization, narrowing, and proteoglycan loss and a significant decrease in physeal height (p < 0.0001) for the SDF-1-treated group. Reversible growth slowing was noted in the uninvolved, control leg of the SDF-1-treated group at six weeks, with resolution of the difference by eight weeks. CONCLUSIONS SDF-1 may be used to induce physeal closure through a targeted infusion system. However, transient systemic effects of SDF-1 may exist and must be evaluated further prior to its clinical use for epiphysiodesis.

Calcaneus osteomyelitis from community-acquired MRSA

Since the identification of methicillin-resistant Staphylococcus aureus (MRSA) as a hospital-acquired pathogen in the late 1960s,3 it has become commonplace in most US healthcare facilities.5 Only recently has there been recognition of the increasing MRSA prevalence in populations without obvious medical risk factors or exposure to hospital or institutional environments.2,9,11,13,22 Community-acquired MRSA (CA-MRSA), also called community-associated MRSA, typically results in skin and subcutaneous infections and rarely involve bone.9 We present a case of CA-MRSA causing hematogenous calcaneal osteomyelitis in a healthy adolescent.

Comparison of S2-Alar and traditional iliac screw pelvic fixation for pediatric neuromuscular deformity

BACKGROUND CONTEXT Many pelvic fixation options exist for posterior spinal fusion of pediatric neuromuscular scoliosis, including standard iliac screws (SISs) or a more recently introduced S2-Alar (S2A) technique. However, little data exist comparing the clinical and radiographic outcomes of these techniques. PURPOSE This study aimed to dentify differences in clinical and radiographic outcomes for pediatric neuromuscular scoliosis patients treated with SIS or S2A pelvic fixation. STUDY DESIGN/SETTING This was a retrospective cohort study at a pediatric orthopedic clinic. PATIENT SAMPLE Patients aged 8-19 years undergoing posterior spinal fusion to the pelvis for neuromuscular scoliosis using SIS or S2A technique, with Gross Motor Function Classification System (GMFCS) Level 4 or 5 were included. OUTCOMES MEASURES Postoperative complication rates associated with pelvic fixation method were the outcome measures. METHODS Charts and radiographs were reviewed for demographics, intra- and postoperative course, levels of instrumentation, operative correction, and implant failure (IF). Postoperative complications were classified according to the Accordion scale. RESULTS We studied 50 patients (28 SIS, 22 S2A) aged 14.0±2.8 years and an average follow-up of 3.5±1.7 years. The average number of levels fused was 16.5±1.1 with an average curve correction of 48°±21° postoperatively. A significant difference in radiographic IF rates was noted between SIS and S2A groups (57% vs. 27%, p=.02). No difference was noted between groups for frequency or severity of postoperative complications, inclusive of wound infections. Subgroup analysis demonstrated equivalent IF rates when comparing the S2A group with the SIS group with cross-links. CONCLUSIONS The S2A group generally demonstrated improved rates of radiographic IF compared with the SIS group, but the rates became equivalent when a cross-link was added to an SIS construct. Further, no difference in postoperative complication rates were identified between SIS and S2A groups.

Utility of early postoperative radiographs after posterior spinal fusion for adolescent idiopathic scoliosis.

Study Design. Retrospective. Objective. Evaluate the ability of serial full-length spine radiographs to detect clinically significant implant-related (IR) and non–implant-related (NIR) radiographical abnormalities in the first 6 months after routine posterior spinal fusion for adolescent idiopathic scoliosis (AIS). Summary of Background Data. Patients with AIS are exposed to repeated doses of ionizing radiation during the course of their treatment with potential consequences for their long-term health. Postoperative algorithms for AIS often involve frequent standing plain radiographs during the first 6 months after surgery to detect IR and NIR abnormalities that may impact a patients clinical course. However, the actual clinical utility of such repeated spine radiographs has not been studied. Methods. Retrospective chart and radiographical review was conducted at a single institution for patients with AIS after posterior spinal fusion between 2007 and 2012. Radiographical abnormalities identified on full-length spine radiographs or additional imaging modalities in the first 6 postoperative months were grouped into IR or NIR findings. The findings were considered clinically significant if they resulted in a deviation from an anticipated postoperative course or additional interventions. Results. For 129 patients, 761 full-length spine radiographs were obtained in the first 6 postoperative months. Eight patients (11 radiographs) had IR or NIR abnormalities, with only 2 of these considered clinically significant. Seven of the remaining 121 were identified to have IR or NIR abnormalities using other imaging modalities, with 2 considered clinically significant. The sensitivity and specificity of a full-length spine radiograph for detecting a clinically significant abnormality was 50% and 95%, respectively. Conclusion. Routine full-length spine radiographs used with high frequency in the first 6 months after posterior spinal fusion rarely detected a radiographical abnormality that resulted in a meaningful change to a patients clinical management. Blanket postoperative screening algorithms should be reconsidered to minimize patient radiation exposure. Level of Evidence: 3

Mortality from Intrathecal Baclofen Withdrawal Following Posterior Spinal Fusion

Baclofen, a centrally acting gamma-aminobutyric acid (GABA) receptor agonist, is a commonly used antispasmodic agent in children and young adults with cerebral palsy or other upper motor neuron disorders. Baclofen is frequently administered intrathecally via a pump and catheter system as this delivery method has the advantage of increased potency with fewer systemic side effects than oral baclofen1-5. Intrathecal baclofen (ITB) improves spasticity scores, decreases pain scores, and allows for increased ease of care in patients with substantial spasticity6,7. Patients with progressive neuromuscular scoliosis who receive ITB therapy pose a unique clinical dilemma. If a posterior spinal fusion is undertaken to treat the neuromuscular scoliosis, the surgical approach exposes the baclofen catheter that enters at the lumbar spine, and this exposure can potentially lead to mechanical complications that inhibit or alter the consistent delivery of ITB1,8-12. We present a case of baclofen withdrawal following posterior spinal fusion that resulted in the patient’s death. The parents of this patient were informed that data concerning the case would be submitted for publication, and they provided consent. A nineteen-year-old man of normal intelligence with C6 tetraplegia, caused by transverse myelitis in infancy, had a progressive neuromuscular scoliosis that prevented comfortable seating (Figs. 1-A and 1-B). He had received an ITB pump at age eleven years in order to control lower-extremity spasticity, with the intrathecal catheter entering at the L1-L2 level and ending proximally at the T3 level. He had undergone two pump and proximal catheter revisions at the ages of sixteen and eighteen years because of catheter malfunctions, but had maintained a good baseline function for at least eighteen months prior to the scoliosis surgery. Fig. 1-A Sitting posteroanterior radiograph of the spine demonstrates a collapsing apex right thoracolumbar neuromuscular scoliosis …

Valve or No Valve: A Prospective Randomized Controlled Trial of Casting Options for Pediatric Forearm Fractures

The purpose of this study was to determine the rate of cast-related complications when using split or intact casts. A total of 60 patients aged 3 to 13 years with closed shaft or distal third radius and ulna fractures requiring reduction were recruited for this study. Patients underwent closed reduction under sedation and were placed into a long-arm fiberglass cast with 1 of 3 modifications: no valve, univalve, or bivalve. Patients were followed to 6 weeks after reduction or surgical treatment if required. The frequency of neurovascular injury, cast saw injury, unplanned office visits, and cast modifications, the need for operative intervention, and pain levels through the follow-up period were recorded. The results showed no incidents of compartment syndrome or neurovascular injury. Additionally, there were no differences between complications associated with cast type (P=.266), frequency of cast modifications (P=.185), or subsequent need for surgical stabilization (P=.361). Therefore, cast splitting following closed reduction of low-energy pediatric forearm fractures does not change clinical outcomes with respect to neurovascular complications, cast modifications, pain levels, or the need for repeat reduction. Consideration should be given to minimizing cast splitting after reduction of low-energy pediatric forearm fractures for practice efficiency and to potentially decrease saw-related injury. [Orthopedics. 2017; 40(5):e849-e854.].

The Distance from Bench to Bedside: Commentary on an article by Benjamin D. Roye, MD, MPH, et al.: "An Independent Evaluation of the Validity of a DNA-Based Prognostic Test for Adolescent Idiopathic Scoliosis".

The holy grail of adolescent idiopathic scoliosis treatment lies in the ability to determine the risk of curve progression. Will the patient with a mild scoliosis eventually require a surgical intervention for a large magnitude deformity, or will the curve remain stable throughout growth and require no particular treatments? Risk of progression is central to the decision to apply an often cumbersome spine brace until the completion of growth and/or to expose the patient to repeated radiographic examinations for the purpose of monitoring changes in the curve. Previous studies had established that the risk of scoliosis progression was related to the patient’s residual growth, sex, curve location, and curve magnitude1-3. However, as modern research into the architecture of human DNA advanced, the understanding of curve progression found roots in a tale of gene diversity. It was hypothesized that groups of genes may conspire to determine scoliosis progression, and the greater the number of specific gene variations that a patient has, the more likely that patient is to progress to a large magnitude curve. In 2010, Ward et al. validated a genetic test of fifty-three single-nucleotide polymorphisms from a saliva sample (ScoliScore) that appeared to risk-stratify adolescents into those whose curves will never progress and those whose curves will inevitably progress4. Suddenly, a noninvasive, reportedly reliable method was available to determine which …