PURPOSE: The purpose of this study was to establish and analyze a simplified scoring system based on anatomic imaging measurements to predict recurrent instability after primary arthroscopic shoulder capsulolabral repair. METHODS: All patients undergoing primary arthroscopic anterior capsulolabral repair of the shoulder were reviewed. Patients were contacted and charts were reviewed for endpoint of recurrent instability and return to prior level of activity. Predictive variables for recurrent instability studied included age, sex, amount of glenoid bone loss, intact anterior articular arc (IAAA), glenohumeral tracking (off-track), contact sports and overhead sports participation. RESULTS: 540 patients met inclusion criteria and follow-up data with magnetic resonance imaging data were available for 337 shoulders. Average follow-up was 6.2 years(range 3.4-9.3 years). Symptomatic recurrent instability occurred in 102 patients (30.3%) and 68% of contacted patients returned to pre-injury activities. In univariate analysis, age under 21 years, off-track lesions, IAAA <150°, and glenoid bone loss (GBL) of 10% or greater displayed an increased risk of recurrent instability. Multivariable analysis showed these factors remained significant: age <21 (odds ratio [ratio] 2.37), off-track glenoid (OR 2.86), IAAA <150 (OR 3.90), and GBL ≥10% (OR 7.47). A scoring system assigning 1 point each for age and off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10% yielded 79% sensitivity, 75% specificity, 58% positive predictive value, and 89% negative predictive value using a probability value of 20 percent for recurrent instability. CONCLUSION: At mid-term follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. Younger age, glenoid bone loss of 10% or more, IAAA <150° and off-track glenoid lesion conferred the greatest risk for postoperative instability. We propose a scoring system assigning 1 point for age, 1 point for off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10%. This schema demonstrated moderate accuracy for predicting recurrent instability when using a cutoff threshold score above 2 points for failure. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.
PURPOSE: We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes. METHODS: Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years). RESULTS: All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively. CONCLUSIONS: Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
OBJECTIVES: To evaluate the maximal force generated by magnetically controlled growing rods (MCGRs) at three different lengthened positions. SUMMARY OF BACKGROUND DATA: The introduction of MCGRs has been met with great enthusiasm by surgeons managing early-onset scoliosis. These devices offer the potential to decrease the cost and morbidity associated with repeated surgeries, compared to traditional growing rods. One potential negative consequences of growing rod treatments is the law of diminishing returns, where the spine length gained decrease with each subsequent lengthening. The cause of this phenomenon is unknown and probably multifactorial, yet it may be affected by the strength of the lengthening mechanism in the MCGRs. METHODS: Twelve MCGRs (90-mm actuator length) were obtained and tested to evaluate the maximal force generated at different lengths. The maximal lengthening force measured in pounds-of-force generated by each rod was recorded at expansion lengths of 0, 25, and 40 mm. Longitudinal analysis was performed using mixed effects linear regression to account for repeated measures and variability between individual implants. RESULTS: At 0 mm of actuator lengthening, the mean maximum force was 46.8 lb (standard deviation [SD] 2.06, range 43-50). At 25 mm of expansion, the mean maximum force was 44.9 lb (SD 2.48, range 39.4-49.5). At 40 mm of lengthening, the mean maximum force was 43.2 lb (SD 5.56, range 27.3-49.1). In the mixed effects linear model, there was a statistically significant decrease in the maximal force generated with progressive MCGR lengthening, at an average decrease of 0.089 lb of force (95% CI, 0.030-0.148; p = .003) per millimeter of lengthening. CONCLUSION: There is a small but statistically significant decrease in the maximal force generated by MCGR as the rods are lengthened. The decrease in force generated may result in diminished spine length gained with each subsequent MCGR lengthening. LEVEL OF EVIDENCE: Level IV.
PURPOSE: To compare femoral version measured with a fluoroscopic Dunn view taken at the time of hip arthroscopy with values derived from axial magnetic resonance imaging (MRI) scans. METHODS: Of 159 hip arthroscopies performed from January 2014 through March 2015, 50 patients had magnetic resonance imaging (MRI) scans with a protocol that incorporates femoral version analysis. Dunn views are performed as a routine part of the preoperative fluoroscopic examination at the time of arthroscopy. Femoral version was measured from the fluoroscopic views and compared with values calculated from axial MRI images. The measurements were compared with a paired t test for difference in means, the intraclass correlation coefficient (ICC) for reliability, and the limits of agreement method of Bland and Altman. RESULTS: There was a very small but statistically significant difference between the measurement on fluoroscopic Dunn view and the value on axial MRI (mean difference, 1.4°, P = .03). The ICC was 0.809 (P < .0001), indicating substantial agreement. By the Bland and Altman method, the 95% limits of agreement for fluoroscopic versus MRI measurement were -7.6 to 10.4, with no significant difference in variance by Pitman test (P = .526). CONCLUSIONS: With careful attention to technique, the fluoroscopically simulated Dunn view can be used to measure femoral version with acceptable accuracy and obviates the need for repeat 3-dimensional imaging for patients who already have an MRI scan without version analysis. LEVEL OF EVIDENCE: Level II, testing of previously developed diagnostic criteria with a gold standard.
The use of magnetically controlled growing rods (MCGR) has the potential to decrease the morbidity associated with repeated surgeries, yet, strength of the lengthening mechanism as it lengthens may have an impact on the length gained with each lengthening.We evaluated the maximal force generated by MCGR at 3 different lengthened positions and found an average decrease of 0.089 pounds per mm of additional length. This decrease may result in diminished spine length gained with each subsequent MCGR lengthening.
Background: Cam deformity is associated with epiphyseal extension onto the anterosuperior femoral head–neck before physeal closure. A century ago, anatomists speculated that this femoral prominence acts as a pulley bar to withstand capsular compression in hip extension with pressure concentrated where the zona orbicularis (ZO) joins the iliofemoral ligament (IFL). An animal model has shown that growth plates deflect laterally and distally when exposed to forces perpendicular to growth. These observations raise the question of whether capsular pressure against the epiphysis can stimulate cam formation.
Purpose: The purposes are to measure: (1) the distance from the ZO/IFL confluence to the maximal epiphyseal extension (MEE) and cam apex; and (2) acetabular depth at this location, since less coverage increases capsular contact on the physis.
Methods: MRI scans of 39 subjects (47 hips) were measured. Acetabular depth was compared between those with and without a cam deformity. Secondarily, anatomic findings were correlated on a cadaveric specimen.
Results: The cam apex and MEE were adjacent to the ZO/IFL confluence in all subjects (mean, 6.3 mm). Controlling for sex, acetabular depth was less (12.5%, p = 0.012) in the group with cam deformity. Contact points were confirmed in the specimen.
Conclusions: The cam apex and MEE occur at the ZO/IFL confluence in the thickest region of the anterosuperior capsule and vary with acetabular depth. This supports a theoretical model postulating that capsular forces against an immature epiphysis may induce cam formation, particularly in individuals who repetitively tension the anterior capsule.
Aims To compare radiographic failure and re-operation rates of anatomical coracoclavicular (CC) ligament reconstructional techniques with non-anatomical techniques after chronic high grade acromioclavicular (AC) joint injuries. Patients and Methods We reviewed chronic AC joint reconstructions within a region-wide healthcare system to identify surgical technique, complications, radiographic failure and re-operations. Procedures fell into four categories: (1) modified Weaver-Dunn, (2) allograft fixed through coracoid and clavicular tunnels, (3) allograft loop coracoclavicular fixation, and (4) combined allograft loop and synthetic cortical button fixation. Among 167 patients (mean age 38.1 years, (standard deviation (sd) 14.7) treated at least a four week interval after injury, 154 had post-operative radiographs available for analysis. Results Radiographic failure occurred in 33/154 cases (21.4%), with the lowest rate in Technique 4 (2/42 4.8%, p = 0.001). Half the failures occurred by six weeks, and the Kaplan-Meier survivorship at 24 months was 94.4% (95% confidence interval (CI) 79.6 to 98.6) for Technique 4 and 69.9% (95% CI 59.4 to 78.3) for the other techniques when combined. In multivariable survival analysis, Technique 4 had better survival than other techniques (Hazard Ratio 0.162, 95% CI 0.039 to 0.068, p = 0.013). Among 155 patients with a minimum of six months post-operative insurance coverage, re-operation occurred in 9.7% (15 patients). However, in multivariable logistic regression, Technique 4 did not reach a statistically significant lower risk for re-operation (odds ratio 0.254, 95% CI 0.05 to 1.3, p = 0.11). Conclusion In this retrospective series, anatomical CC ligament reconstruction using combined synthetic cortical button and allograft loop fixation had the lowest rate of radiographic failure. Take home message: Anatomical coracoclavicular ligament reconstruction using combined synthetic cortical button and allograft loop fixation had the lowest rate of radiographic failure. Cite this article: Bone Joint J 2016;98-B:512–18.
Background: A relationship between spinal distraction and correction of the curvature of scoliosis has long been recognized. While attempts have been made to define the height that is lost with progression of scoliosis, much less information is available to define the height that is gained as a result of surgical correction of the curve and to quantify additional spinal growth after spine fusion. Methods: The present study included 116 patients (mean age, 14.8 years) who underwent spinal instrumentation and fusion for the treatment of idiopathic scoliosis. The study group included ninety-one female patients and twenty-five male patients; all Lenke curve types were represented. The Cobb angle and the T1-L5 spinal height were evaluated on preoperative, postoperative, and two-year follow-up radiographs. Kyphosis, lordosis, and T1-L5 spinal length were measured on lateral radiographs. The Scoliosis Research Society (SRS) questionnaire was completed prior to surgery and at each visit. Multivariate linear regression defined the relationship between spinal height gain, Cobb angle correction, and other variables as well as final spinal height. Results: The mean spinal height gain due to surgery was 27.1 mm (median, 25.1 mm; interquartile range, 14.5 to 37.9 mm; range, -3.8 to 66.1 mm). The magnitude of curve correction (mean, 38.2°; range, 6° to 67°), the number of vertebral levels fused (mean, 9.9; range, three to sixteen), and the preoperative stature (standing height) of the patient were all significant predictors (p < 0.01) of spinal height gain (R2 = 0.8508 for multivariate model). The mean changes in kyphosis and lordosis were small and were not significant predictors. An additional 4.6 mm of mean spinal height was gained at the time of the two-year follow-up; this increase was significantly related to young age, male sex, shorter fusions, and a Risser stage of <=2 at the time of surgery (p < 0.01 for all in multivariate analysis). The SRS-30 scores improved significantly (p < 0.0001), independent of spinal height gain. Conclusions: Patients undergoing surgical correction of idiopathic scoliosis gain substantial height related to the magnitude of surgical correction, the number of levels fused, and preoperative stature. Continued spine growth by two years after surgery is associated with shorter fusions, skeletal immaturity, young age, and male sex. Height gain is a quantifiable outcome of the surgical correction of scoliosis. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Variation in rib numbering has been noted in adolescent idiopathic scoliosis (AIS), but its effect on the reporting of fusion levels has not been studied. We hypothesized that vertebral numbering variations can lead to differing documentation of fusion levels.
To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction.
A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction.
Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups.
Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws.
Objectives: We measured biomechanical stability in simulated supracondylar humeral fractures fixed with each of 6 pin configurations, 2 with associated medial comminution, and developed a technique for reproducible pin placement and divergence.Methods: A transverse supracondylar osteotomy was performed on 36 biomechanical humerus models. Of these, 24 (4 groups of 6 specimens each) were fixed with pins in 1 of 4 lateral entry configurations. The remaining 12 (2 groups of 6 specimens each) had a 30-degree medial wedge removed from the distal humerus and were fixed with 1 of 2 configurations. Half of each group was tested under axial rotation and the other half under varus bending. The distal humerus was divided into 4 equal regions from lateral to medial (1–4). Lateral entry pins were inserted through regions 1–3, whereas the medial pin was inserted through region 4.Results: Without comminution, 3 widely spaced, divergent lateral entry pins resulted in higher torsional stiffness (0.36 Nm/degree) than 2 pins in adjacent regions (P < 0.055), but similar to 2 pins in nonadjacent regions (P = 0.57). Three lateral entry pins had higher bending stiffness (79.6 N/mm) than 2 pins, which ranged from 46.7 N/mm (P < 0.01) to 62.5 N/mm (P = 0.21). With comminution, adding a third medial entry pin increased torsional stiffness (0.13–0.24 Nm/degree, P < 0.01) and increased bending stiffness (38.7–44.7 N/mm, P = 0.10).Conclusions: For fractures without medial column comminution, fixation using 3 lateral entry pins may provide the greatest combination of torsional and bending stiffness. With medial comminution, adding a third medial pin increased torsional stiffness (P < 0.01) and bending stiffness (P = 0.10).
Background: Evaluation of extension-based low back pain in young athletes with suspected pars injury may include a referral for skeletal single photon emission computed tomography (SPECT). However, the diagnostic yield of this technique in children with low back pain before the age of 10 years remains uncertain. We examined a series of consecutive SPECT scans to address this question.Materials and Methods: A retrospective review of department databases revealed 107 consecutive skeletal Tc-99m MDP SPECT scans performed between January 1, 2007 and December 31, 2009 in children less than 10 years of age. Of these, 72 studies were performed for a referral diagnosis of back pain. There were 43 girls (44 studies) and 28 boys (28 studies). The mean age was 7.2 years (range, 1.9 to 9.9 y). All SPECT scans were reviewed and positive findings documented. In addition, all available anatomic imaging, imaging reports (computed tomography, magnetic resonance, and x-ray) and clinical notes were reviewed, and results were compared with those of SPECT studies.
Background: The range of injury severity that can be seen within the category of type II supracondylar humerus fractures (SCHFs) raises the question whether some could be treated nonoperatively. However, the clinical difficulty in using this approach lies in determining which type II SCHFs can be managed successfully without a surgical intervention.Methods: We reviewed clinical and radiographic information on 259 pediatric type II SCHFs that were enrolled in a prospective registry of elbow fractures. The characteristics of the patients who were treated without surgery were compared with those of patients who were treated surgically. Treatment outcomes, as assessed by the final clinical and radiographic alignment, range of motion of the elbow, and complications, were compared between the groups to define clinical and radiographic features that related to success or failure of nonoperative management.
The use of topical hemostatic agents is widespread and has been shown to reduce bleeding during a wide variety of surgical procedures. Nonetheless, as biologically active agents, there is potential for allergic reactions to these products.
This is a report of intraoperative anaphylaxis to gelatin associated with the use of two topical hemostatic agents.
Case report. There is no outside funding or potential conflict of interest.
A patient with anaphylaxis during anterior spinal fusion.
Laboratory assays for tryptase, gelatin-specific immunoglobulin E (IgE), and total IgE.
A 14-year-old male with myelomeningocele and scoliosis was treated with anterior spinal fusion from T12 to L3. Gelfoam sponges were applied during the preparation of the disc spaces. Approximately 1 hour later, Floseal hemostatic matrix was applied to a briskly bleeding screw hole in the L3 vertebral body, and the patient experienced an abrupt onset of hypotension and ventilatory difficulty. Epinephrine, dexamethasone, and blood products were administered for hemodynamic support while the surgical site was closed. Removal of the drapes revealed a widespread erythematous rash, and the patient was then transferred to the intensive care unit. When stable 3 days later, he returned to the operating room for completion of the spinal fusion.
Postoperative laboratory assays were sent that revealed elevated levels of tryptase, total IgE, porcine, and bovine gelatin–specific IgE. The patient was counseled to avoid gelatin-containing products. At 6-month follow-up, his instrumented spine was radiographically fused and he reported no further allergic issues.
Anaphylaxis may occur because of animal gelatin components of topical hemostatic agents. Previous reports have focused on the thrombin components. Care should be taken in the administration of these products, particularly in the atopic individual.
Background: Patients with arthrogryposis often report decreased ambulation and physical activity. Given that skeletal mineralisation is responsive to force, we identified the need to characterize bone mineral density and functional measures in this population, and conducted a cross-sectional study to establish a reference for future investigations.Methods: Thirty consecutive patients aged 5 to 18 years with either the diagnosis of amyoplasia or nonsyndromic arthrogryposis with predominantly lower extremity involvement underwent bone densitometry testing, and lumbar spine Z-scores were calculated against an age and sex-matched control population as is customary in children. Pediatric outcomes data collection instrument (PODCI) and functional independence measure for Children (WeeFIM) assessment forms were completed. Mean Z-scores, PODCI, and WeeFIM scores were calculated. Statistical analysis was performed to compare lumbar spine Z-scores between patients divided by ambulatory status and to correlate WeeFIM and PODCI scores.
Background: Temporary elbow stiffness after the treatment of a supracondylar humeral fracture in a child is often a concern of parents. However, little attention has been devoted to documenting, longitudinally, the time required for motion recovery. The purpose of the present study was to provide a prospective, longitudinal evaluation of elbow motion in a large population of pediatric patients undergoing treatment of a supracondylar humeral fracture. Methods: We prospectively examined 373 patients (375 fractures) who presented to our urgent care center between March 1, 2007, and September 30, 2008. On the basis of a standard protocol, patients were managed with either casting or surgery, depending on the severity of the injury, and then were followed for a minimum of seven weeks. Values of elbow flexion and extension were recorded, and the relative arc of motion was calculated as a percentage of the motion of the contralateral elbow. Results: In general, following a supracondylar humeral fracture, the greatest increases in flexion, extension, and the absolute and relative arcs of motion are observed within the first month after cast removal, with a progressive improvement for up to forty-eight weeks after the injury. Age had a significant effect on the recovery of elbow motion, with patients older than five years of age demonstrating a 3% to 9% lower relative arc of motion at the follow-up points in comparison with younger patients. Similarly, patients with more-severe fractures requiring surgical treatment demonstrated a decrease in relative elbow motion of 10% (with respect to the contralateral side) at the time of cast removal in comparison with those who were managed nonoperatively. Conclusions: The present study demonstrates that an initial rapid recovery in elbow motion can be expected after a supracondylar humeral fracture in a child, followed by a progressive improvement for up to one year after the injury. This motion recovery is slower in older patients and in those with more severe injuries. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.
Background: Occasionally, the treatment of a pediatric supracondylar humeral fracture is delayed owing to lack of an available treating physician, necessitating transfer of the child, or delay in availability of an operating room. The purpose of this study is to prospectively evaluate whether delayed pinning of these fractures affects the outcome or number of complications.Methods: We reviewed information that was prospectively collected on 145 pediatric supracondylar humeral fractures that were treated by closed reduction and percutaneous pinning, with a minimum follow-up of 8 weeks. To determine the effect of delayed treatment, we compared a group of fractures that was treated within the first 21 hours after their presentation to our urgent care center (Group A) with a group that was treated after more than 21 hours (Group B). We compared the following variables: need for open reduction, length of surgery, length of hospitalization, the presence of neurologic complications, vascular complications including compartment syndrome, pin tract infection, loss of fixation, final carrying angle, range of motion, and outcome.Results: Overall, the mean time from presentation to surgery for both groups was 52 hours. This interval was greater for Gartland type II fractures (65 h) than for Gartland type III fractures (19 h) (P=0.00001). There was no need for an open reduction in either group. There were no significant differences between the groups regarding iatrogenic nerve injuries, vascular complications, compartment syndromes, surgical time, final carrying angle, range of motion, and outcome.Conclusions: The results of this prospective study found that a delay in pinning closed supracondylar humeral fractures in children did not lead to a higher incidence of open reduction or a greater number of complications. Although the urgency of treating any child with a supracondylar fracture should be individualized, our study suggests that most of these injuries can be managed safely in a delayed fashion without compromising the clinical outcome. We recommend careful monitoring of any patient with type 3 injury whose treatment is delayed.Level of Evidence: II.