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Chen S, Tulchin-Francis K, Gaines D, Kadado A, Smith C, Klingele K. Acetabular "Fleck" Sign: Outcomes of Surgical Repair. J Pediatr Orthop 2024; 44:e433-e438. [PMID: 38454629 DOI: 10.1097/bpo.0000000000002657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Traumatic, posterior hip dislocations in the pediatric population are typically managed by closed reduction to achieve a concentric hip joint. The presence of an acetabular "fleck" sign, despite concentric reduction, has been shown to signify significant hip pathology. The purpose of this study was to evaluate the outcomes of open labral repair through a surgical hip dislocation (SHD) in a consecutive series of patients with an acetabular "fleck" sign associated with a traumatic hip dislocation/subluxation. METHODS A retrospective review of patients between 2008 and 2022 who presented to a single, level 1 pediatric trauma center with a traumatic posterior hip dislocation/subluxation was performed. Patients were included if they had an acetabular "fleck" sign on advanced imaging and underwent open labral repair through SHD. Medical records were reviewed for sex, age, laterality, mechanism of injury (MOI), and associated orthopaedic injuries. The modified Harris hip score (mHHS) was utilized as the primary clinical outcomes measure. Patients were assessed for the presence of heterotopic ossification (HO) and complications, including implant issues, infection, avascular necrosis (AVN), and post-traumatic dysplasia. RESULTS Twenty-nine patients (23 male, average age: 13.0±2.7 y; range: 5.2 to 17.3) were identified. Eighteen injuries were sports related, 9 caused by motor vehicle accidents, and 1 pedestrian struck. All patients were found to have an acetabular "fleck" sign on CT (26 patients) or MRI (5 patients). Associated injuries included: femoral head fracture (n=6), pelvic ring injury (n=3), ipsilateral femur fracture (n=2), and ipsilateral PCL avulsion (n=1). At the latest follow-up (2.2±1.4 y), all patients had returned to preinjury activity/sport. Three patients developed asymptomatic, grade 1 HO in the greater trochanter region. There was no incidence of AVN. One patient developed post-traumatic acetabular dysplasia due to early triradiate closure. mHHS scores showed excellent outcomes (n=21, 94.9±7.4, range: 81 to 100.1). CONCLUSIONS The acetabular "fleck" sign indicates a consistent pattern of osteochondral avulsion of the posterior/superior labrum. Restoring native hip anatomy and stability is likely to improve outcomes. SHD with open labral repair in these patients produces excellent clinical outcomes, with no reported cases of AVN. LEVEL OF EVIDENCE Level IV-therapeutic.
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Affiliation(s)
| | | | - Dan Gaines
- Department of Orthopaedics, The Ohio State University, Columbus, OH
| | - Allen Kadado
- Department of Orthopaedics, The Ohio State University, Columbus, OH
| | - Craig Smith
- Department of Orthopedic Surgery, Nationwide Children's Hospital
| | - Kevin Klingele
- Department of Orthopedic Surgery, Nationwide Children's Hospital
- Valley Children's Healthcare, Madera, CA
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Morin JP, Fuchs M, Klingele K, Jayanthi R. Novel pelvic immobilization method following bladder exstrophy repair. J Pediatr Urol 2024; 20:318-319. [PMID: 37932196 DOI: 10.1016/j.jpurol.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023]
Abstract
We introduce a novel method of pelvic immobilization following bladder exstrophy repair involving a custom-made brace that offers adequate pelvic immobilization with the added benefits of no added operative time, easy evaluation of surgical sites, simplified wound care including sponge bathing, and overall less cumbersome management for the family given its more streamlined size.
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Affiliation(s)
- Jacqueline P Morin
- Department of Urology, Nationwide Children's Hospital, Columbus, OH, United States.
| | - Molly Fuchs
- Department of Urology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Kevin Klingele
- Department of Orthopedics, Nationwide Children's Hospital, Columbus, OH, United States
| | - Rama Jayanthi
- Department of Urology, Nationwide Children's Hospital, Columbus, OH, United States
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Bjorklund KA, Alexander J, Tulchin-Francis K, Yanes NS, Singh S, Valerio I, Klingele K, Scharschmidt T. Targeted Muscle Reinnervation for Limb Amputation to Avoid Neuroma and Phantom Limb Pain in Patients Treated at a Pediatric Hospital. Plast Reconstr Surg Glob Open 2023; 11:e4944. [PMID: 37063502 PMCID: PMC10101300 DOI: 10.1097/gox.0000000000004944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/24/2023] [Indexed: 04/18/2023]
Abstract
Amputees frequently experience chronic neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) transfers transected nerves to nearby motor nerves to promote healing and prevent neuroma formation and PLP. The purpose of this study was to report outcomes of TMR in a series of children and young adults treated at a pediatric hospital. Methods Patients undergoing major limb amputation with TMR were included with minimum one year follow-up and completed questionnaires. Primary clinical outcomes included incidence of symptomatic neuromas, PLP, residual limb pain, narcotic use, and neuromodulator use. A follow-up phone survey was conducted assessing five pediatric Patient Reported Outcomes Measurement Information System (PROMIS) metrics adapted to assess residual limb and PLP. Results Nine patients (seven male and two female patients, avg. age = 16.83 ± 7.16 years) were eligible. Average time between surgery and phone follow-up was 21.3 ± 9.8 months. Average PROMIS Pediatric t-scores for measures of pain behavior, interference, quality-affective, and quality-sensory for both PLP and residual limb pain were nearly 1 standard deviation lower than the United States general pediatric population. One patient developed a symptomatic neuroma 1 year after surgery. Conclusions Compared with an adult patient sample reported by Valerio et al, our TMR patients at Nationwide Children's Hospital (NCH) showed similar PLP PROMIS t-scores in pain behavior (50.1 versus 43.9) and pain interference (40.7 versus 45.6). Both pediatric and adult populations had similar residual limb pain including PROMIS pain behavior (36.7 adult versus 38.6 pediatric) and pain interference (40.7 adult versus 42.7 pediatric). TMR at the time of amputation is feasible, safe, and should be considered in the pediatric population.
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Affiliation(s)
- Kim A. Bjorklund
- From the Department of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio
| | - John Alexander
- Department of Orthopedic Surgery, The Ohio State University, Columbus, Ohio
| | | | - Natasha S. Yanes
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Satbir Singh
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Ian Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Kevin Klingele
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Ebaugh MP, Grenier G, Singh S, Abousamra O, Klingele K. Ankle Mortise Instability in Multiple Hereditary Exostoses. J Foot Ankle Surg 2022; 61:1240-1245. [PMID: 35370053 DOI: 10.1053/j.jfas.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/21/2019] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.
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Affiliation(s)
| | | | - Satbir Singh
- Department of Orthopedics, Nationwide Children's Hospital, Columbus, OH
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DeLong L, Krishna S, Roth C, Veneziano G, Arce Villalobos M, Klingele K, Tobias JD. Short Communication: Lumbar Plexus Block versus Suprainguinal Fascia Iliaca Block to Provide Analgesia Following Hip and Femur Surgery in Pediatric-Aged Patients - An Analysis of a Case Series. Local Reg Anesth 2021; 14:139-144. [PMID: 34703306 PMCID: PMC8541757 DOI: 10.2147/lra.s334561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/22/2021] [Indexed: 01/07/2023] Open
Abstract
Introduction For surgical procedures involving the hip and femur, various regional anesthetic techniques may be used to provide analgesia. Although there has been an increase in the use of lumbar plexus block (LPB), the technique may be time consuming and associated with complications. Suprainguinal fascia iliaca compartment block (FICB) is a potentially easier and safer alternative. The current study prospectively compares LPB with suprainguinal FICB. Methods This prospective, double-blinded, randomized, study included patients undergoing elective orthopedic procedures of the hip and/or femur. All study patients received general anesthesia with randomization to either an LPB or suprainguinal FICB using 0.5% ropivacaine with epinephrine and dexamethasone. Postoperative pain control was achieved with intravenous hydromorphone delivered by patient-controlled analgesia with scheduled acetaminophen and ketorolac. Outcome data included time to perform the block, perioperative opioid consumption, postoperative pain scores (VAS) and hospital length of stay. Results The study cohort included 15 patients between the ages of 7 and 16 years (LPB N = 7, FICB N = 8). The median block time was 6 minutes (IQR: 4.11) for the LPB group and 3 minutes (IQR: 3.6) for the FICB group (p = 0.107). Median postoperative pain scores were 4 (IQR: 0.6) for the LPB group and 2 (IQR: 0.5) for the FICB group (p = 0.032). There were no differences in the intraoperative or postoperative opioid and NSAID use between the two groups. Discussion The suprainguinal FICB provides analgesia that is at least as effective as a LPB following hip and femur surgery. Time to perform the block was shorter with the FICB due to the supine patient position and limited needle trajectory. Although we noted no adverse effects, the superficial needle trajectory of the FICB offers a less invasive approach and the potential for decreased risks of adverse effects.
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Affiliation(s)
- Lauren DeLong
- Heritage College of Osteopathic Medicine - Athens Campus (Athens, Ohio) and Ohio University, Athens, OH, USA
| | - Senthil Krishna
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mauricio Arce Villalobos
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kevin Klingele
- Department of Orthopedic Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Villalobos MA, Veneziano G, Miller R, Beltran RJ, Krishna S, Tumin D, Klingele K, Tobias JD. Evaluation of postoperative analgesia in pediatric patients after hip surgery: lumbar plexus versus caudal epidural analgesia. J Pain Res 2019; 12:997-1001. [PMID: 31118744 PMCID: PMC6498965 DOI: 10.2147/jpr.s191945] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/18/2019] [Indexed: 11/25/2022] Open
Abstract
Background:There continues to be focus on the value of regional and neuraxial anesthetic techniques when combined with general anesthesia to improve postoperative analgesia. The reported advantages include decreased postoperative opioid requirements, decreased medication-related adverse effects, decreased hospital length of stay, and increased patient satisfaction. Orthopedic procedures of the hip may be amenable to such techniques as there is significant postoperative pain with the requirement for hospital admission and the administration of parenteral opioids. Given the surgical site, various regional anesthetic techniques may be used to provide analgesia including caudal epidural anesthesia (CEA) or lumbar plexus blockade (LPB). Purpose: The objective of this study was to assess the effectiveness of LPB versus CEA as an analgesic thechnique for patients undergoing elective hip surgery from the opioid consumption and pain scores perspective. Patients and methods: The current study retrospectively reviews our experience with CEA and LPB for postoperative analgesia after hip surgery in the pediatric population. Regional anesthesia technique was reviewed as well as opioid requirements and pain scores. Results: The study cohort included 61 patients, 29 who received an LPB and 32 who received CEA. No difference was noted in the demographics between the two groups. Intraoperative opioid use was 0.7 (IQR: 0.5, 1.1) mg/kg of oral morphine equivalents (MEs) in the LPB group compared to 0.6 (IQR: 0.5, 0.9) in the CEA group (p=0.479). Postoperative opioid use over the first 48 hrs was 4 (IQR: 1, 6) mg/kg of oral ME in the LPB group, compared to 2 (interquartile range [IQR]: 1, 3) in the CEA group (p=0.103). Over the first 24 hrs after surgery, the median pain score in the LPB group was 5 (IQR: 1–6), compared to 3 (IQR: 0, 5) in the CEA group (p=0.014).Conclusion: These retrospective data suggest a modest postoperative benefit of CEA when compared to LPB following hip surgery in the pediatric population. Postoperative pain scores were lower in patients receiving CEA; however, no difference in the intraoperative or postoperative opioid requirements was noted between the two groups.
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Affiliation(s)
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Rebecca Miller
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ralph J Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Senthil Krishna
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kevin Klingele
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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7
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Hakim M, Klingele K, Tumin D, Tobias JD, Bhalla T. Diagnosis and Management of Postoperative Conversion Disorder in an Adolescent Following Arthroscopic Meniscectomy. J Med Cases 2017. [DOI: 10.14740/jmc2905w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Gable A, Burrier C, Stevens J, Wrona S, Klingele K, Bhalla T, Martin DP, Veneziano G, Tobias JD. Home peripheral nerve catheters: the first 24 months of experience at a children's hospital. J Pain Res 2016; 9:1067-1072. [PMID: 27920572 PMCID: PMC5125993 DOI: 10.2147/jpr.s110947] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
CONTEXT Home peripheral nerve catheters (PNCs) have become common practice for adult patients after major orthopedic surgery. However, use in pediatric patients is a recent application. OBJECTIVES The purpose of this study was to review the demographics and outcomes of pediatric patients receiving a PNC at our institution. METHODS This retrospective study included patients from October 2012 through October 2014 undergoing orthopedic procedures with a PNC placed for postoperative pain management. RESULTS A total of 118 patients aged 3.2-25.3 years were identified. The types of catheters included femoral (80.5%), interscalene (11.9%), sciatic (5.9%), and supraclavicular (1.7%). The majority of patients were discharged to home on the day of surgery (77.1%). In the postanesthetic care unit, the average pain score was 2.5, the incidence of nausea/emesis was 5.9%, and the need for opioid administration was 50.8%. There were no major complications. Minor complications included a 7.6% rate of early catheter removal with 5.9% of those due to catheter leakage and an unsecure dressing. There was one case of metallic taste in the mouth without other symptoms of local anesthetic toxicity that resolved without further complication. CONCLUSION The implementation of a home PNC program in pediatric patients at our institution has been highly successful with a high rate of ambulatory catheters, low pain scores, low rates of nausea and vomiting, and no serious complications. Minor complications included leaking of the catheter and early discontinuation of the catheter.
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Affiliation(s)
- Andrew Gable
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus; Heritage College of Osteopathic Medicine, Ohio University, Athens
| | - Candice Burrier
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus; Department of Anesthesiology and Pain Medicine, The Ohio State University
| | - Jenna Stevens
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus
| | - Sharon Wrona
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus
| | - Kevin Klingele
- Department of Orthopedics, Nationwide Children's Hospital; Department of Orthopedics, The Ohio State University, Columbus, OH, USA
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus; Department of Anesthesiology and Pain Medicine, The Ohio State University
| | - David P Martin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus; Department of Anesthesiology and Pain Medicine, The Ohio State University
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus; Department of Anesthesiology and Pain Medicine, The Ohio State University
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus; Department of Anesthesiology and Pain Medicine, The Ohio State University
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Veneziano G, Tripi J, Tumin D, Hakim M, Martin D, Beltran R, Klingele K, Bhalla T, Tobias JD. Femoral nerve blockade using various concentrations of local anesthetic for knee arthroscopy in the pediatric population. J Pain Res 2016; 9:1073-1079. [PMID: 27920573 PMCID: PMC5125980 DOI: 10.2147/jpr.s117692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Femoral nerve blockade (FNB) provides effective postoperative analgesia in children undergoing arthroscopic knee surgery as evidenced by their opioid-sparing effects and decreased postoperative pain scores. Increasing the local anesthetic concentration in peripheral nerve blockade for adults undergoing orthopedic surgery has been shown to be beneficial, increasing block success rate, and providing a longer duration of analgesia. The effect of increasing the concentration of local anesthetic in extremity blocks in children remains largely unexplored. METHODS We retrospectively evaluated the effectiveness of FNB using three concentrations of local anesthetic (ropivacaine 0.2%, bupivacaine 0.25%, and ropivacaine 0.5%) in children and adolescents undergoing arthroscopic knee surgery. The primary outcome evaluated was postoperative opioid consumption before discharge. Secondary outcomes included post-anesthesia care unit (PACU) and hospital discharge times, first pain score in PACU, and the incidence of adverse events. RESULTS Two hundred and sixty-nine children and adolescents who received a FNB for arthroscopic knee surgery from January 2010 to December 2013 were included for analysis. Local anesthetic used in FNB was ropivacaine 0.2% in 116 (43%) cases, ropivacaine 0.5% in 75 (28%) cases, and bupivacaine 0.25% in 78 (29%) cases. Median postoperative opioid consumption (mg/kg intravenous morphine equivalents) in the ropivacaine 0.5% group was 0 mg/kg (interquartile ranges [IQR]: 0 mg, 0.03 mg/kg) compared to 0.02 mg/kg (IQR: 0, 0.08 mg/kg) in the ropivacaine 0.2% group and 0.01 mg/kg (IQR: 0, 0.08 mg/kg) in the bupivacaine 0.25% group (p=0.009). Median PACU time was shortest in the ropivacaine 0.5% group (47 min; IQR: 36, 68 min) compared to the ropivacaine 0.2% (58 min; IQR: 41, 77) and bupivacaine 0.25% (54 min; IQR: 35, 75 min) groups (p=0.040). Among groups, there were no significant differences in first postoperative pain scores or incidence of nausea and vomiting. No patient in any group experienced a serious adverse event. CONCLUSION The results suggest that ropivacaine 0.5% for FNB offers superior postoperative analgesia in the form of decreased postoperative opioid consumption and earlier PACU/hospital discharge, when compared to ropivacaine 0.2% and bupivacaine 0.25% in the pediatric population. LEVEL OF EVIDENCE III, Retrospective Comparative Study.
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Affiliation(s)
- Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
| | - Jennifer Tripi
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital
| | - Mumin Hakim
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital
| | - David Martin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
| | - Ralph Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
| | - Kevin Klingele
- Department of Orthopedic Surgery, Nationwide Children's Hospital; Department of Orthopedic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Tarun Bhalla
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
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Trinh T, Mundy A, Beran M, Klingele K. Radiographic Assessment of Anatomic Risk Factors Associated with Acute, Lateral Patellar Dislocation in the Immature Knee. Sports (Basel) 2016; 4:sports4020024. [PMID: 29910272 PMCID: PMC5968917 DOI: 10.3390/sports4020024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/11/2016] [Accepted: 04/14/2016] [Indexed: 01/16/2023] Open
Abstract
Acute patellar dislocation remains a common injury in both adult and pediatric patients. Non-operative management has been advocated for patients without a history of recurrent instability. Although pathologic thresholds for consideration of operative management have previously been reported in adults, it is largely unknown in children. A retrospective review of all skeletally immature patients diagnosed with acute lateral patellar dislocation who had MRI imaging were included for analysis. An age-based control group was also identified. Six radiographic measurements were compared: lateral trochlear inclination (LTI), trochlear facet asymmetry (TFA), trochlear depth (TD), tibial tuberosity⁻trochlear groove (TT⁻TG), sulcus angle (SA) and patellar height ratio. A total of 178 patients were included for analysis (study: n = 108, control: n = 70). The mean age of patients in the study and control groups was 13.7 and 12.1 years respectively (p ≤ 0.001). Study group patients had significant differences in all radiographic measurements including a decreased LTI (p < 0.001), increased TFA (p < 0.001) and SA (p < 0.001). The mean trochlear depth was 3.4 mm and 5.6 mm for patients in the study and control groups respectively (p < 0.001). Study group patients had an increased patellar height ratio (p < 0.001) and TT⁻TG distance (p < 0.001). Morphologic abnormalities may predispose skeletally immature patients to an increased risk of acute lateral patellar instability.
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Affiliation(s)
- Thai Trinh
- Mount Carmel Health Systems, Department of Orthopedics 793 West State Street Columbus, Columbus, OH 43222, USA.
| | - Andrew Mundy
- Ohio State University Medical Center, Department of Orthopaedics, 410 W 10th Ave, Columbus, OH 43210, USA.
| | - Matthew Beran
- Nationwide Children's Hospital, Department of Orthopedics, 700 Children's Drive, Ste. A2630, Columbus, OH 43205-2696, USA.
| | - Kevin Klingele
- Nationwide Children's Hospital, Department of Orthopedics, 700 Children's Drive, Ste. A2630, Columbus, OH 43205-2696, USA.
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Bono K, Klingele K. Pediatric orthopaedic infection season: An analysis of the seasonal variation of pediatric osteomyelitis and septic arthritis. J PEDIAT INF DIS-GER 2015. [DOI: 10.3233/jpi-140415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Background: There continues to be a significant focus on the value of regional and neuraxial anesthesia techniques for adjunctive use when combined with general anesthesia. The reported advantages include decreased patient opiate exposure, decreased medication-related adverse effects, decreased postanesthesia recovery room time and hospital stay, and increased patient satisfaction. Materials and Methods: The authors present a case-controlled series evaluating the use of a single caudal epidural injection prior to incision as an adjunct to general anesthesia for the open repair of slipped capital femoral epiphysis. Opiate consumption, pain scores, and hospital stay were compared between the two cohorts of 16 adolescent patients. All patients received a demand-only patient-controlled opiate delivery system. Results: Although the failed block rate was high (31%), there was decreased opioid use in the perioperative arena as well as during the first 24 postoperative hours in patients who had a successful caudal epidural block. Furthermore, discharge home was possible in 27% of patients who received a caudal epidural block compared to 0% of patients who did not receive a caudal block. Conclusion: The potential utility of caudal epidural block as an adjunct to general anesthesia during major hip surgery in adolescents is presented. Factors resulting in a failed block in this patient population as well as the use of the ultrasound as an added modality to increase block success are reviewed.
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Affiliation(s)
- Brian Schloss
- Department of Anesthesiology, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - David Martin
- Department of Anesthesiology, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Jennifer Tripi
- The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Kevin Klingele
- Department of Orthopedic Surgery, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Joseph D Tobias
- Department of Anesthesiology, Nationwide Children's Hospital, Columbus, Ohio, United States
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13
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Abstract
Few studies have analyzed necrotizing fasciitis in children, and all have relied on cases of necrotizing fasciitis in the abdomen, head, and neck region. The authors sought to correlate the preoperative values of several laboratory tests previously validated in the adult literature, such as the Laboratory Risk Indicator for Necrotizing Fasciitis, with surgically confirmed necrotizing fasciitis in children to provide clinical guidance for the preoperative laboratory workup of necrotizing fasciitis. A retrospective chart review was performed on consecutive patients younger than 18 years with a diagnosis of necrotizing fasciitis. A total of 13 patients with an average age of 7.9 years (range, 9 months-16 years) were included. Ten (76.9%) infections were found in the lower extremity and 3 (23.1%) in the upper extremity. Seven (53.8%) patients had ecchymosis on examination. All patients presented with an elevated white blood cell count. No amputations were performed, and no mortality occurred. All patients underwent surgery within 24 hours of presentation. Elevated temperature, white blood count, erythrocyte sedimentation rate, and C-reactive protein values are typically seen in pediatric patients with necrotizing fasciitis; however, no correlation existed between other the preoperative laboratory values with the previously described scoring systems, such as the Laboratory Risk Indicator for Necrotizing Fasciitis. Aggressive monitoring of signs and symptoms is suggested, even if a patient does not meet all conventional diagnostic criteria. The authors recommend prompt surgical debridement and early administration of antibiotics, which should include clindamycin.
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Affiliation(s)
- Aleksandar Tancevski
- Mount Carmel Medical Center, Nationwide Children’s Hospital, Columbus, OH 43205-2696, USA
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14
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Abstract
Although the reported incidence of fat embolism syndrome (FES) is low (approximately 1%), it is likely that microscopic fat emboli are showered during manipulation of long bone fractures. Even though there continues to be debate regarding the etiology and proposed mechanism responsible for FES, significant systemic manifestations may occur. Treatment is generally symptomatic based on the clinical presentations. We report a 10-year-old girl who developed hypoxemia following treatment of a displaced Salter-Harris type II fracture of the distal tibia. The subsequent evaluation and hospital course pointed to fat embolism as the most likely etiology for the hypoxemia. We discuss the etiology for FES, review the proposed pathophysiological mechanisms responsible for its clinical manifestations, present currently accepted diagnostic criteria, and discuss its treatment.
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Affiliation(s)
- Tarun Bhalla
- Department of Anesthesiology, Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio
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15
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Bickel BA, Fowler TT, Mowbray JG, Adler B, Klingele K, Phillips G. Preoperative magnetic resonance imaging cross-sectional area for the measurement of hamstring autograft diameter for reconstruction of the adolescent anterior cruciate ligament. Arthroscopy 2008; 24:1336-41. [PMID: 19038703 DOI: 10.1016/j.arthro.2008.07.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 07/23/2008] [Accepted: 07/23/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE We conducted this study to determine if preoperative magnetic resonance imaging (MRI) cross-sectional area measurements would correlate with intraoperative graft size in hamstring anterior cruciate ligament (ACL) reconstructions. METHODS We retrospectively reviewed ACL reconstructions performed by a single surgeon using a quadruple-looped hamstring allograft. Preoperative MRI axial images were used to determine the combined cross-sectional area of the semitendinosis and gracilis tendons. These cross-sectional areas were correlated to the intraoperative graft size. RESULTS We found a strong correlation between the MRI cross-sectional areas and graft size. If the combined cross-sectional areas were >or=18 mm(2), there was an 88% probability of obtaining a graft of sufficient size at the time of surgery. CONCLUSIONS We conclude that our technique is a reliable option to assist the surgeon with preoperative determination of graft size. This is valuable to the orthopaedist to more accurately discuss graft options with the patient and improve preoperative preparation with respect to graft choice. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on the basis of consecutive patients with universally applied gold standard.
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Affiliation(s)
- Brent A Bickel
- Department of Orthopaedic Surgery, Mount Carmel Health System, Columbus, OH 43222, USA.
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16
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Bickel BA, Fowler TT, Mowbray JG, Adler B, Klingele K, Phillips G. Preoperative magnetic resonance imaging cross-sectional area for the measurement of hamstring autograft diameter for reconstruction of the adolescent anterior cruciate ligament. Arthroscopy 2008. [PMID: 19038703 DOI: 10.1016/j.arthro.2008.07.012)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE We conducted this study to determine if preoperative magnetic resonance imaging (MRI) cross-sectional area measurements would correlate with intraoperative graft size in hamstring anterior cruciate ligament (ACL) reconstructions. METHODS We retrospectively reviewed ACL reconstructions performed by a single surgeon using a quadruple-looped hamstring allograft. Preoperative MRI axial images were used to determine the combined cross-sectional area of the semitendinosis and gracilis tendons. These cross-sectional areas were correlated to the intraoperative graft size. RESULTS We found a strong correlation between the MRI cross-sectional areas and graft size. If the combined cross-sectional areas were >or=18 mm(2), there was an 88% probability of obtaining a graft of sufficient size at the time of surgery. CONCLUSIONS We conclude that our technique is a reliable option to assist the surgeon with preoperative determination of graft size. This is valuable to the orthopaedist to more accurately discuss graft options with the patient and improve preoperative preparation with respect to graft choice. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on the basis of consecutive patients with universally applied gold standard.
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Affiliation(s)
- Brent A Bickel
- Department of Orthopaedic Surgery, Mount Carmel Health System, Columbus, OH 43222, USA.
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17
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Kocher MS, Mandiga R, Klingele K, Bley L, Micheli LJ. Anterior cruciate ligament injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop 2004; 24:185-8. [PMID: 15076605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Both midsubstance anterior cruciate ligament (ACL) injury and tibial spine avulsion fracture occur in the skeletally immature knee. The purpose of this study was to determine whether there are differences in skeletal maturation or notch parameters between these two groups. A retrospective case-control study of 25 skeletally immature patients with tibial spine fractures compared with 25 age- and sex-matched skeletally immature patients with midsubstance ACL injuries was performed. Bone age and notch width index were determined from preoperative radiographs. There were no significant differences between the tibial spine fracture group and the ACL injury group with respect to skeletal maturation, comparing bone age to chronological age (-0.5 vs. -0.3 years; P = 0.617). The ACL injury group had narrower notch indices than the tibial spine fracture group (0.230 vs. 0.253; P = 0.020). Thus, in a comparison of age- and sex-matched skeletally immature patients, those with midsubstance ACL injuries had a significantly narrower notch index than those with tibial spine fractures. This association may account for some of the variation in injury patterns in the skeletally immature knee.
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Affiliation(s)
- Mininder S Kocher
- Division of Sports Medicine, Department of Orthopaedic Surgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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18
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Abstract
Meniscal injuries in children and adolescents are being seen with increased frequency. Meniscal tears are typically traumatic injuries in adolescents. Because of increased healing potential and the younger age of these patients, attempts at meniscal preservation should be emphasized for outer and middle third tears. Discoid meniscus typically presents as a snapping knee in younger children or as a meniscal tear in older children. Again, meniscal preservation by saucerization is emphasized. Careful attention should be given to the need for additional meniscal repair. Popliteal cysts typically present as a painless mass. Because they are usually not associated with an internal pathology and often resolve spontaneously, the preferred treatment is observation.
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Affiliation(s)
- Mininder S Kocher
- Harvard Medical School, Department of Orthopaedic Surgery, Division of Sports Medicine, Children Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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19
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Madsen HP, Rupp E, Meilli�re G, Utz F, Klingele K. Untersuchung von Quecksilberpr�paraten. Anal Bioanal Chem 1906. [DOI: 10.1007/bf01462001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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