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Paulson AE, Martus JE, Mencio GA, Louer CR. Correction: Information exchange on adolescent scoliosis discussion forums among patients and caregivers: a thematic analysis. Spine Deform 2024:10.1007/s43390-024-00871-6. [PMID: 38619785 DOI: 10.1007/s43390-024-00871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Ambika E Paulson
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA.
| | - Jeffrey E Martus
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Gregory A Mencio
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Craig R Louer
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
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Paulson AE, Martus JE, Mencio GA, Louer CR. Information exchange on adolescent scoliosis discussion forums among patients and caregivers: a thematic analysis. Spine Deform 2024; 12:293-303. [PMID: 38175498 DOI: 10.1007/s43390-023-00802-x] [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: 09/15/2023] [Accepted: 12/02/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Online health-related support groups have increasingly become a regular resource for patients and caregivers; however, the content of these forums is largely unknown to medical teams. The purposes of this study were to (1) review posts from scoliosis discussion forums to establish common themes related to the care experience of patients with scoliosis and (2) understand how common themes vary among pediatric and adult patients, as well as caregivers. METHODS Posts were collected from two public scoliosis forums. Analysis was performed using grounded theory-a methodology that relies on the repeated analyses of qualitative data to identify recurring concepts, which are then coded and grouped into categories and ultimately central themes that seek to synthesize the relationships between categories. Information posts were reviewed by a board-certified orthopedic surgeon who performs scoliosis surgery for factual basis or misinformation. RESULTS Analysis of 911 posts revealed five central themes. The two most common themes among patients ≥ 18 and caregivers involve seeking out emotional support and information about surgical treatment. Patients < 18 frequently sought out emotional support but were also largely interested in information about bracing. The most prevalent theme among all contributors involved seeking out emotional support. There was very little medical misinformation found within posts. CONCLUSION Scoliosis forums serve as an informal outlet where patients and families can offer emotional support and share experiences. Physicians should provide direct emotional support to patients and offer these forums as a resource, without significant concerns about propagating medical misinformation.
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Affiliation(s)
- Ambika E Paulson
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA.
| | - Jeffrey E Martus
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Gregory A Mencio
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Craig R Louer
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
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LaBarge ME, Waddell WH, Chanbour H, Stephens BF, Martus JE, Mencio GA, Louer CR. Flexibility-tilt agreement best predicts shoulder balance following posterior spine fusion for adolescent idiopathic scoliosis. Spine Deform 2024; 12:391-401. [PMID: 38123895 DOI: 10.1007/s43390-023-00797-5] [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: 04/20/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE We propose a novel concept, called flexibility-tilt agreement (FTA), which could be applied intra-operatively to improve shoulder balance following posterior spine fusion for Adolescent Idiopathic Scoliosis (AIS). We retrospectively applied this concept to a cohort with thoracic-only curves, seeking to: (1) evaluate the impact of FTA and other peri-operative variables on post-operative shoulder balance, and (2) evaluate deformity characteristics associated with achieving FTA. METHODS A single-institution registry was queried for patients undergoing PSF from 2000 to 2017 with main thoracic and double thoracic curves with at least 2-year follow-up. Flexibility was defined as the Cobb angle of the unfused proximal thoracic curve (cephalad to chosen UIV) on pre-operative bender. Tilt refers to post-operative UIV tilt angle. FTA means these values cancel (Flexibility + Tilt = 0 ± 5°). Logistic regression was performed to determine the association between peri-operative variables and shoulder balance. RESULTS One hundred and sixty-one patients were included, mean age 13.6 years old, and 47-month mean follow-up. FTA was achieved in 74 (46%) patients and was associated with post-operative (OR = 4.59) and final (OR = 6.98) medial shoulder balance with a threshold of 6° (AUC = 0.77, p = 0.038). FTA was the best predictor of shoulder balance of all tested variables. CONCLUSION Patients that showed flexibility-tilt agreement, or FTA, had vastly increased odds of medial and lateral shoulder balance at a minimum of 2-year follow-up for all thoracic curves. Future studies can evaluate whether applying FTA to determine intra-operative corrective maneuvers prospectively leads to improvements in shoulder balance. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
- Matthew E LaBarge
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - William H Waddell
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Hani Chanbour
- Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Byron F Stephens
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
- Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey E Martus
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Gregory A Mencio
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA
| | - Craig R Louer
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Suite 4202, Nashville, TN, 37232, USA.
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LaBarge ME, Chanbour H, Waddell WH, Vickery J, Jonzzon S, Roth SG, Croft AJ, Abtahi AM, Louer CR, Martus JE, Mencio GA, Zuckerman SL, Stephens BF. Clinical and radiographic outcomes following correction of idiopathic scoliosis in adolescence vs young adulthood. Spine Deform 2023; 11:1443-1451. [PMID: 37433979 DOI: 10.1007/s43390-023-00708-8] [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: 07/28/2022] [Accepted: 05/13/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE The natural history of adolescent idiopathic scoliosis (AIS) has been well documented, but the impact of age at the time of surgical correction is relatively understudied. In this study, we matched patients undergoing surgical correction of adult idiopathic scoliosis (AdIS) with a cohort of AIS patients to compare: (1) coronal and sagittal radiographic correction, (2) operative variables, and (3) postoperative complications. METHODS A single-institution scoliosis registry was queried for patients undergoing idiopathic scoliosis surgery from 2000-2017. INCLUSION CRITERIA patients with idiopathic scoliosis, no previous spine surgery, and 2-year follow-up. AdIS patients were matched 1:2 with AIS patients based on Lenke classification and curve characteristics. Independent sample t-test and Chi-square test was used to analyze the data. RESULTS 31 adults underwent surgical correction of idiopathic scoliosis and were matched with 62 adolescents. Mean age of adults was 26.2 ± 11.05, mean BMI was 25.6 ± 6.0, and 22 (71.0%) were female. Mean age of adolescents was 14.2 ± 1.8, mean BMI was 22.7 ± 5.7, and 41(66.7%) were female. AdIS had significantly less postoperative major Cobb correction (63.9% vs 71.3%, p = 0.006) and final major Cobb correction (60.6% vs 67.9%, p = 0.025). AdIS also had significantly greater postoperative T1PA (11.8 vs 5.8, p = 0.002). AdIS had longer operative times (p = 0.003), higher amounts of pRBCs transfused (p = 0.005), longer LOS (p = 0.016), more ICU requirement (p = 0.013), higher overall complications (p < 0.001), higher rate of pseudarthrosis (p = 0.026), and more neurologic complications (p = 0.013). CONCLUSION Adult patients undergoing surgical correction of idiopathic scoliosis had significantly worse postoperative coronal and sagittal alignment when compared with adolescent patients. Adult patients also had higher rates of complications, longer operative times, and longer hospital stays. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matthew E LaBarge
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William H Waddell
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Justin Vickery
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Soren Jonzzon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven G Roth
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew J Croft
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Craig R Louer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Gregory A Mencio
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Scott L Zuckerman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21St Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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LaBarge ME, Shirely Z, Rodgers J, Kuhn AW, Martus JE, Riccio AI. Dysplasia Epiphysealis Hemimelica in the Lower Extremity. J Pediatr Orthop 2023; 43:e481-e486. [PMID: 36998171 DOI: 10.1097/bpo.0000000000002406] [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: 04/01/2023]
Abstract
BACKGROUND Because of the rarity of dysplasia epiphysealis hemimelica (DEH), little is known about the relationship between disease classification and clinical symptoms or patient outcomes. This studies therefore aims to characterize DEH of the lower extremity and correlate radiographic classification to presenting symptomatology and need for surgical intervention. METHODS A multi-center, retrospective review of all patients with DEH of the lower extremity over a 47-year period was conducted. Demographic data, presenting complaints, treatments, and symptoms at final follow-up were recorded. Radiographs were reviewed to classify lesions using the Universal Classification System for Osteochondromas (UCSO) and document the presence of solitary or multiple lesions within the involved joint. Correlative statistics were used to determine whether presenting complaints, lesion location or radiographic classification predicted the need for surgery or a pain-free outcome. RESULTS Twenty-eight patients met inclusion criteria with an average age at presentation of 7.8 years. The ankle was the most commonly affected joint with 20/28 patients (71%) having lesions of the talus, distal tibia, or distal fibula. Patients with chief complaints of pain were more likely to undergo surgery than those with complaints of a mass or deformity ( P =0.03). Ankle lesions were more likely to be managed operatively than those of the hip or knee ( P =0.018) and all 12 patients with talar lesions underwent surgery. Neither the number of lesions nor lesion classification was predictive of surgical intervention or a pain-free outcome after surgery. Patients presenting with pain were more likely to have a pain-free outcome (11/14 patients) after surgery ( P =0.023) whereas all patients presenting with deformity who underwent surgery had pain at final follow-up. CONCLUSIONS Although no single radiographic characteristic of DEH was predictive of surgical intervention or outcome, painful lesions of the ankle, and lesions of the talus were more likely to be managed operatively. Although surgery does not always result in a pain-free outcome, the operative management of painful lesions was more likely to provide a pain-free outcome than surgery for deformity or a mass.
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Strouse PJ, Hilmes MA, Martus JE, Garver KA. Too close to home. . . Pediatr Radiol 2023; 53:825-826. [PMID: 37067566 DOI: 10.1007/s00247-023-05665-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Room 3-231, Michigan Medicine, University of Michigan, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4252, USA.
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Melissa A Hilmes
- Division of Pediatric Radiology, Vanderbilt Children's Hospital, Nashville, TN, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey E Martus
- Division of Pediatric Orthopaedics, Vanderbilt Children's Hospital, Nashville, TN, USA
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly A Garver
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Allen JH, Yengo-Kahn AM, Cools MJ, Greeno A, Ghani MOA, Unni P, Martus JE, Lovvorn HN, Bonfield CM. Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019. J Neurosurg Pediatr 2022; 30:386-393. [PMID: 35962971 DOI: 10.3171/2022.7.peds22178] [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: 05/07/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. METHODS Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. RESULTS Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). CONCLUSIONS Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.
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Affiliation(s)
| | | | | | - Amber Greeno
- 3Pediatric Surgery, Vanderbilt University Medical Center; and
| | | | - Purnima Unni
- 3Pediatric Surgery, Vanderbilt University Medical Center; and
| | - Jeffrey E Martus
- 4Department of Orthopedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
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Kuhn AW, Troyer SC, Martus JE. Pediatric Open Long-Bone Fracture and Subsequent Deep Infection Risk: The Importance of Early Hospital Care. Children (Basel) 2022; 9:1243. [PMID: 36010133 PMCID: PMC9406608 DOI: 10.3390/children9081243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 06/15/2023]
Abstract
The purpose of the current study was to identify risk factors for deep infection after an open long-bone fracture in pediatric patients. Systematic billing queries were utilized to identify pediatric patients who presented to a level I trauma center from 1998 to 2019 with open long-bone fractures. There were 303 open long-bone fractures, and 24 (7.9%) of these became infected. Fractures of the tibia/fibula (p = 0.022), higher revised Gustilo-Anderson type (p = 0.017), and a longer duration of time between the injury and hospital presentation (p = 0.008) were all associated with the presence of deep infection. Those who went on to have a deep infection also required more operative debridements (p = 0.022) and a total number of operative procedures (p = 0.026). The only factor that remained significant in multivariable regression was the duration between the injury and hospital presentation (OR 1.01 [95%CI 1.003-1.017]; p = 0.009), where the odds of deep infection increased by 1% for every minute of delayed presentation.
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Affiliation(s)
- Andrew W. Kuhn
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO 63108, USA
| | - Stockton C. Troyer
- Washington University School of Medicine in St. Louis, St. Louis, MO 63108, USA
| | - Jeffrey E. Martus
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Gibson BHY, Duvernay MT, McKeithan LJ, Benvenuti TA, Warhoover TA, Martus JE, Mencio GA, Emerson BR, Moore-Lotridge SN, Borst AJ, Schoenecker JG. Variable Response to Antifibrinolytics Correlates with Blood-loss and Transfusion in Posterior Spinal Fusion. Spine Deform 2022; 10:841-851. [PMID: 35247191 PMCID: PMC9891390 DOI: 10.1007/s43390-022-00489-6] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 02/19/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE Posterior spinal fusion (PSF) activates the fibrinolytic protease plasmin, which is implicated in blood loss and transfusion. While antifibrinolytic drugs have improved blood loss and reduced transfusion, variable blood loss has been observed in similar PSF procedures treated with the same dose of antifibrinolytics. However, both the cause of this and the appropriate measures to determine antifibrinolytic efficacy during high-blood-loss spine surgery are unknown, making clinical trials to optimize antifibrinolytic dosing in PSF difficult. We hypothesized that patients undergoing PSF respond differently to antifibrinolytic dosing, resulting in variable blood loss, and that specific diagnostic markers of plasmin activity will accurately measure the efficacy of antifibrinolytics in PSF. METHODS A prospective study of 17 patients undergoing elective PSF with the same dosing regimen of TXA was conducted. Surgery-induced plasmin activity was exhaustively analyzed in perioperative blood samples and correlated to measures of inflammation, bleeding, and transfusion. RESULTS While markers of in vivo plasmin activation (PAP and D-dimer) suggested significant breakthrough plasmin activation and fibrinolysis (P < 0.01), in vitro plasmin assays, including TEG, did not detect plasmin activation. In vivo measures of breakthrough plasmin activation correlated with blood loss (R2 = 0.400, 0.264; P < 0.01), transfusions (R2 = 0.388; P < 0.01), and complement activation (R2 = 0.346, P < 0.05). CONCLUSIONS Despite all patients receiving a high dose of TXA, its efficacy among patients was variable, indicated by notable intra-operative plasmin activity. Markers of in vivo plasmin activation best correlated with clinical outcomes. These findings suggest that the efficacy of antifibrinolytic therapy to inhibit plasmin in PSF surgery should be determined by markers of in vivo plasmin activation in future studies. LEVEL OF EVIDENCE Level II-diagnostic.
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Affiliation(s)
| | - Matthew T Duvernay
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Teresa A Benvenuti
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tracy A Warhoover
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey E Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA
| | - Gregory A Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA
| | - Brian R Emerson
- Department of Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandra J Borst
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan G Schoenecker
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA.
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA.
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Rees AB, Schultz JD, Wollenman LC, Moore-Lotridge SN, Martus JE, Schoenecker JG, Mencio GA. A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought. J Bone Joint Surg Am 2022; 104:33-40. [PMID: 34673662 DOI: 10.2106/jbjs.21.00301] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning. METHODS Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded. RESULTS In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks. CONCLUSIONS The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew B Rees
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Jacob D Schultz
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Stephanie N Moore-Lotridge
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory A Mencio
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
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Schultz JD, Rees AB, Wollenman LC, McKeithan LJ, Tadepalli VR, Wessinger BC, Attipoe G, Gay JC, Martus JE, Moore-Lotridge SN, Schoenecker JG. Factors That Drive Annual Variation in Pediatric Elbow Fracture Occurrence, Severity, and Resource Utilization. J Pediatr Orthop 2021; 41:e755-e762. [PMID: 34325445 DOI: 10.1097/bpo.0000000000001915] [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: 02/07/2023]
Abstract
BACKGROUND Elbow fractures are the most common pediatric fractures requiring operative treatment. To date, few studies have examined what annual factors drive pediatric elbow fracture incidence and no studies have examined which annual factors drive elbow fracture severity or resource utilization. The goal of this study was to not only document the annual patterns of pediatric elbow fracture incidence and severity but also the impact of these patterns on resource utilization in the emergency department, emergency medical service transportation, and the operating room (OR). METHODS Retrospective cohort study of 4414 pediatric elbow fractures from a single tertiary hospital (2007 to 2017). Exclusion criteria included outside treatment or lack of diagnosis by an orthopaedist. Presentation information, injury patterns, transport, and treatment requirements were collected. Pearson correlations were used to analyze factors influencing fracture incidence, severity, and resource utilization. RESULTS Pediatric elbow fracture incidence positively correlated with monthly daylight hours, but significantly fewer elbow fractures occurred during summer vacation from school compared with surrounding in school months. While fewer overall fractures occurred during summer break, the fractures sustained were greater in severity, conferring higher rates of displacement, higher risk of neurovascular injury, and greater needs for emergency transportation and operative treatment. Yearly, elbow fractures required 320.6 OR hours (7.7% of all pediatric orthopaedic OR time and 12.3% of all pediatric orthopaedic operative procedures), 203.4 hospital admissions, and a total of 4753.7 miles traveled by emergency medical service transportation to manage. All-cause emergency department visits were negatively correlated with daylight hours, inversing the pattern seen in elbow fractures. CONCLUSION Increased daylight, while school was in session, was a major driver of the incidence of pediatric elbow fractures. While summer vacation conferred fewer fractures, these were of higher severity. As such, increased daylight correlated strongly with monthly resource utilization, including the need for emergency transportation and operative treatment. This study provides objective data by which providers and administrators can more accurately allocate resources. LEVEL OF EVIDENCE Level III-Retrospective comparative study.
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Affiliation(s)
| | | | | | | | | | | | - Graham Attipoe
- Vanderbilt University School of Medicine
- The Wharton School at the University of Pennsylvania, Philadelphia, PA
| | | | - Jeffrey E Martus
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
- Department of Orthopaedics, Vanderbilt University Medical Center
- Pediatrics
| | - Stephanie N Moore-Lotridge
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
- Department of Orthopaedics, Vanderbilt University Medical Center
- Center for Bone Biology, Nashville, TN
| | - Jonathan G Schoenecker
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
- Department of Orthopaedics, Vanderbilt University Medical Center
- Departments of Pharmacology
- Pediatrics
- Pathology, Microbiology, and Immunology
- Center for Bone Biology, Nashville, TN
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12
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Rees AB, Schultz JD, Wollenman LC, Moore-Lotridge SN, Martus JE, Mencio GA, Schoenecker JG. Internal Rotation Stress Test Reduces Cross-Pinning and Improves Outcomes in Displaced Pediatric Supracondylar Humeral Fractures. JB JS Open Access 2021; 6:JBJSOA-D-21-00014. [PMID: 34337285 PMCID: PMC8318649 DOI: 10.2106/jbjs.oa.21.00014] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Stabilization of the medial column is vital in preventing the loss of fixation and malunion in displaced pediatric supracondylar humeral fractures (SCHFs). The preferred percutaneous pin configuration for medial column fixation remains controversial between medial pinning (cross-pinning) and additional lateral-based pinning. The intraoperative internal rotation stress test (IRST) has been proposed to reliably determine the optimal fixation strategy for each unique fracture. This study evaluated the impact of implementing the IRST on both the choice of pin configuration and institution-wide complications in pediatric patients treated operatively for SCHFs. Methods Pediatric patients undergoing percutaneous pinning for SCHFs between 2007 and 2017 at a single center were retrospectively reviewed. The IRST was made a universal institutional practice in 2013. Patients were divided into 2 groups for analysis: (1) patients who underwent treatment before the IRST was implemented in 2013 (the pre-IRST group), and (2) patients who were treated after the IRST was implemented in 2013 (the IRST group). Subgroup analysis was completed for patients in the IRST group who were treated with cross-pinning or 3 lateral-based pins. Results In this study, 820 patients in the pre-IRST group and 636 patients in the IRST group were included. After the IRST implementation, the rate of loss of fixation fell from 1.2% to 0% (p = 0.003), and the reoperation rate fell from 3.3% to 0.2% (p < 0.001). No cases resulted in a loss of fixation after the adoption of the IRST. The number of patients treated with cross-pinning decreased significantly from 53.2% to 31.6% (p < 0.001) after the IRST implementation, yet cross-pinning continued to be used for more severe fractures. Complication rates within the IRST group were not significantly different (p > 0.05) between cross-pinning and 3 lateral-based pins. Conclusions In the largest cohort reported on to date, to our knowledge, institutional implementation of the IRST resulted in a significant reduction in the use of cross-pinning. Although the usage of cross-pinning decreased, cross-pinning was still used frequently in the most severe fractures. The IRST use also resulted in significantly fewer complications such as loss of fixation after institution-wide implementation of the IRST for treating pediatric SCHFs. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew B Rees
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Jacob D Schultz
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Stephanie N Moore-Lotridge
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory A Mencio
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Saarinen AJ, Bauer JM, Verhofste B, Sponseller PD, Krengel WF, Hedequist D, Cahill PJ, Larson AN, Pahys JM, Martus JE, Yaszay B, Phillips JH, Helenius IJ. Results of Conservative and Surgical Management in Children with Idiopathic and Nonidiopathic Os Odontoideum. World Neurosurg 2020; 147:e324-e333. [PMID: 33333287 DOI: 10.1016/j.wneu.2020.12.043] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The outcomes of conservative and operative treatment of os odontoideum in children remain unclear. Our objective was to study the outcomes of conservative and surgical treatment of idiopathic os odontoideum in children and compare these outcomes in age- and treatment-matched nonidiopathic children with os odontoideum. METHODS A retrospective multicenter review identified 102 children with os odontoideum, of whom 44 were idiopathic with minimum 2-year follow-up. Ten patients were treated conservatively, and 34 underwent spinal arthrodesis. Both groups were matched with nonidiopathic patients by age and type of treatment. Cervical arthrodesis was recommended for patients with increased atlantoaxial distance or reduced space available for the cord in flexion-extension radiographs. RESULTS All 20 children undergoing conservative treatment remained asymptomatic during follow-up, but 1 nonidiopathic patient developed cervical instability. The idiopathic group had significantly less severe radiographic cervical instability and less neurologic complications than the nonidiopathic group (P < 0.05 for all comparisons). Thirty-three (97%) patients in the idiopathic group and 32 (94%) patients in the nonidiopathic group (94%) had spinal fusion at final follow-up (P = 0.55). The risk of complications (15% vs. 41%; odds ratio 0.234, 95% confidence interval 0.072-0.757, P = 0.015) and nonunion (6% vs. 24%; odds ratio 0.203, 95% confidence interval 0.040-0.99, P = 0.040) were significantly lower in the idiopathic than in the nonidiopathic group. Idiopathic children undergoing rigid fixation achieved spinal fusion. CONCLUSIONS Idiopathic patients with stable atlantoaxial joint at presentation remained asymptomatic and intact during conservative treatment. Idiopathic children with os odontoideum undergoing spinal arthrodesis had significantly fewer complications and nonunion than nonidiopathic children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Antti J Saarinen
- Department of Paediatric Orthopaedic Surgery, Turku University Hospital, Turku, Finland; Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, Finland.
| | - Jennifer M Bauer
- Department of Orthopedics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Bram Verhofste
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Walter F Krengel
- Department of Orthopedics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Patrick J Cahill
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua M Pahys
- Department of Orthopaedic Surgery, Shiners Hospitals for Children, Philadelphia, Pennsylvania, USA
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt Children's Hospital, Nashville, Tennessee, USA
| | - Burt Yaszay
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Jonathan H Phillips
- Department of Pediatric Orthopedics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Ilkka J Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, Finland
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14
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Evans PT, Pennings JS, Samade R, Lovvorn HN, Martus JE. The financial burden of musculoskeletal firearm injuries in children with and without concomitant intra-cavitary injuries. J Pediatr Surg 2020; 55:1754-1760. [PMID: 31704045 DOI: 10.1016/j.jpedsurg.2019.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 06/18/2019] [Revised: 09/15/2019] [Accepted: 09/18/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Musculoskeletal pediatric firearm injuries are a clinically significant and expensive public health problem in the United States. In this retrospective cohort analysis, we sought to characterize musculoskeletal firearm injuries in children and to describe the financial burden associated with these injuries. METHODS This study is a single center, retrospective review. Patients were identified from January 2002 - December 2015 from an institutional database using ICD-9 codes pertaining to firearm injury. Inclusion criteria were: 1) age < 18 years at injury; 2) firearm injury to an extremity, spine, or pelvis; and 3) patient received orthopedic evaluation and/or treatment. 140 patients with 142 distinct orthopedic injuries meeting inclusion criteria were analyzed (N = 142). Primary measures were demographic and situational data including intent, length of stay, follow-up, and complications; and financial outcomes including charges, costs, and net revenues. RESULTS Median age was 15.3 years [IQR: 13.3, 16.4], 84% were male, and 52% were African American. 59% of the firearm injuries were of violent intent. 32% of patients were privately insured, 61% were publicly insured, and 6% were uninsured. Median length of stay was 2 days [0, 4], with 73% of patients being admitted. 43% of patients required additional hospitalizations, emergency room visits, and/or outpatient surgeries, and 93% of patients had outpatient follow-up. 42% of patients experience an injury-related or long-term orthopedic complication. Total charges for the cohort were $11.4 million, with $3.7 million in costs and $45,042 in net revenues. In the multivariable analysis, more surgeries predicted higher charges, and more secondary encounters predicted higher costs and net revenues. Only privately-insured patients had a positive median net revenue. CONCLUSIONS Children who sustain musculoskeletal injuries from firearms experience high rates of orthopedic complications. Institutional costs to manage these preventable injuries are excessive. Policy makers should continue to pursue measures to reduce gun violence and improve gun safety in the pediatric population. LEVEL OF EVIDENCE Level III, economic/decision.
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Affiliation(s)
- Parker T Evans
- Vanderbilt University Medical Center, Department of Surgery, Nashville, TN.
| | - Jacquelyn S Pennings
- Vanderbilt University Medical Center, Department of Orthopedic Surgery, Nashville, TN
| | - Richard Samade
- The Ohio State University, Department of Orthopedic Surgery, Columbus, OH
| | - Harold N Lovvorn
- Vanderbilt University Medical Center, Department of Pediatric Surgery, Nashville, TN
| | - Jeffrey E Martus
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Division of Pediatric Orthopedics, Nashville, TN
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15
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Daniel B, Wanner JP, Emerson B, Martus JE. Anaphylaxis secondary to albumin infusion during posterior spinal fusion for pediatric scoliosis. Spine Deform 2020; 8:327-331. [PMID: 32030641 DOI: 10.1007/s43390-020-00027-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/19/2019] [Accepted: 07/28/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Case report. OBJECTIVES To describe intraoperative administration of albumin as a cause of immunoglobulin E (IgE)-mediated anaphylaxis and cardiac arrest in an adolescent with adolescent idiopathic scoliosis. BACKGROUND Albumin is considered the reference intraoperative colloidal solution, and is used commonly as a volume expander for treating hypovolemia. Albumin rarely causes an anaphylactic reaction, with a documented rate of only 0.099%. METHOD An adolescent with scoliosis experienced acute, intraoperative hypotension during exposure for planned T5-L4 posterior spinal fusion shortly after infusion of albumin. She was treated rapidly and successfully with CPR and epinephrine. RESULTS Intraoperative transesophageal echocardiogram, chest radiograph, and serum histamine, serum tryptase, and urine N-methyl-histamine laboratory tests confirmed albumin anaphylaxis to be the etiology of the intraoperative event. Further postoperative complications were avoided as a result of the rapid diagnosis and treatment. CONCLUSIONS Although rare, IgE-mediated anaphylaxis to albumin, if administered, must be considered a possible cause of acute, intraoperative hypotension. Rapid management of anaphylaxis with communication between the surgeon, anesthesia team, and operative staff are essential if additional complications are to be avoided.
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Affiliation(s)
- Benjamin Daniel
- School of Medicine, Medical College of Georgia, 1120 15th St, Augusta, GA, 30912, USA
| | - J P Wanner
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Brian Emerson
- Division of Pediatric Anesthesiology, Vanderbilt Children's Hospital, 2200 Children's Way, Nashville, TN, 37232, USA
| | - Jeffrey E Martus
- Division of Pediatric Orthopaedics, Vanderbilt Children's Hospital, 2200 Children's Way, Nashville, TN, 37232, USA.
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16
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Hysong AA, Posey SL, Blum DM, Benvenuti MA, Benvenuti TA, Johnson SR, An TJ, Devin JK, Obremskey WT, Martus JE, Moore-Lotridge SN, Schoenecker JG. Necrotizing Fasciitis: Pillaging the Acute Phase Response. J Bone Joint Surg Am 2020; 102:526-537. [PMID: 31977818 PMCID: PMC8590823 DOI: 10.2106/jbjs.19.00591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Samuel L Posey
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Deke M Blum
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Michael A Benvenuti
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Teresa A Benvenuti
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel R Johnson
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas J An
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica K Devin
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - William T Obremskey
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
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17
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Helenius IJ, Bauer JM, Verhofste B, Sponseller PD, Krengel WF, Hedequist D, Cahill PJ, Larson AN, Pahys JM, Anderson JT, Martus JE, Yaszay B, Phillips JH. Os Odontoideum in Children: Treatment Outcomes and Neurological Risk Factors. J Bone Joint Surg Am 2019; 101:1750-1760. [PMID: 31577680 DOI: 10.2106/jbjs.19.00314] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment outcomes and risk factors for neurological deficits in pediatric patients with an os odontoideum are unclear. METHODS We reviewed the data for 102 children with os odontoideum who were managed at 11 centers between 2000 and 2016 and had a minimum duration of follow-up of 2 years. Thirty-one children had nonoperative treatment, and 71 underwent instrumented posterior cervical spinal arthrodesis for the treatment of C1-C2 instability. Nonoperative treatment consisted of observation (n = 29) or immobilization with a cervical collar (n = 1) or halo body jacket (n = 1). Surgical treatment consisted of atlantoaxial (n = 50) or occipitocervical (n = 21) arthrodesis. One patient also underwent transoral odontoidectomy. RESULTS Thirty children (29%) presented with neurological deficits, 28 of whom had radiographic atlantoaxial instability (atlantoaxial distance >5 mm) or limited space (≤13 mm) available for the spinal cord (risk ratio, 7.8 [95% confidence interval, 2.0 to 31] compared with children with no radiographic risk factors). The 27 children without neurological deficits or atlantoaxial instability at presentation underwent nonoperative treatment and remained asymptomatic. Of the initial nonoperative cohort, one child developed atlantoaxial instability, and another had a persistent neurological deficit; both children underwent spinal arthrodesis during the study period. One child with cervical instability declined surgery and remained asymptomatic. Spinal fusion occurred in 68 patients in the surgical group by the end of the study period (mean, 3.7 years; range, 2.0 to 11.8 years). Surgical complications occurred in 21 children, including nonunion in 12, new neurological deficits in 4, cerebrospinal fluid leak in 2, symptomatic instrumentation requiring removal 2, and vertebral artery injury in 1. Nine children underwent revision surgery. In the surgical group, Japanese Orthopaedic Association neurological function scores improved significantly from preoperatively to the latest follow-up for the upper extremities (p = 0.026) and lower extremities (p = 0.007). CONCLUSIONS The risk of developing a neurological deficit was strongly associated with atlantoaxial instability and limited space available for the spinal cord in children with os odontoideum. Nonoperative treatment was safe for asymptomatic patients without atlantoaxial instability. Spinal arthrodesis resolved the neurological deficits of children with symptomatic os odontoideum. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ilkka J Helenius
- Department of Paediatric Orthopaedic Surgery, Turku University Hospital, Turku, Finland
| | - Jennifer M Bauer
- Department of Orthopedics, Seattle Children's Hospital, Seattle, Washington
| | - Bram Verhofste
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Walter F Krengel
- Department of Orthopedics, Seattle Children's Hospital, Seattle, Washington
| | - Daniel Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Patrick J Cahill
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joshua M Pahys
- Department of Orthopaedic Surgery, Shiners Hospitals for Children, Philadelphia, Pennsylvania
| | - John T Anderson
- Department of Orthopaedic Surgery, Children's Mercy, Kansas City, Missouri
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt Children's Hospital, Nashville, Tennessee
| | - Burt Yaszay
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California
| | - Jonathan H Phillips
- Department of Pediatric Orthopedics, Arnold Palmer Hospital for Children, Orlando, Florida
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18
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Reynolds BB, By S, Weinberg QR, Witt AA, Newton AT, Feiler HR, Ramkorun B, Clayton DB, Couture P, Martus JE, Adams M, Wellons JC, Smith SA, Bhatia A. Quantification of DTI in the Pediatric Spinal Cord: Application to Clinical Evaluation in a Healthy Patient Population. AJNR Am J Neuroradiol 2019; 40:1236-1241. [PMID: 31196859 PMCID: PMC7048550 DOI: 10.3174/ajnr.a6104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of the study is to characterize diffusion tensor imaging indices in the developing spinal cord, evaluating differences based on age and cord region. Describing the progression of DTI indices in the pediatric cord increases our understanding of spinal cord development. MATERIALS AND METHODS A retrospective analysis was performed on DTI acquired in 121 pediatric patients (mean, 8.6 years; range, 0.3-18.0 years) at Monroe Carell Jr. Children's Hospital at Vanderbilt from 2017 to 2018. Diffusion-weighted images (15 directions; b = 750 s/mm2; slice thickness, 5 mm; in-plane resolution, 1.0 × 1.0 mm2) were acquired on a 3T scanner in the cervicothoracic and/or thoracolumbar cord. Manual whole-cord segmentation was performed. Images were masked and further segmented into cervical, upper thoracic, thoracolumbar, and conus regions. Analyses of covariance were performed for each DTI-derived index to investigate how age affects diffusion across cord regions, and 95% confidence intervals were calculated across age for each derived index and region. Post hoc testing was performed to analyze regional differences. RESULTS Analyses of covariance revealed significant correlations of age with axial diffusivity, mean diffusivity, and fractional anisotropy (all, P < .001). There were also significant differences among cord regions for axial diffusivity, radial diffusivity, mean diffusivity, and fractional anisotropy (all, P < .001). CONCLUSIONS This research demonstrates that diffusion evolves in the pediatric spinal cord during development, dependent on both cord region and the diffusion index of interest. Future research could investigate how diffusion may be affected by common pediatric spinal pathologies.
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Affiliation(s)
- B B Reynolds
- Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | - S By
- Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | - Q R Weinberg
- Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | - A A Witt
- Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | - A T Newton
- From the Department of Radiology and Radiological Sciences (A.T.N., P.C., S.A.S., A.B.).,Pediatrics (A.T.N.).,Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | - H R Feiler
- Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | - B Ramkorun
- Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
| | | | - P Couture
- From the Department of Radiology and Radiological Sciences (A.T.N., P.C., S.A.S., A.B.)
| | - J E Martus
- Division of Pediatric Orthopaedics (J.E.M.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | | - J C Wellons
- From the Department of Radiology and Radiological Sciences (A.T.N., P.C., S.A.S., A.B.).,Department of Ophthalmology (S.A.S., J.C.W. III), Vanderbilt University Medical Center, Nashville, Tennessee
| | - S A Smith
- From the Department of Radiology and Radiological Sciences (A.T.N., P.C., S.A.S., A.B.).,Department of Biomedical Engineering (S.A.S.).,Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee.,Department of Ophthalmology (S.A.S., J.C.W. III), Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Bhatia
- From the Department of Radiology and Radiological Sciences (A.T.N., P.C., S.A.S., A.B.) .,Institute of Imaging Science (B.B.R., S.B., Q.R.W., A.A.W., A.T.N., H.R.F., B.R., S.A.S., A.B.), Vanderbilt University, Nashville, Tennessee
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19
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Benvenuti MA, An TJ, Mignemi ME, Martus JE, Mencio GA, Lovejoy SA, Schoenecker JG, Williams DJ. A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity. J Pediatr Orthop 2019; 39:153-157. [PMID: 30730420 PMCID: PMC5368021 DOI: 10.1097/bpo.0000000000000880] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE There are currently no algorithms for early stratification of pediatric musculoskeletal infection (MSKI) severity that are applicable to all types of tissue involvement. In this study, the authors sought to develop a clinical prediction algorithm that accurately stratifies infection severity based on clinical and laboratory data at presentation to the emergency department. METHODS An IRB-approved retrospective review was conducted to identify patients aged 0 to 18 who presented to the pediatric emergency department at a tertiary care children's hospital with concern for acute MSKI over a 5-year period (2008 to 2013). Qualifying records were reviewed to obtain clinical and laboratory data and to classify in-hospital outcomes using a 3-tiered severity stratification system. Ordinal regression was used to estimate risk for each outcome. Candidate predictors included age, temperature, respiratory rate, heart rate, C-reactive protein (CRP), and peripheral white blood cell count. We fit fully specified (all predictors) and reduced models (retaining predictors with a P-value ≤0.2). Discriminatory power of the models was assessed using the concordance (c)-index. RESULTS Of the 273 identified children, 191 (70%) met inclusion criteria. Median age was 5.8 years. Outcomes included 47 (25%) children with inflammation only, 41 (21%) with local infection, and 103 (54%) with disseminated infection. Both the full and reduced models accurately demonstrated excellent performance (full model c-index 0.83; 95% confidence interval, 0.79-0.88; reduced model 0.83; 95% confidence interval, 0.78-0.87). Model fit was also similar, indicating preference for the reduced model. Variables in this model included CRP, pulse, temperature, and an interaction term for pulse and temperature. The odds of a more severe outcome increased by 30% for every 10 U increase in CRP. CONCLUSIONS Clinical and laboratory data obtained in the emergency department may be used to accurately differentiate pediatric MSKI severity. The predictive algorithm in this study stratifies pediatric MSKI severity at presentation irrespective of tissue involvement and anatomic diagnosis. Prospective studies are needed to validate model performance and clinical utility. LEVEL OF EVIDENCE Level II-prognostic study.
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Affiliation(s)
| | | | - Megan E Mignemi
- Department of Orthopaedics, Division of Pediatric Orthopedics
| | | | | | | | - Jonathan G Schoenecker
- Department of Orthopaedics, Division of Pediatric Orthopedics
- Department of Pharmacology
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
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20
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Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, Mody KS, Leonard JC, Moront M, Brockmeyer DL, Anderson RCE, Alder AC, Anderson JT, Bernstein RM, Booth TN, Braga BP, Cahill PJ, Joglar JM, Martus JE, Nesiama JAO, Pahys JM, Rathjen KE, Riccio AI, Schulz JF, Stans AA, Shah MI, Warner WC, Yaszay B. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am 2019; 101:e1. [PMID: 30601421 DOI: 10.2106/jbjs.18.00217] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Martin J Herman
- Orthopedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Kristin O Brown
- Orthopedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | | | - Philip M Petrucelli
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Darshan J Parikh
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Kush S Mody
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew Moront
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Douglas L Brockmeyer
- Department of Neurological Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Richard C E Anderson
- Department of Neurosurgery, Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Adam C Alder
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - John T Anderson
- Department of Orthopedic Surgery, Children's Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Robert M Bernstein
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Timothy N Booth
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Bruno P Braga
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Patrick J Cahill
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeanne M Joglar
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Jeffrey E Martus
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jo-Ann O Nesiama
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Joshua M Pahys
- Shriners Hospitals for Children, Philadelphia, Pennsylvania
| | - Karl E Rathjen
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Anthony I Riccio
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Jacob F Schulz
- Department of Orthopedic Surgery, The Children's Hospital at Montefiore, Bronx, New York
| | - Anthony A Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Manish I Shah
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - William C Warner
- Department of Orthopedic Surgery, University of Tennessee - Campbell Clinic and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital and University of California-San Diego Medical Center, San Diego, California
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21
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Amaro E, Marvi TK, Posey SL, Benvenuti MA, An TJ, Dale KM, Lovejoy SA, Martus JE, Johnson ME, Mencio GA, Moore-Lotridge SN, Thomsen IP, Schoenecker JG. C-Reactive Protein Predicts Risk of Venous Thromboembolism in Pediatric Musculoskeletal Infection. J Pediatr Orthop 2019; 39:e62-e67. [PMID: 30300275 DOI: 10.1097/bpo.0000000000001256] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The rate of venous thromboembolism in children with musculoskeletal infections (MSKIs) is markedly elevated compared with hospitalized children in general. Predictive biomarkers to identify high-risk patients are needed to prevent the significant morbidity and rare mortality associated with thrombotic complications. We hypothesize that overactivation of the acute phase response is associated with the development of pathologic thrombi and we aim to determine whether elevations in C-reactive protein (CRP) are associated with increased rates of thrombosis in pediatric patients with MSKI. METHODS A retrospective cohort study measuring CRP in pediatric MSKI patients with or without thrombotic complications. RESULTS The magnitude and duration of elevation in CRP values correlated with the severity of infection and the development of pathologic thrombosis. In multivariable logistic regression, every 20 mg/L increase in peak CRP was associated with a 29% increased risk of thrombosis (P<0.001). Peak and total CRP were strong predictors of thrombosis with area under the receiver-operator curves of 0.90 and 0.92, respectively. CONCLUSIONS Future prospective studies are warranted to further define the discriminatory power of CRP in predicting infection-provoked thrombosis. Pharmacologic prophylaxis and increased surveillance should be strongly considered in patients with MSKI, particularly those with disseminated disease and marked elevation of CRP. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephanie N Moore-Lotridge
- Departments of Orthopaedics and Rehabilitation.,Department of Pharmacology, Vanderbilt University, Nashville, TN
| | - Isaac P Thomsen
- Pediatrics.,Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan G Schoenecker
- Departments of Orthopaedics and Rehabilitation.,Pediatrics.,Department of Pharmacology, Vanderbilt University, Nashville, TN.,Pathology Microbiology and Immunology
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22
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Baker CE, Marvi T, Austin TM, Payne S, Mignemi ME, Gailani D, Wheeler AP, Nguyen TT, Lovejoy SA, Martus JE, Mencio GA, Schoenecker JG. Dilutional coagulopathy in pediatric scoliosis surgery: A single center report. Paediatr Anaesth 2018; 28:974-981. [PMID: 30295357 DOI: 10.1111/pan.13488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 08/23/2017] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Children undergoing posterior spinal fusion experience high blood loss often necessitating transfusion. An appropriately activated coagulation system provides hemostasis during surgery, but pathologic dysregulation can cause progressive bleeding and increased transfusions. Despite receiving antifibrinolytics for clot stabilization, many patients still require transfusions. AIMS We sought to examine the association of dilutional coagulopathy with blood loss and blood transfusion in posterior spinal fusion for pediatric scoliosis patients. METHODS A retrospective, single institution study of children undergoing posterior spinal fusion >6 levels with a standardized, prospective anesthetic protocol utilizing antifibrinolytics. Blood loss was evaluated using a hematocrit-based calculation. To evaluate transfusions, a normalized Blood Product Transfusion calculation was developed. Factors associated with blood loss and blood transfusions were determined by univariate analysis and multivariate regression modeling with multicollinearity and mediation analysis. RESULTS Patients received 73.7 mL/kg (standard deviation ±30.8) of fluid poor in coagulation factors. Estimated blood loss was 42.6 mL/kg (standard deviation ±18.0). There was a significant association between estimated blood loss and total fluids delivered (Spearman's rho = 0.51, 95% confidence interval 0.33-0.65, P < 0.001). Factors significantly associated with normalized Blood Product Transfusion in this cohort included age, weight, scoliosis type, levels fused, total osteotomies, pelvic fixation, total fluid, maximum prothrombin time, and minimum fibrinogen. Regression modeling showed the best combination of variables for modeling normalized Blood Product Transfusion included patient weight, number of levels fused, total fluid administered, and maximum prothrombin time. CONCLUSION Blood product transfusion remains a frustrating problem in pediatric scoliosis. Identifying and controlling dilutional coagulopathy in these patients may reduce blood loss and the need for blood transfusion.
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Affiliation(s)
- Courtney E Baker
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tanya Marvi
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas M Austin
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Shelby Payne
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megan E Mignemi
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thanh T Nguyen
- University of Colorado School of Medicine, Aurora, Colorado
| | - Steven A Lovejoy
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory A Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
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23
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Kelly DM, VanderHave K, Martus JE. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2018; 100:348-354. [PMID: 29462042 DOI: 10.2106/jbjs.17.01139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Kelly VanderHave
- Carolinas HealthCare System and Levine Children's Hospital, Charlotte, North Carolina
| | - Jeffrey E Martus
- Vanderbilt Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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24
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Hale AT, Alvarado A, Bey AK, Pruthi S, Mencio GA, Bonfield CM, Martus JE, Naftel RP. X-ray vs. CT in identifying significant C-spine injuries in the pediatric population. Childs Nerv Syst 2017; 33:1977-1983. [PMID: 28656384 DOI: 10.1007/s00381-017-3448-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 12/28/2016] [Accepted: 05/01/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Evaluation of cervical spine injury (CSI) in children requires rapid, yet accurate assessment of damage. Given concerns of radiation exposure, expert consensus advises that computed tomography (CT) should be used sparingly. However, CT can provide superior image resolution and detection of pathology. Herein, we evaluate if X-ray offers equal diagnostic accuracy compared to CT imaging in identifying CSI in children. METHODS We conducted a retrospective study between October 2000 and March 2012 of pediatric patients evaluated for cervical spine injury at a level 1 trauma center. All patients included in this study were imaged with cervical spine X-rays and CT at the time of injury. Demographic information, mechanism of injury, significant versus non-significant injury (as defined by the NEXUS criteria), radiographic findings, level of the injury, presence of spinal cord injury, treatment, clinical outcome, and length of follow-up were collected. Chi-squared (χ 2) and Fisher's exact tests were used as appropriate and means and standard deviations were reported. RESULTS We identified 1296 patients who were screened for CSI. Of those, 164 patients were diagnosed with spinal cord/column injuries (CSI). Eighty-nine patients were excluded for only having a CT or X-ray imaging without the other modality. Thus, a total of 75 patients with CSI were included in the final cohort. Using the NEXUS definitions, 78% of patients had clinically significant injuries while 22% had non-significant injuries. There were no injuries detected on X-ray that were not also detected on CT. For all injuries, X-ray sensitivity was 50.7%. X-rays were more sensitive to significant injuries (62.3%) compared in non-significant injuries, which were missed on all X-rays (0%). Therefore, X-rays did not identify 24 significant cervical spine injuries (32%) as defined by NEXUS. CONCLUSIONS CT is superior to X-rays in detecting both clinically significant and insignificant cervical spine injuries. These results were not dependent on patient age or location of the injury. We recommend CT imaging in the evaluation of suspected cervical spine injuries in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Andrew T Hale
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.
| | - Abraham Alvarado
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Amita K Bey
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Sumit Pruthi
- Department of Radiology, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Gregory A Mencio
- Division of Orthopedic Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Christopher M Bonfield
- Division of Neurological Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Jeffrey E Martus
- Division of Orthopedic Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Neurological Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
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25
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Chan EW, Gannon SR, Shannon CN, Martus JE, Mencio GA, Bonfield CM. The impact of curve severity on obstetric complications and regional anesthesia utilization in pregnant patients with adolescent idiopathic scoliosis: a preliminary analysis. Neurosurg Focus 2017; 43:E4. [DOI: 10.3171/2017.7.focus17321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAdolescent idiopathic scoliosis (AIS), the most common type of scoliosis, often presents immediately prior to a woman’s childbearing years; however, research investigating the impact of AIS on women’s health, particularly pregnancy delivery outcomes, is sparse, with existing literature reporting mixed findings. Similarly limited are studies examining the change in scoliotic curve during or after pregnancy. Therefore, this study aims to determine 1) the impact of scoliotic curvature on obstetric complications (preterm births, induction of labor, and urgent/emergency caesarean section delivery), 2) regional anesthetic decision making and success during delivery for these patients, and 3) the effect of pregnancy on curve progression.METHODSRecords of all pregnant patients diagnosed with AIS at the authors’ institution who delivered between January 2002 and September 2016 were retrospectively reviewed. Demographic information, pre- and postpartum radiographic Cobb angles, and clinical data for each pregnancy and delivery were recorded and analyzed. The Wilcoxon rank-sum test and the Wilcoxon signed-rank test were used for statistical analyses.RESULTSFifty-nine patients (84 deliveries) were included; 14 patients had undergone prior posterior spinal fusion. The median age at AIS diagnosis was 15.2 years, and the median age at delivery was 21.8 years. Overall, the median major Cobb angle prior to the first pregnancy was 25° (IQR 15°–40°). Most births were by spontaneous vaginal delivery (n = 45; 54%); elective caesarean section was performed in 17 deliveries (20%). Obstetric complications included preterm birth (n = 18; 21.4%), induction of labor (n = 20; 23.8%), and urgent/emergency caesarean section (n = 12; 14.0%); none were associated with severity of scoliosis curve or prior spinal fusion. Attempts at spinal anesthesia were successful 99% of the time (70/71 deliveries), even among the patients who had undergone prior spinal fusion (n = 13). There were only 3 instances of provider refusal to administer spinal anesthesia. In the subset of 11 patients who underwent postpartum scoliosis radiography, there was no statistically significant change in curve magnitude either during or immediately after pregnancy.CONCLUSIONSThe results of this study suggest that there was no effect of the severity of scoliosis on delivery complications or regional anesthetic decision making in pregnant patients with AIS. Moreover, scoliosis was not observed to progress significantly during or immediately after pregnancy. Larger prospective studies are needed to further investigate these outcomes, the findings of which can guide the prenatal education and counseling of pregnant patients with AIS.
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Affiliation(s)
- Emily W. Chan
- 1Surgical Outcomes Center for Kids, and
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | | | | | - Christopher M. Bonfield
- 1Surgical Outcomes Center for Kids, and
- 4Neurological Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville; and
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26
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Halverson SJ, Warhoover T, Mencio GA, Lovejoy SA, Martus JE, Schoenecker JG. Leptin Elevation as a Risk Factor for Slipped Capital Femoral Epiphysis Independent of Obesity Status. J Bone Joint Surg Am 2017; 99:865-872. [PMID: 28509827 PMCID: PMC5426400 DOI: 10.2106/jbjs.16.00718] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Slipped capital femoral epiphysis (SCFE) is strongly associated with childhood obesity, yet the prevalence of obesity is orders of magnitude greater than the prevalence of SCFE. Therefore, it is hypothesized that obesity is not, by itself, a sufficient condition for SCFE, but rather one component of a multifactorial process requiring preexisting physeal pathology. Leptin elevation is seen to varying degrees in patients with obesity, and as leptin has been shown to cause physeal pathology similar to the changes seen in SCFE, we propose that leptin may be a factor distinguishing between patients with SCFE and equally obese children without hip abnormalities. METHODS Serum leptin levels were obtained from 40 patients with SCFE and 30 control patients with approximate body mass index (BMI) matching. BMI percentiles were calculated according to Centers for Disease Control and Prevention population data by patient age and sex. Patients were compared by demographic characteristics, leptin levels, odds of leptin elevation, and odds of SCFE. RESULTS The odds of developing SCFE was increased by an odds ratio of 4.9 (95% confidence interval [CI], 1.31 to 18.48; p < 0.02) in patients with elevated leptin levels, regardless of obesity status, sex, and race. When grouping patients by their obesity status, non-obese patients with SCFE showed elevated median leptin levels at 5.8 ng/mL compared with non-obese controls at 1.7 ng/mL (p = 0.006). Similarly, obese patients with SCFE showed elevated median leptin levels at 17.9 ng/mL compared with equally obese controls at 10.5 ng/mL (p = 0.039). Serum leptin levels increased in association with obesity (p < 0.001), with an increase in leptin of 0.17 ng/mL (95% CI, 0.07 to 0.27 ng/mL) per BMI percentile point. CONCLUSIONS To our knowledge, this study is the first to clinically demonstrate an association between elevated serum leptin levels and SCFE, regardless of BMI. This adds to existing literature suggesting that SCFE is a multifactorial process and that leptin levels may have profound physiological effects on the development of various disease states. Despite a strong association with adiposity, leptin levels vary between patients of equal BMI and may be a vital resource in prognostication of future obesity-related comorbidities. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Schuyler J. Halverson
- Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, Nashville, Tennessee
| | - Tracy Warhoover
- Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, Nashville, Tennessee
| | - Gregory A. Mencio
- Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, Nashville, Tennessee
| | - Steven A. Lovejoy
- Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, Nashville, Tennessee
| | - Jeffrey E. Martus
- Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, Nashville, Tennessee
| | - Jonathan G. Schoenecker
- Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, Nashville, Tennessee,E-mail address for J.G. Schoenecker:
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27
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Kelly DM, Weiss JM, Martus JE. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2017; 99:353-359. [PMID: 28196040 DOI: 10.2106/jbjs.16.01192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Derek M Kelly
- 1Campbell Clinic, Department of Orthopaedic Surgery and Biomechanical Engineering, University of Tennessee, Memphis, Tennessee 2Division of Orthopedic Surgery, Southern California Kaiser Permanente Medical Group, Los Angeles, California 3Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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28
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Callan AK, Bauer JM, Martus JE. Deep Spine Infection After Acupuncture in the Setting of Spinal Instrumentation. Spine Deform 2016; 4:156-161. [PMID: 27927549 DOI: 10.1016/j.jspd.2015.09.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 12/15/2014] [Revised: 08/09/2015] [Accepted: 09/27/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acupuncture can be used to manage chronic pain. The most common complications related to acupuncture include pain, bruising, bleeding, or symptom exacerbation. Rarely, more serious adverse events occur, including infection, pneumothorax, septic arthritis, and peripheral nerve injury. To our knowledge, there are no reports of complications associated with acupuncture following spinal instrumentation. PURPOSE To report a case of deep infection as a rare complication of acupuncture following posterior spinal fusion for adolescent idiopathic scoliosis. STUDY DESIGN Case report. METHODS Case report. RESULTS A 15-year-old female presented 21 months after spinal arthrodesis for idiopathic scoliosis with a deep spine infection. The patient had recently been receiving a variation of acupuncture (dry needling therapy) in her medial periscapular region to manage chronic back and shoulder pain. She underwent serial irrigation and debridement with implant removal. Intraoperative cultures revealed pseudomonas and aerobic diptheroids. Two weeks later, the patient developed a periscapular abscess requiring additional operative debridement; cultures from this abscess were negative. After an 8-week course of antibiotics, the patient remains infection free with normalized inflammatory markers 2 years postoperatively. CONCLUSIONS Acupuncture is sometimes pursued as part of a multimodality pain management program for back pain, but it is not without risk and can lead to infection. Deep infection from acupuncture may contaminate existing spinal instrumentation and require operative debridement, implant removal, and long-term antibiotic therapy. Accordingly, there is an increased risk for deformity progression in this scenario related to the implant removal.
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Affiliation(s)
- Alexandra K Callan
- Department of Orthopaedic Surgery, Vanderbilt University Hospital, Nashville, TN
| | - Jennifer M Bauer
- Department of Orthopaedic Surgery, Vanderbilt University Hospital, Nashville, TN
| | - Jeffrey E Martus
- Division of Pediatric Orthopaedic Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN.
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Affiliation(s)
- Jeffrey E Martus
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | | - Derek M Kelly
- Department of Orthopaedic Surgery and Biomedical Engineering, Le Bonheur Children's Hospital, University of Tennessee-Campbell Clinic, Memphis, Tennessee
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Ramo BA, Martus JE, Tareen N, Hooe BS, Snoddy MC, Jo CH. Intramedullary Nailing Compared with Spica Casts for Isolated Femoral Fractures in Four and Five-Year-Old Children. J Bone Joint Surg Am 2016; 98:267-75. [PMID: 26888674 DOI: 10.2106/jbjs.o.00706] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age). METHODS A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables. RESULTS Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p < 0.001), were heavier (mean, 21.5 versus 18.0 kg; p < 0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p > 0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p < 0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p < 0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p < 0.001), primarily for elective implant removal. CONCLUSIONS Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.
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Affiliation(s)
- Brandon A Ramo
- Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | | | - Benjamin S Hooe
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Mark C Snoddy
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Chan-Hee Jo
- Texas Scottish Rite Hospital for Children, Dallas, Texas
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Grantham WJ, Raynor MB, Martus JE. Articular Sinus Tract with Mycobacterium fortuitum Osteomyelitis After Anterior Cruciate Ligament Reconstruction: A Case Report. JBJS Case Connect 2015; 5:e105. [PMID: 29252811 DOI: 10.2106/jbjs.cc.o.00033] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Three weeks after transphyseal anterior cruciate ligament reconstruction with a hamstring autograft, a fourteen-year-old boy presented with fevers, joint effusion, and elevated inflammatory markers. Cultures from an operative debridement grew Mycobacterium fortuitum, for which he received six months of antibiotics. Continued drainage prompted magnetic resonance imaging, which revealed osteomyelitis of the tibial tunnel. CONCLUSION This case report describes a postoperative infection with an atypical organism that had a protracted course despite early diagnosis. Complete resolution was achieved following tibial tunnel debridement with a high-speed burr and bone-grafting with an antibiotic-laden allograft.
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Affiliation(s)
- W Jeffrey Grantham
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
| | - M Brett Raynor
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
| | - Jeffrey E Martus
- Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 4202, Nashville, TN 37232-9565
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Abstract
This past year has seen an increase in the quality of studies in pediatric orthopaedics, and the completion of BrAIST demonstrated that high-level studies of important questions can be addressed in pediatric orthopaedics. The current commitment of improving quality of care for children promises a healthy future for pediatric orthopaedics.
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Affiliation(s)
- James O Sanders
- University of Rochester, Golisano Children's Hospital at URMC, 601 Elmwood Avenue, Rochester, NY 14625. E-mail address:
| | - Norman Y Otsuka
- Center for Children, NYU Hospital for Joint Diseases, NYU Langone Medical Center, Department of Orthopaedic Surgery, 301 East 17th Street, Suite 301/303, New York, NY 10003
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565
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Kim EJ, Crosby SN, Mencio GA, Green NE, Lovejoy SA, Schoenecker JG, Martus JE. Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using a Lateral Trochanteric Entry Portal. JBJS Essent Surg Tech 2014; 4:e19. [PMID: 30775126 DOI: 10.2106/jbjs.st.n.00009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction We describe rigid intramedullary nailing using a trochanteric entry for internal fixation of femoral shaft fractures in older children and adolescents. Step 1 Preparation Prior to Incision Appropriate preparation prior to the operation is key to minimizing intraoperative and postoperative complications. Step 2 Perform Incision and Exposure A well-positioned incision will facilitate and reduce difficulty with ideal guidewire placement. Step 3 Place and Overream the Guide Pin Ensure that the guide pin is properly positioned on the greater trochanter, while avoiding the piriformis fossa. Step 4 Place the Guidewire and Reduce the Fracture Prepare the definitive guidewire. Insert the guidewire into the proximal fragment via the trochanteric portal. While maintaining the fracture reduction, advance the guidewire into the distal fragment. Step 5 Measure Nail Length and Begin Overreaming Pay careful attention to the amount of reaming as well as distraction across the fracture site to provide the best fit for the nail. Step 6 Insert the Nail Be sure to maintain the reduction while advancing the nail across the fracture site. Reconfirm that traction has been reduced to avoid distraction at the fracture site. Step 7 Insert Proximal and Distal Interlocks Use the interlocking screws to secure the proper rotational alignment. Step 8 Make Final Images and Close the Wound Confirm the reduction and adequate fixation before closure. Results In our original study, a cohort of 246 femoral shaft fractures among 241 skeletally immature patients treated with trochanteric entry rigid intramedullary nailing was retrospectively reviewed.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Elliott J Kim
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Samuel N Crosby
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Gregory A Mencio
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Neil E Green
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Steven A Lovejoy
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Jonathan G Schoenecker
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
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Crosby SN, Kim EJ, Koehler DM, Rohmiller MT, Mencio GA, Green NE, Lovejoy SA, Schoenecker JG, Martus JE. Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients. J Bone Joint Surg Am 2014; 96:1080-1089. [PMID: 24990973 DOI: 10.2106/jbjs.m.01128] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Debate exists over the safety of rigid intramedullary nailing of femoral shaft fractures in skeletally immature patients. The goal of this study was to describe functional outcomes and complication rates of rigid intramedullary nailing in pediatric patients. METHODS A retrospective review was performed of femoral shaft fractures in skeletally immature patients treated with trochanteric rigid intramedullary nailing from 1987 to 2009. Radiographs made at initial injury, immediately postoperatively, and at the latest follow-up were reviewed. Patients were administered the Nonarthritic Hip Score and a survey. RESULTS The study population of 241 patients with 246 fractures was primarily male (75%) with a mean age of 12.9 years (range, eight to seventeen years). The majority of fractures were closed (92%) and associated injuries were common (45%). The mean operative time was 119 minutes, and the mean estimated blood loss was 202 mL. The mean clinical follow-up time was 16.2 months (range, three to seventy-nine months), and there were ninety-three patients with a minimum two-year clinical and radiographic follow-up. An increase of articulotrochanteric distance of >5 mm was noted in 15.1% (fourteen of ninety-three patients) at a minimum two-year follow-up; however, clinically relevant growth disturbance was only observed in two patients (2.2%) with the development of asymptomatic coxa valga. There was no femoral head osteonecrosis. Among the 246 fractures, twenty-four complications (9.8%) occurred. At the time of the latest follow-up, 1.7% (four of 241 patients) reported pain. The average Nonarthritic Hip Score was 92.4 points (range, 51 to 100 points), and 100% of patients reported satisfaction with their treatment. CONCLUSIONS Rigid intramedullary nailing is an effective technique for treatment of femoral shaft fractures in pediatric patients with an acceptable rate of complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Samuel N Crosby
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Elliott J Kim
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Daniel M Koehler
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242
| | - Michael T Rohmiller
- Beacon Orthopedics and Sports Medicine, 500 E-business Way, Sharonville, OH 45241
| | - Gregory A Mencio
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Neil E Green
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Steven A Lovejoy
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Jonathan G Schoenecker
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
| | - Jeffrey E Martus
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, 4202 DOT, 2200 Children's Way, Nashville, TN 37232-9565. E-mail address for J.E. Martus:
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Martus JE, Preston RK, Schoenecker JG, Lovejoy SA, Green NE, Mencio GA. Complications and outcomes of diaphyseal forearm fracture intramedullary nailing: a comparison of pediatric and adolescent age groups. J Pediatr Orthop 2013; 33:598-607. [PMID: 23872805 DOI: 10.1097/bpo.0b013e3182a11d3b] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [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] [Indexed: 02/07/2023]
Abstract
BACKGROUND Flexible intramedullary nailing (IMN) has become a popular technique for the management of unstable or open forearm fractures. Recent publications have suggested an increased incidence of delayed union and poor outcomes in older children and adolescents. The objective of this study was to review forearm fractures treated with IMN, comparing the rate of complications and outcomes between the 2 age groups. Our hypothesis was that IMN is an effective technique with a similar rate of complications in both age groups. METHODS An Institutional Review Board-approved retrospective review was conducted of pediatric forearm fractures treated from 1998 to 2008 at a single institution. Over the study time period, 4161 pediatric forearm fractures were managed nonoperatively (92%) and 353 were treated operatively with plate, cross-pin, or intramedullary fixation (8%). Patients with inadequate follow-up, cross-pin, or plate fixation were excluded. Medical records were reviewed for indications and complications. Complications were graded with a modification of the Clavien-Dindo classification. Outcomes were judged by a new grading system. RESULTS A total of 205 forearm fractures treated with IMN in 203 patients were identified. The mean age was 9.7 years (range, 1.7 to 16.2 y) and mean follow-up was 42 weeks. Operative indications were failure of closed treatment in 165 (80%) and open fracture in 40 (20%). Mean time from injury to IMN was 5.9 days (range, 0 to 25 d). Single bone IMN was performed in 40 of 185 both bone fractures (26%); there were 20 single-bone forearm fractures treated with IMN. Open reduction was required in 61/165 (37%) of closed fractures. Asymptomatic delayed union (grade 1 complication) was observed in 9 fractures (4%). More severe complications were noted in 17% (grade 2 to 4 complications). Postoperative compartment syndrome occurred in 3 isolated forearm fractures with a significant younger mean age (6.0 vs. 10 y, P=0.031). Overall, complications were significantly more frequent in children older than 10 years of age (25/101) as compared with younger children (13/104, P=0.031). In particular, delayed union was more common in children over the age of 10 years (9/101 vs. 1/104, OR=9.99, P=0.009). Outcomes were good or excellent in 91% of fractures. There was no statistical association of patient age with a fair or poor outcome. CONCLUSIONS IMN is an effective technique for pediatric forearm fractures with good to excellent outcomes in 91%. Complications are not infrequent with this technique, with complications of grade 2 to 4 severity in 17%. There was a 2-fold increase in the rate of complications in children over the age of 10 years. Compartment syndrome was more common in younger children. Patients and families should be counseled about the risks preoperatively.
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Affiliation(s)
- Jeffrey E Martus
- Department of Orthopaedics and Rehabilitation, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN 37232-9565, USA.
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Mansour AA, Watson JT, Martus JE. Displaced dorsal metaphyseal cortex associated with delayed extensor pollicis longus tendon entrapment in a pediatric Smith's fracture. J Surg Orthop Adv 2013; 22:173-5. [PMID: 23628574 DOI: 10.3113/jsoa.2013.0173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Extensor pollicis longus (EPL) tendon entrapment has been rarely reported as a complication of closed treatment of a pediatric Smith's type distal radius fractures. This article presents the unique case of an initially functional EPL tendon that became entrapped in fracture callus in a 9-year-old boy, the youngest reported in the literature.
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Affiliation(s)
- Alfred A Mansour
- Division of Pediatric Orthopaedics, Vanderbilt Children's Hospital, Nashville, Tennessee 34232-9565, USA
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Mignemi ME, Martus JE. Mechanical Failure of the OrthoPediatrics PediPlate in Late-Onset Tibia Vara with Moderate Deformity: A Report of Three Cases. JBJS Case Connect 2013; 3:e48. [PMID: 29252400 DOI: 10.2106/jbjs.cc.l.00209] [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: 06/07/2023]
Affiliation(s)
- Megan E Mignemi
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, South Tower, Suite 4200, Nashville, TN 37232
| | - Jeffrey E Martus
- Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, 4202 Doctors' Office Tower, Nashville, TN 37232.
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Butler MA, Martus JE, Schoenecker JG. Pediatric variants of the transolecranon fracture dislocation: recognition and tension band fixation: report of 3 cases. J Hand Surg Am 2012; 37:999-1002. [PMID: 22541155 DOI: 10.1016/j.jhsa.2012.02.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [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] [Received: 09/29/2011] [Revised: 02/16/2012] [Accepted: 02/22/2012] [Indexed: 02/02/2023]
Abstract
Anterior transolecranon fracture dislocation of the elbow is relatively uncommon in children. We reviewed the experience over the past 5 years at our institution in treating this injury to identify pediatric variants and outline a rational treatment strategy. We found 2 pediatric variants to the injury pattern and determined that tension band constructs can successfully be used to treat certain pediatric transolecranon fracture dislocations. The pediatric variants identified in this report are fracture dislocations with associated medial epicondyle fracture and radial neck fracture. We recommend a heightened vigilance in looking for a fracture through the ulna when an anterior dislocation is present, as physeal injuries can be challenging to see on plain radiographs.
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Larson AN, Sucato DJ, Herring JA, Adolfsen SE, Kelly DM, Martus JE, Lovejoy JF, Browne R, Delarocha A. A prospective multicenter study of Legg-Calvé-Perthes disease: functional and radiographic outcomes of nonoperative treatment at a mean follow-up of twenty years. J Bone Joint Surg Am 2012; 94:584-92. [PMID: 22488614 DOI: 10.2106/jbjs.j.01073] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long-term studies have indicated good outcomes for most patients with Legg-Calvé-Perthes disease. However, clinical experience suggests that less favorable outcomes are common. We sought to prospectively document pain and function in a cohort of adults who had previously been treated nonoperatively for Legg-Calvé-Perthes disease. METHODS Patients in our region with Legg-Calvé-Perthes disease were enrolled between 1984 and 1991 as part of a multicenter prospective trial and were treated with hip range-of-motion exercises or bracing. Patients returned for physical examination, radiographs, and completion of outcome measures including the Nonarthritic Hip Score (NAHS) and the Iowa Hip Score (IHS). RESULTS Fifty-six patients (fifty-eight hips) were examined at a mean of 20.4 years (range, 16.3 to 24.5 years) after enrollment. The mean NAHS was 79 (range, 35 to 100), and the mean IHS was 74 (range, 43 to 100). Three patients had required hip arthroplasty and one patient had required a pelvic osteotomy. Fourteen (26%) of the remaining hips had no hip osteoarthritis, sixteen (30%) had mild osteoarthritis (Tönnis grade 1), and twenty-four (44%) had moderate or severe osteoarthritic changes on radiographs (grade 2 or 3). Femoroacetabular impingement indicated by physical examination was associated with pain and with poorer outcomes on the IHS and the NAHS (p = 0.0004, 0.0014, and 0.0007, respectively). The Stulberg classification was significantly associated with impingement on physical examination (p = 0.0495), the NAHS (p = 0.003), and the Tönnis grade (p = 0.012). Multivariate logistic regression showed that only the Stulberg classification was significantly associated with the NAHS (p = 0.0032); the odds ratio for a Stulberg type of I or II compared with IV or V in patients with a fair or poor NAHS was 0.101 (95% confidence interval, 0.018 to 0.573). CONCLUSIONS Pain, arthritis, and ongoing hip dysfunction are common in patients with Legg-Calvé-Perthes disease that was treated nonoperatively. Hips rated as Stulberg type III or IV more frequently had poor or fair outcomes on the IHS and NAHS (61% and 72% for type III and 77% and 60% for type IV). Patients with a lateral pillar type of B, B/C, or C frequently had pain and radiographic evidence of osteoarthritis. Clinical signs of femoroacetabular impingement were associated with pain and with lower functional scores. This prospective study establishes a modern benchmark for outcomes following nonoperative, weight-bearing treatment of Legg-Calvé-Perthes disease.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
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Desai AA, Martus JE, Schoenecker J, Kan JH. Spica MRI after closed reduction for developmental dysplasia of the hip. Pediatr Radiol 2011; 41:525-9. [PMID: 21279341 DOI: 10.1007/s00247-010-1965-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [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] [Received: 09/30/2010] [Revised: 11/27/2010] [Accepted: 12/08/2010] [Indexed: 11/26/2022]
Abstract
Spica MRI is a fast and effective tool to assess morphology after closed reduction for developmental dysplasia of the hip (DDH) without the need for sedation. The multiplanar capabilities allow depiction of coronal and axial reduction of the hips. Due to MRI's inherent ability to delineate soft tissue structures, both intrinsic and extrinsic obstacles to failed reduction may be identified. Technical and interpretative challenges of spica MRI are discussed.
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Affiliation(s)
- Aditi A Desai
- Vanderbilt University School of Medicine, 1211 Medical Center Drive, Nashville, TN 37232, USA.
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Johnson DP, Hernanz-Schulman M, Martus JE, Lovejoy SA, Yu C, Kan JH. Significance of epiphyseal cartilage enhancement defects in pediatric osteomyelitis identified by MRI with surgical correlation. Pediatr Radiol 2011; 41:355-61. [PMID: 20936273 DOI: 10.1007/s00247-010-1849-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [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: 06/09/2010] [Revised: 09/02/2010] [Accepted: 09/13/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Epiphyseal cartilage enhancement defects (ED) may occur in the setting of epiphyseal osteomyelitis (OM), and its significance is uncertain. OBJECTIVE The aim of this study is to evaluate the incidence and clinical impact of epiphyseal cartilage ED in pediatric epiphyseal OM. MATERIALS AND METHODS The 13 children involved in this retrospective review were younger than 6 years of age and diagnosed with OM. They underwent contrast-enhanced MRI and surgical exploration yielding 14 study epiphyses. Seventeen age-matched children without evidence of infection who underwent contrast-enhanced MRI in the same period yielded 28 control epiphyses. Images were reviewed for focal/global ED, correlated with cartilage abscesses and compared with surgical reports. RESULTS Study and control ED were respectively present in 10/14 (71.4%-6 global, 4 focal) and 6/28 (21.4%-0 global, 6 focal), P=0.0017. An analysis of ED patterns between study and control patients showed significant difference for global (P=0.0006), but no difference for focal ED (P=0.71). For the six study epiphyses with global ED, epiphyseal abscesses were present in two (33.3%). For the four study epiphyses with focal ED, epiphyseal abscesses were present in two (50%). For the controls, no abnormalities were found on follow-up of epiphyses with focal ED. CONCLUSION ED are seen normally but more commonly in children with OM. ED should not be confused with epiphyseal abscesses.
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Affiliation(s)
- David P Johnson
- Vanderbilt University School of Medicine, Nashville, TN, USA
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Abstract
BACKGROUND The accessory anterolateral talar facet may be associated with talocalcaneal impingement in the painful flatfoot. We performed an anatomic study to identify this accessory facet and its associated osteologic features. METHODS Within the Hamann-Todd Human Osteological Collection, seventy-nine paired tali and calcanei were identified among forty-three skeletons from individuals who had had an average age of 13.4 years at the time of death. Each specimen was surveyed for an accessory anterolateral talar facet, a calcaneal neck anterior extension facet, a dorsal talar beak, and the talocalcaneal facet pattern. Measurements included the angle of Gissane, posterior facet inclination, calcaneal neck length, posterior facet length, overall calcaneal and talar lengths, and accessory facet dimensions. Lateral radiographs of specimens with accessory facets were made in neutral and everted subtalar alignment. RESULTS An accessory anterolateral talar facet was identified in twenty-seven (34%) of the seventy-nine specimens and was large in two (2.5%). Of the thirty-six skeletons with paired specimens, fifteen had an accessory facet and, of those, ten had the finding bilaterally. Degenerative changes or tarsal coalitions were not observed. Lateral radiographs demonstrated that subtalar eversion obscured observation of the facet. The accessory facet was associated with greater mean age (16.7 compared with 10.9 years; p < 0.0001), male sex (63% compared with 21%; p = 0.011), and a smaller mean angle of Gissane (116.2 degrees compared with 122.2 degrees; p = 0.018). Relative accessory facet volume was positively correlated with increased relative calcaneal posterior facet length (r = 0.53, p = 0.029). The accessory facet was significantly associated with dorsal talar beaking (29% compared with 4%; p = 0.028). CONCLUSIONS An accessory anterolateral talar facet was found in 34% of the specimens in a pediatric osteologic collection. The facet was associated with male sex, a smaller angle of Gissane, and dorsal talar beaking.
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Affiliation(s)
- Jeffrey E Martus
- Department of Orthopaedics and Rehabilitation, Vanderbilt University, 2200 Children's Way, 4202 DOT, Nashville, TN 37232-9565, USA.
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Martus JE, Femino JE, Caird MS, Kuhns LR, Craig CL, Farley FA. Accessory anterolateral talar facet as an etiology of painful talocalcaneal impingement in the rigid flatfoot: a new diagnosis. Iowa Orthop J 2008; 28:1-8. [PMID: 19223941 PMCID: PMC2603342] [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] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A retrospective review identified six patients with seven painful rigid flatfeet. In each case, pain was localized laterally to an accessory facet of the anterolateral talus. cross-sectional imaging demonstrated no evidence of tarsal coalition. In five of the six, preoperative magnetic resonance imaging (MRI) was obtained and in each case demonstrated focal abutting bone marrow edema consistent with impingement between the accessory facet and the anterior calcaneus.Seven feet in six patients underwent resection of the accessory facet with additional subtalar joint-sparing reconstructive procedures. At an average follow-up of 11 months, clinical results were graded as four good and two fair.An association between this accessory facet and pain in the rigid flatfoot has not been previously reported. Obesity was universal and may represent a risk factor for facet impingement. At early follow-up, facet resection with subtalar joint-sparing flatfoot reconstruction provided good results with symptomatic and functional improvement in the majority of patients.
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Affiliation(s)
- Jeffrey E Martus
- Department of Orthopaedics and Rehabilitation, Vanderbilt University, Nashville, TN 37232-9565, USA.
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Bedi A, Jebson PJL, Hayden RJ, Jacobson JA, Martus JE. Internal fixation of acute, nondisplaced scaphoid waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes. J Hand Surg Am 2007; 32:326-33. [PMID: 17336838 DOI: 10.1016/j.jhsa.2007.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [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] [Received: 06/13/2006] [Revised: 12/23/2006] [Accepted: 01/02/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical and radiographic outcomes of a consecutive series of patients who had internal fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach. METHODS Twenty consecutive patients had surgical fixation of a nondisplaced scaphoid waist (Herbert B2) fracture via a limited dorsal approach. Eighteen patients were available for follow-up evaluation at a mean duration of 98 weeks after surgery (range, 12-272 wk). Fifteen males and 3 females with a mean age of 25 years (range, 16-62 y) were examined. Wrist range of motion; grip strength; visual analog and numeric pain scores; and a Disabilities of the Arm, Shoulder, and Hand (DASH) outcomes questionnaire were assessed. Postoperative radiographs were reviewed in a blinded fashion to assess the fracture union and screw position. RESULTS Seventeen of 18 fractures healed at a mean duration of 8 weeks. No case of proximal pole avascular necrosis occurred. All patients were satisfied and returned to their pre-injury level of employment. Five of 6 collegiate or professional athletes returned to play without limitations. The mean subjective and visual analog pain scores were 0.3 and 0.4 (maximum of 10 for each scale). The mean DASH score was 6.12 (out of 100), which is consistent with an excellent functional outcome. Central axis screw position was achieved on anteroposterior and lateral radiographs in 17 of 18 patients. CONCLUSIONS Fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach is safe and effective. The limited dorsal approach allows for accurate insertion of the screw in the central scaphoid, which is biomechanically advantageous for fracture union and early restoration of function. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Asheesh Bedi
- Division of Elbow, Hand, and Microvascular Surgery, Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI 48105, USA
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Abstract
Scaphoid fractures are common in the young, active patient. Treatment is challenging because of the complex three-dimensional anatomy of the scaphoid and the tenuous blood supply. Traditionally, cast immobilization has been used for the management of non-displaced fractures with satisfactory outcomes reported in the literature. However, non-surgical treatment may result in a delayed union or nonunion particularly if the fracture is unstable, displaced, or involves the proximal pole. Recently there has been increased interest in the fixation of non-displaced scaphoid fractures. The proposed advantages for operative treatment include avoiding the morbidity and inconvenience of prolonged cast immobilization and a lower incidence of delayed union or nonunion. A variety of surgical approaches for fixation of an acute scaphoid fracture have been described. The most common techniques include percutaneous fixation, arthroscopically assisted reduction and fixation, or open reduction and internal fixation via a volar approach. The senior author favors a limited dorsal approach with compression screw fixation of all proximal pole fractures as well as displaced and non-displaced fractures of the waist region. The technique is simple permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important for achieving union.
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Affiliation(s)
- Jeffrey E Martus
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor 48109, USA
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