Viral V. Jain

Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures

BACKGROUNDnIn vitro mechanical studies have demonstrated equal or superior fixation of pediatric femoral fractures with use of titanium elastic nails as compared with stainless steel elastic nails, and the biomechanical properties of titanium are often considered to be superior to those of stainless steel for intramedullary fracture fixation. We are not aware of any clinical studies in the literature that have directly compared stainless steel and titanium elastic nails for the fixation of pediatric femoral fractures. The purpose of the present study was to compare the complications associated with the use of similarly designed titanium and stainless steel elastic nails for the fixation of pediatric femoral fractures.nnnMETHODSnA group of fifty-six children with femoral fractures that were treated with titanium elastic nails was compared with another group of forty-eight children with femoral fractures that were treated with stainless steel elastic nails. Both nail types were of similar design, and a similar retrograde insertion technique was used. The groups were compared with regard to complications as well as insertion and extraction time. Major complications were defined as malunion with sagittal angulation of >15 degrees and coronal angulation of >10 degrees, nail irritation requiring revision surgery, infection, delayed union, and rod breakage. Minor complications were defined as nail irritation or superficial infection not requiring surgery.nnnRESULTSnThe malunion rate was nearly four times higher in association with the titanium nails (23.2%; thirteen of fifty-six) as compared with the stainless steel nails (6.3%; three of forty-eight) (p = 0.017, chi-square test; odds ratio = 4.535 [95% confidence interval, 1.208 to 17.029]). The rate of major complications was 35.7% (twenty of fifty-six) for titanium nails and 16.7% (eight of forty-eight) for stainless steel nails. The rates of minor complications were similar for the two groups, as were the insertion times and extraction times. The supplier price of one titanium nail ranges from

Mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion: a meta-analysis.

259 to

Complications of elastic stable intramedullary nailing in pediatric fracture management: AAOS exhibit selection.

328, depending on size, whereas the price of one stainless steel nail would be

Complications of Surgical Treatment of Pediatric Spinal Deformities

78 in current United States dollars.nnnCONCLUSIONSnOur results indicate that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion.

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs.

Study Design. Meta-analysis on mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion. Objective. To compare mid- to long-term outcomes and complications of the most commonly used instrumentation systems in adolescent idiopathic scoliosis. Summary of Background Data. A meta-analysis of mid- to long-term results of different methods of instrumentation, including the most currently used all-pedicle screw construct, is lacking. Methods. A structured literature review was conducted for studies concerning management of patients with adolescent idiopathic scoliosis with instrumented posterior fusion. Pooled means, standard deviations, and sample sizes were either identified or calculated on the basis of the results of each study. Results. Meta-analyses were performed on outcomes from 27 studies. Overall, 1613 patients who had been treated with Harrington rods, 361 patients who had undergone Cotrel-Dubousset instrumentation, and 298 patients who managed with all-pedicle screw constructs were reviewed. The mean follow-up was 14.9 years. Cotrel-Dubousset and pedicle screw instrumentations achieved a significantly greater degree of correction of the thoracic curve than Harrington rods (40.3° vs. 14.7°; P < 0.001 and 21.9° vs. 14.7°; P = 0.005, respectively). Cotrel-Dubousset technique achieved a significantly higher degree of correction than all-pedicle screw construct in both the thoracic (40.3° vs. 21.9°, respectively; P < 0.001) and lumbar curves (37.2° vs. 16°, respectively; P < 0.001). Similarly, Cotrel-Dubousset construct achieved a greater correction of both thoracic kyphosis (33.5° vs. 23°, respectively; P < 0.001) and lumbar lordosis (46° vs. 50.7°, respectively; P = 0.002) than pedicle screws. All-pedicle screw fixation was associated with the lower risk of pseudarthrosis, infection, neurological deficit, and reoperation. Conclusion. This study confirms the negative effect of Harrington rods on sagittal alignment. We further found that the degree of correction in the coronal and sagittal planes was higher after Cotrel-Dubousset instrumentation than all-pedicle screw fixation. All-pedicle screw constructs offered the lower risk of mid- to long-term complications and revision surgery.

Does the presence of dystrophic features in patients with type 1 neurofibromatosis and spinal deformities increase the risk of surgery

Elastic stable intramedullary nailing (ESIN) for pediatric fracture management has gained increasing popularity since its introduction in the late 1970s. Relatively few modifications have been made to the original technique in the last forty years, which illustrates the sound biomechanical principles and simplicity of the technique. Jean-Paul Metaizeau, the originator of the technique, pointed out that poor results after ESIN were typically due to incorrect constructs, incorrect indications, and insufficient surgeon training1. The initial (1977 to 1980) indications for ESIN were limited to pediatric patients with multiple injuries or head trauma in whom cast or traction treatment was not practical. Later, its use was extended to all diaphyseal fractures of long bones in children. With widespread acceptance, the indications have been further expanded to metaphyseal fractures, comminuted fractures, pathologic fractures, and fractures of smaller bones (including clavicular, supracondylar humeral, and metacarpal fractures). ESIN was introduced in the United States in 19972. The literature is replete with reports of the clinical success of ESIN, but reports related to its complications are scarce. The aim of this manuscript was to review the common complications related to ESIN and provide technical pearls to manage and avoid complications.nnThe principle of ESIN involves balanced nailing (i.e., use of two flexible nails of the same diameter to provide elasticity and stability in opposite directions at the fracture site). This principle is different from the principle of the Ender nail, which is based on maximal filling of the medullary canal3. To achieve balanced nailing when two nails are used, the apex of curvature of each nail should be at the fracture site. To achieve this, both nails should have the curvature of the letter “C” if they are inserted from opposite sides of the bone, or one nail should have …

Could junctional problems at the end of a long construct be addressed by providing a graduated reduction in stiffness? A biomechanical investigation.

Surgery in a child with spinal deformity is challenging. Although current orthopedic practice ensures good long-term surgical results, complications occur. Idiopathic scoliosis represents the most extensively investigated deformity of the pediatric spine. Nonidiopathic deformities of the spine are at higher risk for perioperative and long-term complications, mainly because of underlying comorbidities. A multidisciplinary treatment strategy is helpful to assure optimization of medical conditions before surgery. Awareness of complications that occur during or after spine surgery is essential to avoid a poor outcome and for future surgical decision making. This article summarizes the complications of surgical treatment of the growing spine.

Presacral retroperitoneal approach to axial lumbar interbody fusion: a new, minimally invasive technique at L5-S1: Clinical outcomes, complications, and fusion rates in 50 patients at 1-year follow-up

Background The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum. Methods On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum. Results Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P<0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P<0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P=0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P<0.001). The angle between the neck and shaft lines correlated positively with LCD (P<0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (&kgr;=0.40-0.75). Conclusions The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment. Level of Evidence Diagnostic Level 3.

Obstructive Lung Disease in Children with Idiopathic Scoliosis

Study Design. Retrospective chart and radiographical review. Objective. To present the demographics of patients with scoliosis and neurofibromatosis type 1 (NF-1), to record the incidence of dystrophic features, and to determine whether the presence of dystrophic features increase the risk of surgery in patients with NF-1 and associated spinal pathology. Summary of Background Data. The most common of the osseous complications of NF-1 is spinal deformity, occurring in 10% to 30% of individuals with NF-1. Many of these patients will eventually require surgery for curve progression, which makes study of demographics and identification of features predicting the need for surgery essential in this patient population. Methods. A retrospective review was performed in patients with NF-1 and spinal deformities, followed in a multidisciplinary neurofibromatosis center. A subset of 56 patients with complete radiographical evaluation was reviewed for identification of risk factors for spine surgery. Results. One hundred thirty-one patients from a population of 694 patients with NF-1 (19%) had scoliosis. Mean age at diagnosis of scoliosis was 9 years (range; 1–17 yr). Scoliosis and need for surgery were equally distributed between males and females. In the group of 56 patients, 63% had 3 or more dystrophic features. The presence of 3 or more dystrophic features was the strongest predictor of the need for surgery (odds ratio = 14.34; P < 0.001). Individual features most predictive of need for surgery were the presence of vertebral scalloping (odds ratio = 13.19; P < 0.001) followed by the presence of dural ectasia (odds ratio = 6.38; P = 0.005). Patients with no dystrophic features were unlikely to progress to need for surgery. Conclusion. Scoliosis and need for surgery were equally distributed between males and females. The presence of 3 or more dystrophic features was highly predictive of the need for surgery, with the most significant individual predictors being vertebral scalloping and dural ectasia. A combination of radiographical and MRI features can be used to predict need for spinal surgery. Level of Evidence: 3

Assessment of rib hump deformity correction in adolescent idiopathic scoliosis with or without costoplasty using the double rib contour sign.

Study Design. The effect of long, rigid fixation on adjacent level hypermobility was investigated in a human cadaver model with and without a transitional posterior dynamic stabilization (PDS) device placed at the last caudal level. Objective. To evaluate if PDS devices are useful in the setting of spinal deformities to restore increased adjacent level motions, which occur in long constructs. The hypothesis is that load-sharing benefits of these devices will be most suitable in long constructs and may reduce thoracolumbar junctional effects. The PDS device evaluated has a compressive spacer and flexion-dampening bumper. Summary of Background Data. Mechanical factors such as excessive mobility, increased disc height due to instrumentation, and abnormal loading are thought to accentuate distal level problems, which occur in extended instrumentation. Specifically adjacent level degeneration and distal junctional kyphosis are known to occur in these cases. Methods. Seven cadaver spines were tested from T7 to L3. Long instrumentation was applied in 2 rigid groups, R1: Rigid (T8–L2) and R2: Rigid (T8–L1), and PDS to the last caudal level of each, RP1: Rigid (T8–L1) + PDS (L1–L2), and RP2: Rigid (T8–T12) + PDS (T12–L1). Range of motion was evaluated at surgical and distal adjacent levels after displacement controlled loading in a spine tester. Results. Distal adjacent level motion was increased after 5- and 6-level rigid fixation in flexion-extension, lateral bending, and axial rotation. Most of the increases were seen in axial rotation and lateral bending. Replacing the last caudal instrumented level with the PDS test device was able to alleviate hypermobile conditions of the adjacent noninstrumented level, closer to intact (24%, 12% reduction in RP2, RP1, respectively). Conclusion. Reduction of hypermobility caused by extended arthrodesis may represent a new and ideally suited function for PDS devices. Mechanically, the devices were seen to kinematically restore abnormal distal motion, especially with placement of the PDS at the thoracolumbar junction.