Unni G. Narayanan

Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them.

Flexible intramedullary nailing has become a popular method of fixation of pediatric femoral fractures. The authors analyzed their first 5-year experience with titanium elastic stable intra-medullary nailing, specifically to report the complications associated with this technique and to provide recommendations to avoid these complications. Seventy-eight children with 79 femoral fractures were treated by this method. Complications included pain/irritation at the insertion site (41), radiographic malunion (8), refracture (2), transient neurologic deficit (2), and superficial wound infection (2). Ten patients required reoperation prior to union. Malunion and/or loss of reduction requiring reoperation was strongly associated with the use of nails of mismatched diameters (odds ratio = 19.4) and comminution of more than 25% (odd ratio = 5.5). Pain at the insertion site was significantly associated with bent or prominent nail ends. Most complications are minor, and many are preventable. Surgeons should advance nail ends to lie against the supracondylar flare of the femur to avoid symptoms at the insertion site and should avoid implanting nails of two different diameters. Comminuted fractures should be monitored carefully and might benefit from additional immobilization.

A Randomized, Controlled Trial of a Removable Brace Versus Casting in Children With Low-Risk Ankle Fractures

OBJECTIVES. Isolated distal fibular ankle fractures in children are very common and at very low risk for future complications. Nevertheless, standard therapy for these fractures still consists of casting, a practice that carries risks, inconveniences, and use of subspecialty health care resources. Therefore, the main objective of this study was to determine whether children who have these low-risk ankle fractures that are treated with a removable ankle brace have at least as effective a recovery of physical function as those that are treated with a cast. METHODS. This was a noninferiority, randomized, single-blind trial in which children who were 5 to 18 years of age and treated in a pediatric emergency department for low-risk ankle fractures were randomly assigned to a removable ankle brace or a below-knee walking cast. The primary outcome at 4 weeks was physical function, measured by using the modified Activities Scale for Kids. Additional outcomes included patient preferences and costs. RESULTS. The mean activity score at 4 weeks was 91.3% in the brace group (n = 54), and this was significantly higher than the mean of 85.3% in the cast group (n = 50). Significantly more children who were treated with a brace had returned to baseline activities by 4 weeks compared with those who were casted (80.8% vs 59.5%). Fifty-four percent of the casted children would have preferred the brace, but only 5.7% of children who received the brace would have preferred the cast. The cost-effectiveness acceptability curve was always >80%; therefore, the brace was cost-effective compared with the cast. CONCLUSIONS. The removable ankle brace is more effective than the cast with respect to recovery of physical function, is associated with a faster return to baseline activities, is superior with respect to patient preferences, and is also cost-effective.

Integrated complex care coordination for children with medical complexity: A mixed-methods evaluation of tertiary care-community collaboration

BackgroundPrimary care medical homes may improve health outcomes for children with special healthcare needs (CSHCN), by improving care coordination. However, community-based primary care practices may be challenged to deliver comprehensive care coordination to complex subsets of CSHCN such as children with medical complexity (CMC). Linking a tertiary care center with the community may achieve cost effective and high quality care for CMC. The objective of this study was to evaluate the outcomes of community-based complex care clinics integrated with a tertiary care center.MethodsA before- and after-intervention study design with mixed (quantitative/qualitative) methods was utilized. Clinics at two community hospitals distant from tertiary care were staffed by local community pediatricians with the tertiary care center nurse practitioner and linked with primary care providers. Eighty-one children with underlying chronic conditions, fragility, requirement for high intensity care and/or technology assistance, and involvement of multiple providers participated. Main outcome measures included health care utilization and expenditures, parent reports of parent- and child-quality of life [QOL (SF-36®, CPCHILD©, PedsQL™)], and family-centered care (MPOC-20®). Comparisons were made in equal (up to 1 year) pre- and post-periods supplemented by qualitative perspectives of families and pediatricians.ResultsTotal health care system costs decreased from median (IQR)

Femoral Fractures in Adolescents: A Comparison of Four Methods of Fixation

244 (981) per patient per month (PPPM) pre-enrolment to

A comparison of ankle foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic clubfoot by the Ponseti method

131 (355) PPPM post-enrolment (p=.007), driven primarily by fewer inpatient days in the tertiary care center (p=.006). Parents reported decreased out of pocket expenses (p<.0001). Parental QOL did not significantly change over the course of the study. Child QOL improved between baseline and 6 months in two PedsQL™ domains [Social (p=.01); Emotional (p=.003)], and between baseline and 1 year in two CPCHILD© domains [Health Standardization Section (p=.04); Comfort and Emotions (p=.03)], while total CPCHILD© score decreased between baseline and 1 year (p=.003). Parents and providers reported the ability to receive care close to home as a key benefit.ConclusionsComplex care can be provided in community-based settings with less direct tertiary care involvement through an integrated clinic. Improvements in health care utilization and family-centeredness of care can be achieved despite minimal changes in parental perceptions of child health.

EOS Low-Dose Radiography: A Reliable and Accurate Upright Assessment of Lower-Limb Lengths

BACKGROUND The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. METHODS We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. RESULTS The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for débridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required débridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. CONCLUSIONS External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

Management of Children With Ambulatory Cerebral Palsy: An Evidence-based Review

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis.

Treatment of neuromuscular and syndrome-associated (nonidiopathic) clubfeet using the Ponseti method.

BACKGROUND Children with lower-limb-length discrepancy require repeated radiographic assessment for monitoring and as a guide for management. The need for accurate assessment of length and alignment is balanced by the need to minimize radiation exposure. We compared the accuracy, reliability, and radiation dose of EOS, a novel low-dose upright biplanar radiographic imaging system, at two different settings, with that of conventional radiographs (teleoroentgenograms) and computed tomography (CT) scanograms, for the assessment of limb length. METHODS A phantom limb in a standardized position was assessed ten times with each of four different imaging modalities (conventional radiographs, CT scanograms, EOS-Slow, EOS-Fast). A radiation dosimeter was placed on the phantom limb, on a portion closest to the radiation source for each modality, in order to measure skin-entrance radiation dose. Standardized measurements of bone lengths were made on each image by consultant orthopaedic surgeons and residents and then were assessed for accuracy and reliability. RESULTS The mean absolute difference from the true length of the femur was significantly lower (most accurate) for the EOS-Slow (2.6 mm; 0.5%) and EOS-Fast (3.6 mm; 0.8%) protocols as compared with CT scanograms (6.3 mm; 1.3%) (p < 0.0001), and conventional radiographs (42.2 mm; 8.8%) (p < 0.0001). There was no significant difference in accuracy between the EOS-Slow and EOS-Fast protocols (p = 0.48). The mean radiation dose was significantly lower for the EOS-Fast protocol (0.68 mrad; 95% confidence interval [CI], 0.60 to 0.75 mrad) compared with the EOS-Slow protocol (13.52 mrad; 95% CI, 13.45 to 13.60 mrad) (p < 0.0001), CT scanograms (3.74 mrad; 95% CI, 3.67 to 3.82 mrad) (p < 0.0001), and conventional radiographs (29.01 mrad; 95% CI, 28.94 to 29.09 mrad) (p < 0.0001). Intraclass correlation coefficients showed excellent (>0.90) agreement for conventional radiographs, the EOS-Slow protocol, and the EOS-Fast protocol. CONCLUSIONS Upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure. In addition, the ability of this technology to obtain images while subjects are standing upright makes this the ideal modality with which to assess limb alignment in the weight-bearing position. This method has the potential to become the new standard for repeated assessment of lower-limb lengths and alignment in growing children. CLINICAL RELEVANCE This study assesses the reliability and accuracy of a diagnostic test used for clinical decision-making.

Comparison of Surgeon and Physiotherapist-Directed Ponseti Treatment of Idiopathic Clubfoot

This article reviews the current best evidence for musculoskeletal interventions in children with ambulatory cerebral palsy (CP). The effectiveness of interventions in CP must first consider what CP and its associated pathophysiology are and take into account the heterogeneity and natural history of CP to put definitions of “effectiveness” into perspective. This article reviews the current standards of the definition and classification of CP, discusses the natural history and specific goals for the management of ambulatory CP, as well as the outcome measures available to measure these goals. The current best evidence of effectiveness is reviewed for specific interventions in children with ambulatory CP including spasticity management with botulinum toxin A injections and selective dorsal rhizotomy; multilevel orthopaedic surgery to address contractures and bony deformity; and the role of gait analysis for surgical decision-making before orthopaedic surgery.

Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula.

Background: Clubfeet are associated with many neuromuscular and congenital conditions. Nonidiopathic clubfeet are typically thought to be resistant to nonoperative management. The Ponseti method has revolutionized the treatment of patients with idiopathic clubfeet. The purpose of this study was to describe the use of the Ponseti method in the treatment of patients whose clubfeet are associated with a neuromuscular diagnosis or a syndrome. Methods: All patients with clubfeet who were treated at the Hospital for Sick Children, Toronto, from 2001 to 2005 were reviewed. Patients were included only if a neuromuscular condition or a syndrome associated with clubfeet could be identified and if the primary treatment was at our institution. Twenty-three patients with 40 nonidiopathic clubfeet and 171 patients with 249 idiopathic clubfeet have been treated with a minimum follow-up time of 1 year. The outcomes evaluated included the number of casts, the percentage of patients requiring percutaneous Achilles tendon lengthening (tenotomy of the Achilles tendon [TAT]), rate of recurrences, rate of failures, and the need for additional secondary procedures. Results: The mean age at presentation for nonidiopathic clubfeet was 11 weeks. The mean follow-up time was 33 months, and the mean number of casts was 6.4; a percutaneous TAT was necessary in 27 (68%) of 40 feet. Failure of the Ponseti casting occurred in 4 (10%) of the 40 feet. Recurrence requiring additional treatment occurred in 16 (44%) of 36 feet. Additional procedures included second percutaneous TAT, limited posterior/plantar release, or complete posteromedial release totaling 11 (28%) of 40. When compared with idiopathic clubfeet, nonidiopathic clubfeet required more casts and had a higher rate of failures, recurrences, and additional procedures than idiopathic clubfeet. Conclusions: Although not as successful as for idiopathic clubfeet, when the Ponseti technique is applied to nonidiopathic clubfeet, correction can be achieved and maintained in most patients. Level of Evidence: Prognostic level 2.