Neeraj M. Patel

Computed tomography-guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal.

Study Design. Retrospective study of computed tomography–guided navigation (CTGN) of thoracic pedicle screw placement in patients with adolescent idiopathic scoliosis (AIS). Objective. To compare the accuracy and safety of thoracic pedicle screw placement and frequency of intraoperative removal using CTGN versus conventional freehand technique in AIS. Summary of Background Data. Even in experienced hands, more than 10% of the thoracic pedicle screws are misplaced. CTGN may improve accuracy and safety, but there is little published data on its efficacy. Methods. We reviewed intraoperative computed tomographic images in a consecutive series of AIS cases undergoing posterior fusion during a 1-year period. Three types of screws were identified: an optimal screw—the central axis is in the plane and axis of the pedicle with the tip completely within the vertebral body; an acceptable screw—the majority of its shank is outside the central axis of the pedicle, but not potentially unsafe; and a potentially unsafe screw—(1) the central axis of the screw traversed the canal, (2) left anterior/lateral vertebral body perforation, risking the aorta, or (3) any screw repositioned or removed after the postimplant computed tomography. Results. In 42 patients, 485 screws were evaluable with a visible pedicle and screw (300 navigated and 185 non-navigated). Screws were classified as follows: optimal screws, 74% CTGN versus 42% non-navigated; acceptable screws, 23% CTGN versus 49% non-navigated; and potentially unsafe, 3% CTGN versus 9% non-navigated (P < 0.001). A potentially unsafe screw was 3.8 times less likely to be inserted with navigation (P = 0.003). The odds of a significant medial breach were 7.6 times higher without navigation (P < 0.001). A screw was 8.3 times more likely to be removed intraoperatively in the non-navigated cohort (P = 0.003). Conclusion. CTGN resulted in more optimally placed thoracic pedicle screws, fewer potentially unsafe screws, and fewer screw removals.

Tibial eminence fractures in children: earlier posttreatment mobilization results in improved outcomes.

Background: Arthrofibrosis and decreased range of motion (ROM) are well-described sequelae of tibial eminence fractures. We sought to evaluate the effects of timing of ROM rehabilitation and postsurgical immobilization on clinical outcomes in children with fractures of the tibial eminence. Methods: We retrospectively reviewed the records of all children diagnosed with closed tibial eminence fractures between 2000 and 2010. Patients were treated by experienced surgeons with uniform requirements for return to full activity. Results: Fourteen females and 26 males (40 knees) of mean age 12 years (range, 5 to 17 y) started ROM therapy for a mean of 23 days after treatment (range, 4 to 47 d). Seven patients required additional surgeries for arthrofibrosis at a mean of 3 months after initial fracture treatment (range, 1.5 to 5.5 mo). Compared with patients who started ROM rehabilitation within 4 weeks of treatment, those who started later than 4 weeks required more days to return to full activity (215 vs. 103 d; P=0.011) and were 12 times more likely to develop arthrofibrosis (P=0.029). Even when accounting for other factors in multivariate regression, earlier initiation of ROM therapy was associated with earlier return to full activity (P<0.001). Surgical patients who were immobilized postoperatively required more days to return to full activity (217.5 vs. 103 d; P=0.015) and had a higher rate of arthrofibrosis (36% vs. 0%; P=0.043) than those who were not. Age, sex, fracture classification, and operative versus nonoperative treatment did not have a statistically significant effect on our multivariate model. Conclusions: After definitive treatment, early implementation of ROM rehabilitation results in a more rapid return to full activity. ROM therapy within 4 weeks of treatment results in sooner return to full activity and decreases the likelihood of eventual arthrofibrosis. In surgical patients, postoperative immobilization results in a longer delay until return to full activity and a higher rate of arthrofibrosis. Level of Evidence: Therapeutic study, level III.

Medial epicondyle fractures of the humerus: how to evaluate and when to operate.

The fundamental principles of fracture care apply to medial epicondyle fractures in that the goals of treatment are to obtain fracture healing and to promote a return of appropriate motion, strength, and stability. Recent studies have revealed limitations of some classically described evaluation methods and have revealed more precise methods of measuring displacement. The authors of this manuscript describe established principles of care and incorporate recent evidence-based articles to help the clinician study the issues relative to the clinical evaluation and the operative and nonoperative treatment of medial epicondyle fractures.

Femoral version of the general population: does "normal" vary by gender or ethnicity?

Objective: The purpose of this study was to compare various gender and ethnic groups to characterize differences in baseline version and rates of retroversion. Design: Retrospective. Setting: Level 1 trauma center. Patients/Participants: Between 2000 and 2009, 417 consecutive patients with femur fractures were treated with an intramedullary nail at level I trauma and tertiary referral center. Of these, 328 with computed tomography scanogram of the normal, uninjured contralateral femur were included in this study. Main Outcome Measurements: Femoral version. Results: The mean alignment for the all patients was 8.84 ± 9.66° of anteversion. There were no statistically significant differences in mean version between African American, white, and Hispanic patients for males or females. Although there were also no significant differences in rates between ethnicities, retroversion was found to be common in white males (21.4%), African American males (15.1%), and all groups of females (>14.3%). Furthermore, nearly 6% of both African American males and females exhibited >10° retroversion. Conclusions: Although there may not be a significant difference in average femoral version between ethnic and gender groups, retroversion is relatively common, and retroversion >10° was observed in nearly 6% of the African American population. This may have important implications in proper alignment restoration and successful clinical outcomes after intramedullary nailing of femur fractures.

VEPTR to treat nonsyndromic congenital scoliosis: a multicenter, mid-term follow-up study.

Background: Traditional surgical management of multiple congenital vertebral anomalies in young children, including fusion in situ and hemiepiphyseodesis, do not promote spinal growth nor address the associated thoracic insufficiency syndrome. We hypothesize that vertical expandable prosthetic titanium rib (VEPTR) with expansion thoracoplasty may control spinal deformity, allow spinal growth, and address thoracic insufficiency syndrome in children with nonsyndromic complex congenital spinal deformities. Methods: Eight pediatric spine centers prospectively entered clinical and radiographic data into a database on every congenital spinal deformity treated with VEPTR as part of an Food and Drug Administration study. We retrospectively reviewed these data and excluded patients with spina bifida, Jarcho-Levin, or other syndromes. Data analysis focused on surgical technique and expansion frequency, change in Cobb angle and thoracic heights, and adverse events for a consecutive series of patients with at least 2 years of follow-up. Results: Twenty-four children with an average age at surgery of 3.3 years (range, 1.0 to 12.5 y) were treated with VEPTR insertion and expansion thoracostomy and were followed for an average of 40.7 months (range, 25 to 78 mo). Twenty-three (95.8%) had associated rib fusions. All patients had subsequent expansion surgery; 50% had 5 or more expansions. Twenty patients (83.3%) had an improvement in Cobb angle during treatment with an average improvement of 8.9 degrees. All had an increase in thoracic height, with a mean increase of 3.41 cm. The most common adverse events were device migration in 7 patients and infection or skin problems in 6 patients. Conclusions: VEPTR insertion with expansion thoracoplasty represents a successful treatment paradigm for nonsyndromic congenital spinal deformities. We report multicenter data with midterm follow-up of children without syndromic diagnoses, in which the vast majority had an improvement in Cobb angle and thoracic height over the treatment period. Challenges include the demands of multiple procedures, skin problems, and device migration. Level of Evidence: Level IV—prognostic study.

The pediatric knee: current concepts in sports medicine.

As the popularity and intensity of childrens athletics have increased, so has the risk for knee injuries. Fractures of the tibial eminence may be treated operatively or nonoperatively depending on fracture classification, but arthrofibrosis is a potentially significant complication. Anterior cruciate ligament rupture presents treatment challenges as regards the optimal timing and method of reconstruction. A number of novel reconstructive techniques have been developed to minimize risks to the physes in this population. Recent studies have focused on the prognosis, surgical indications, and operative techniques for osteochondritis dissecans in children. A number of authors have also sought to better-define the optimal diagnostic testing and management of patellar dislocation. In this review, we provide an update on current concepts for tibial eminence fractures, anterior cruciate ligament injuries, osteochondritis dissecans of the knee, and patellar dislocation in young athletes.

Pediatric monteggia fractures: a multicenter examination of treatment strategy and early clinical and radiographic results.

Background: Monteggia fractures remain challenging pediatric injuries because of difficulties in diagnosis, propensity for instability, and complexity of late reconstruction. The objective of this investigation was to assess the efficacy of the following treatment strategy based upon ulnar fracture pattern: closed reduction (CR) for plastic/greenstick fractures, intramedullary (IM) pin fixation for transverse/short oblique fractures, and open reduction and internal fixation for long oblique/comminuted fractures. Methods: A total of 112 acute Monteggia fracture patients were retrospectively analyzed at two level 1 pediatric trauma centers from 2000 to 2011. Mean age was 6.9±2.9 years (range, 0.6 to 16.7 y); 54% were male. Mean clinical follow-up was 19.8 weeks. Fracture patterns were classified and patients were separated into 3 groups: treatment according to the strategy versus more rigorous versus less rigorous intervention. The Fisher exact test was used to compare the rates of failure between the groups. “Failure” was defined as failure to obtain and maintain an anatomic reduction of the radial head and/or loss of ulnar reduction during follow-up. Results: None of the 57 patients treated according to the strategy experienced failure, nor did any of the 23 patients treated more rigorously. In contrast, 6 of 32 patients (19%) who were treated less rigorously compared with the recommended strategy demonstrated recurrent radiocapitellar instability (n=3), loss of ulnar fracture reduction requiring revision surgery (n=2), or both events together (n=1) (P<0.001). Specifically, all treatment failures occurred in complete fractures treated nonoperatively—there were 6/18 failures (33% failure rate) of complete fractures treated nonoperatively compared with 0/52 failures of complete fractures treated operatively (P<0.001). Other complications were similarly distributed between the treatment groups and consisted of 1 ulnar nonunion, 2 compartment syndromes, and 3 transient nerve palsies/neuropraxias. Comminuted fractures required open reduction of the radiocapitellar joint more than other fracture types (P<0.001). Conclusions: In this pediatric Monteggia series, recurrent instability only occurred in patients who were not treated according to the ulnar-based strategy. Complete ulnar fracture patterns are at risk of failure without initial operative treatment. Level of Evidence: Level III, therapeutic.

Femoral malrotation after intramedullary nailing in obese versus non-obese patients

OBJECTIVE Intramedullary nailing (IMN) of obese patients with femoral fractures can be difficult due to soft tissue considerations and overall body habitus. Complications including malrotation can occur and have significant impact on postoperative function. The purpose of this study was to evaluate femoral rotation after intramedullary nailing of obese and non-obese patients to see if there was a difference in rotation, complications and any risk factors for malrotation. MATERIALS AND METHODS Between 2000 and 2009, 417 consecutive patients with femur fractures treated with IM nail at Level I trauma and tertiary referral center. Of these, 335 with postoperative computed tomography (CT) scanogram of the bilateral lower extremities were included in this study. Baseline demographic, perioperative and postoperative femoral version calculations were included in the dataset. Statistical analysis included chi-squared test for categorical data, t-test for continuous data, and univariate and multivariate regression analysis. Significance was set at p<0.05. RESULTS Of the 417 patients with femur fractures between 2000 and 2009, 335 met criteria for this study. There were 111 patients with a BMI <25, 129 with BMI 25-29.9, and 95 patients with a BMI >30. When BMI was categorised into 3 groups (<25, 25-29.9, or 30+), none of these groups were predictive of version in univariate or multivariate regressions. Among only obese patients (BMI 30+), BMI of 35+ was not a significant predictor of version when compared to BMI 30-34.9. There were no significant differences in femoral version based on entry point (antegrade vs. retrograde) in any BMI category. There were also no significant difference between groups of patients with a DFV of >15̊ (p=0.212). CONCLUSIONS Based on this study, BMI did not have an effect on postoperative difference in femoral version. In fact, in our multivariate regression analysis, BMI of over 30 was actually predictive of significantly lower difference in femoral version. While other studies have documented the intraoperative difficulties encountered with obese patients with femur fractures, the outcome of femoral rotation is not affected by an increasing BMI.

Symptomatic bilateral discoid menisci in children: a comparison with unilaterally symptomatic patients.

Background: In previous studies, 5% to 20% of patients with a discoid lateral meniscus eventually require surgery bilaterally for symptomatic discoid menisci. However, there are little published data specifically on children who require treatment for discoid menisci in both knees. The purpose of this study is to identify differences in clinical and arthroscopic findings between children who require bilateral versus unilateral treatment for symptomatic discoid lateral menisci. Methods: We retrospectively reviewed the records of all patients aged 18 years or younger requiring treatment of discoid lateral meniscus between 1998 and 2007. Data were collected on 16 patients (32 knees) with symptomatic bilateral discoid menisci and 60 patients treated unilaterally with an asymptomatic contralateral knee. Results: At initial presentation, children who were treated bilaterally for discoid menisci were younger than those treated unilaterally (10.4 vs. 12.5 y; P=0.021). Patients under 12 years of age were 4.6 times more likely to eventually require surgery on both knees (P=0.015). Watanabe classification was as follows: complete, 65% bilateral versus 30% unilateral; incomplete, 22% bilateral versus 68% unilateral; and Wrisberg, 13% bilateral versus 2% unilateral (P<0.001). The odds of current or future bilateral symptoms requiring treatment were 4.5 times higher in patients with a complete discoid meniscus (P=0.0017) and 8.4 times higher in those with a Wrisberg type (P=0.048). A tear of the lateral meniscus was more likely to be found intraoperatively in unilateral knees than bilateral (90% vs. 72%; P=0.037). Conclusions: Patient education and long-term follow-up are important for children who present with a discoid meniscus at a young age or with a complete or Wrisberg type, as these patients may be at increased odds of symptomatic discoid meniscus in the contralateral knee, even several years later. Furthermore, evaluation and treatment of discoid lateral meniscus requires vigilance for meniscal tears. Level of Evidence: Prognostic study, level III.

Intramedullary nailing of diaphyseal femur fractures secondary to gunshot wounds: predictors of postoperative malrotation.

Objectives: The purpose of this study was to determine significant factors that may impact the postoperative differences in femoral version (DFV) and differences in femoral length (DFL) between the fixed and uninjured sides after intramedullary nailing (IMN) secondary to gunshot wounds. Design: Retrospective data registry study. Setting: Academic level I trauma center. Patients: Over a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (OTA/AO 32A-C). Of these, 57 patients sustained fractures caused by gunshots and had a postoperative computed tomographic scanogram. Main Outcome Measures: DFV and DFL. The effect of the following variables on DFV and DFL were determined through univariate and stepwise multivariate regression analyses: age, sex, body mass index, trauma fellowship-trained versus nontrauma surgeon, daytime versus nighttime surgery, antegrade versus retrograde nail insertion, use of traction, type of operating table, and AO and Winquist classifications. Results: The mean postoperative DFV for all patients was 8.62 degrees (±6.67 degrees). Postoperative DFV greater than 15 degrees was found in 12.3% of all patients. After IMN, no significant differences in DFV were found with increasing complexity of AO/OTA or Winquist fracture classification. None of the aforementioned independent variables were significantly predictive of postoperative DFV in univariate or multivariate analyses. The mean postoperative DFL for all patients was 5.25 mm (±4.36 mm). In a multivariate model, classification as Winquist type 3 or 4 was weakly (adjusted R2 = 0.075) but significantly predictive of less DFL than categorization as type 1 or 2 (P = 0.027). Conclusions: Although gunshot-associated femur fractures may present surgical challenges for treatment through IMN, acceptable femoral rotation and length are obtainable regardless of the fracture complexity or a variety of demographic and surgically-related variables. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.