Stephen A. Albanese

Early Clinical Experience with the Syracuse I-Plate: An Anterior Spinal Fixation Device

Sixteen patients were treated with a new anterior internal fixation device after thoracolumbar or lumbar decompression, and fusion with bone grafting. Ten patients had acute burst fractures, four had metastatic tumors, and two had old, healed fractures with deformity. In the acute fracture group, eight patients had neurologic deficits and seven patients experienced improvement. Six patients had lesions of the conus medullarls, all of which improved. The four patients with metastatic tumors underwent surgery for back and leg pain and all gained significant relief. Two patients had correction of old fracture deformity with satisfactory outcome. Complications were minimal. The new anterior stabilization device provided early stability, allowed early patient mobilization, was easy to insert, and has a low profile. Late collapse, non-union, and kyphotic deformity have not been noted thusfar.

Pulsed color-flow Doppler analysis of arterial deficiency in idiopathic clubfoot.

This prospective study used pulsed color-flow Doppler sonography to determine differences in the presence and direction of flow through the dorsalis pedis, posterior tibial, and peroneal arteries in a group of children with clubfoot and a comparison group of controls. There was a statistically significant difference in the prevalence of deficient (absent or retrograde flow) dorsalis pedis arteries in children with clubfoot (45%) compared with controls (8%). This indicates that there is an association between some clubfeet and deficiency of the dorsalis pedis artery. There was a trend toward difference in the prevalence of deficiency of the dorsalis pedis artery in the clubfeet that required surgery (54%) compared with those that did not (20%), suggesting that dorsalis pedis artery deficiency may be more prevalent among clubfeet with greater deformity.

Pediatric disk herniation.

&NA; Pediatric disk herniation is a rare condition that should be considered in the differential diagnosis of the child with back pain or radiating leg pain. Because pediatric disk herniation is relatively uncommon, there is typically a delay in diagnosis compared with time to diagnosis of adult disk herniation. Pediatric disk herniations are often recalcitrant to nonsurgical care, but such measures should be attempted in patients who present with isolated pain symptoms and have a normal neurologic examination. Twenty‐eight percent of adolescent disk herniations involve apophyseal fractures; this presentation has a higher rate of surgical intervention than do herniations without fracture. Surgical management of pediatric disk herniation involves laminotomy and fragment excision. Short‐term data demonstrate excellent pain relief, with 1% of children requiring repeat surgery for lumbar disk pathology in the first year. Long‐term data suggest that 20% to 30% of patients will require additional surgery later in life.

Slipped capital femoral epiphysis in Down syndrome

Slipped capital femoral epiphysis (SCFE) and Down syndrome are both uncommon in the population at large, and rarely are both conditions present in a single individual. Institutional records were searched for both Down syndrome and SCFE. At least 2 years of follow-up was required. Eight patients were identified. At presentation four patients could not walk due to pain and four could walk. Six of eight hips presented with grade III SCFE. Four hips were treated with internal fixation in situ and four were manipulatively reduced in the operating room at the time of fixation with percutaneous screws or pins. Three hips healed uneventfully. Five hips developed aseptic necrosis (three partial, two whole head). This small retrospective study suggests an extremely high rate of complications in adolescents with Down syndrome and SCFE.

Spine deformity in familial dysautonomia (Riley-Day syndrome).

Familial dysautonomia spanning a 30-year period reviewed retrospectively. The 16 patients identified included nine with spine deformities. Serious general medical problems were common. Spine deformities included kyphosis, scoliosis, or a combination of both. Brace treatment was attempted and was unsuccessful in three patients. Seven underwent surgical stabilization. Although all seven patients tolerated the surgical procedures, at least one postoperative complication was noted in each case. Follow-up ranged from 11/2 to 161/2 years. We recommend close observation of the deformities, early stabilization when disorders are progressive, and a high level of awareness of potential complications.

Ultrasonography for urinary tract evaluation in patients with congenital spine anomalies.

Outpatient pediatric orthopedic records were reviewed retrospectively in an attempt to identify all patients with congenital spine and urinary tract anomalies. All patients with a positive intravenous pyelogram (IVP) were asked to return for ultrasonographic evaluation. Urinary tract abnormalities were identified in seven (26%) of the 27 patients with documented IVPs. An additional patient was later added to the series, making a total of seven patients who returned for an ultrasonogram, which was then compared with the IVP. Observations and a review of the literature suggest that ultrasonography combined with urinalysis and serum creatinine is the screening protocol of choice in this patient population.

Supracondylar Fracture Practice Improvement Module

Practice Improvement Module In Reply: The study “Assessing Quality and Safety in Pediatric Supracondylar Humerus Fracture Care” published in this issue of the Journal of Pediatric Orthopaedics utilized the supracondylar practice improvement module (PIM) developed by the Pediatric Orthopaedic Society of North America (POSNA) as part of the American Board of Orthopedic Surgery (ABOS) Maintenance of Certification (MOC) process. Founded in 1934 as a private, voluntary, nonprofit, autonomous organization, the ABOS exists to serve the best interest of the public and the medical profession by establishing educational standards for orthopaedic residents and by evaluating the initial and continuing qualifications and competence of orthopaedic surgeons (ABOS Website). The ABOS is one of 24 member specialty societies which compose the American Board of Medical Specialties (ABMS) and like all the participating specialty boards, the ABOS has agreed to abide by the policies and decisions made by the ABMS. Advancement in medicine has evolved from an approach relying on individual knowledge and skill, to a strategy emphasizing practice-based learning and improvement with a growing body of evidence demonstrating that practice improvement activities improve patient care.2–4 The ABMS and its member specialty boards have committed themselves to a process of ensuring that practicebased learning and improvement is an essential component of the recertification process, referred to as MOC. The MOC process centers around 4 components: Part I: professionalism and professional standing. Part II: lifelong learning and selfassessment. Part III: assessment of knowledge, judgment, and skills. Part IV: improvement in medical practice. The ABOS, in collaboration with the American Academy of Orthopaedic Surgeons (AAOS) and orthopaedic subspecialty societies, have developed PIM’s for the purpose of satisfying MOC requirements. In June of 2011, a Practice Improvement Summit was held at the AAOS headquarters, which 55 representatives from 15 subspecialty societies attended. Following the Summit, POSNA attendees began the process of building a Supracondylar Humerus Fracture PIM. A 33 question data collection tool was developed; 6 questions record data pertaining to the preoperative assessment, 14 questions are related to treatment, and 13 questions collect information regarding follow-up. The study by Iobst et al utilizes the supracondylar PIM to evaluate the outcomes and variations in care for pediatric supracondylar humerus fracture patients among a group of 35 pediatric orthopedic surgeons. The survey responses from the surgeons at 6 different hospitals demonstrate that there is considerable variation in care among surgeons, even for such a routine injury. The authors conclude that the variations in operating room time, anesthesiology time, number of postoperative visits, number of radiographs ordered and initial intraoperative immobilization all point to opportunities for standardization and lowering of costs. These results support the usefulness of PIM’s to compare a surgeon’s practices and outcomes with the practices of peers. The individual surgeon can then evaluate the results and decide if there is potential for outcome improvement and cost savings through practice modification. The ABOS has approved the Supracondylar PIM for 20 Part II MOC Self-Assessment Examination (SAE) credits. Twenty SAE credits are required in Part II during the first 3 years of each ABOS Diplomate’s 10 year MOC cycle. An additional 20 SAE credits are required of each Diplomate before taking a secure cognitive examination. Part II involves lifelong learning and selfassessment. The decision to accept the Supracondylar PIM in place of a scored and recorded self-assessment examination reflects the ABOS commitment to practice-based learning and improvement. This PIM has not been approved for ACCME CME credit and will not meet the requirements of organizations outside of the ABOS that require ACCME certification of education activities. We encourage ABOS Diplomates participating in MOC to use the Supracondylar PIM and become involved in practice-based learning. The Supracondylar Humerus Fracture PIM is offered free of charge and can be accessed through the ABOS website at: www.abos.org/moc/other-saeoptions/practice-improvement-modules. aspx

Magnetically controlled growing rods for scoliosis surgery

ABSTRACT Introduction: Early onset scoliosis can be both a disfiguring as well as a life threatening condition. When more conservative treatments fail, pediatric spinal surgeons are forced to consider operative interventions. Traditionally, these interventions have involved the insertion of a variety of implants into the patient with a limited number of anchor points controlling the spine. In the past, these pediatric patients have had multiple surgeries for elective lengthening of these devices to facilitate their growth while attempting to control the scoliosis. These patients often experience a physical and emotional toll from their multiple repeated surgeries. Growing spine techniques have also had a noted high complication rate due to implant dislodgement and infections. Recently, the development of non-invasively, self-lengthening growing rods has occurred. These devices have the potential to allow for the devices to be lengthened magnetically in a conscious patient in the surgeon’s office. Areas covered: This review summarized previously published articles in the English literature using a key word search in PubMed for: ‘magnetically controlled growing rods’, ‘Magec rods’, ‘magnetic growing rods’ and ‘growing rods’. Expert commentary: Magnetically controlled growing rods have an advantage over growing rods in lengthening the growing spine in the absence of repetitive surgeries.