JAAOS

JAAOS, Volume 27, No. 9


Approaching Unusual Pediatric Distal Humerus Fracture Patterns

Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.

      • Subspecialty:
      • Pediatric Orthopaedics

      • Shoulder and Elbow

    Understanding Skeletal Growth and Predicting Limb-Length Inequality in Pediatric Patients

    Limb-length inequality in a child can be a complex condition for patients, parents, and medical providers. Managing these patients and explaining the treatment options to families requires knowledge of the potential risks associated with leaving a discrepancy untreated and a thorough understanding of skeletal growth. The provider must also be familiar with the available growth prediction methods as treatment is influenced by the anticipated discrepancy at skeletal maturity. This article provides an overview to skeletal growth, assessing skeletal maturity and growth prediction to help providers develop an organized and thoughtful approach to treating pediatric patients with limb-length inequalities.

        • Subspecialty:
        • Pediatric Orthopaedics

      The Use of Spinal Cord Stimulation/Neuromodulation in the Management of Chronic Pain

      Chronic pain causes a tremendous burden on the society in terms of economic factors and social costs. Rates of spinal surgery, especially spinal fusion, have increased exponentially over the past decade. The opioid epidemic in the United States has been one response to the management of pain, but it has been fraught with numerous catastrophic-related adverse effects. Clinically, spinal cord stimulation (SCS)/neuromodulation has been used in the management of chronic pain (especially spine-related pain) for more than two decades. More recent advances in this field have led to new theories and approaches in which SCS can be used in the management of chronic spine-related pain with precision and efficacy while minimizing adverse effects commonly seen with other forms of chronic pain treatment (eg, narcotics, injections, ablations). Narcotic medications have adverse effects of habituation, nausea, constipation, and the like. Injections sometimes lack efficacy and can have only limited duration of efficacy. Also, they can have adverse effects of cerebrospinal fluid leak, infection, and so on. Ablations can be associated with burning discomfort, lack of efficacy, recurrent symptoms, and infection. High-frequency stimulation, burst stimulation, tonic stimulation with broader paddles, and new stimulation targets such as the dorsal root ganglion hold promise for improved pain management via neuromodulation moving forward. Although a significant rate of complications with SCS technology are well described, this can be a useful tool in the management of chronic spine-related pain.

      STATUSONLINE-ONLY

          • Subspecialty:
          • Spine

        Two Surgeon Approach for Complex Spine Surgery: Rationale, Outcome, Expectations, and the Case for Payment Reform

        There is an increased trend in complex spine deformity cases toward a two attending surgeon approach, but the practice has not become widely accepted by payers. Multiple studies have shown that spine surgery complications increase with the duration of case, estimated blood loss, and use of transfusions, as well as in certain high-risk populations or those requiring three-column osteotomies. Dual-surgeon cases have been shown to decrease estimated blood loss, transfusion rate, surgical times, and therefore complication rates. Although this practice comes at an uncertain price to medical training and short-term costs, the patient's quality of care should be prioritized by institutions and payers to include dual-surgeon coverage for these high-risk cases. Because we enter an era where the value of spine care and demonstrating cost-effectiveness is essential, dual surgeon attending approaches can enhance these tenets.

        STATUSONLINE-ONLY

            • Subspecialty:
            • Spine

          Septic Arthritis of the Hip—Risk Factors Associated With Secondary Surgery

          Introduction: Septic arthritis of the hip (SAH) is a common condition encountered by pediatric orthopaedic surgeons and is treated with arthrotomy and irrigation. Depending on the response to initial treatment, some patients require surgical treatment beyond the index procedure. The purpose of this study was to investigate risk factors for repeat surgical intervention after initial arthrotomy for presumed SAH.

              • Subspecialty:
              • Adult Reconstruction

            The Spinal Structure and Lung Function Relationship in an Untreated Nonambulatory Myelomeningocele Group of Patients

            Introduction: The relationship between spinal structure and respiratory function has been coined as thoracic insufficiency syndrome and is defined as the inability of the thorax to support normal respiratory function or lung growth. Little is known about what supports this relationship in untreated nonambulatory myelomeningocele patients.

                • Subspecialty:
                • Spine

              The Importance of a Standardized Screening Tool to Identify Thromboembolic Risk Factors in Pediatric Lower Extremity Arthroscopy Patients

              Introduction: Deep vein thrombosis and pulmonary embolism are major complications that can occur in common orthopaedic procedures such as knee arthroscopy. The purpose of this study is to determine the incidence of venous thromboembolism (VTE) risk factors in adolescent patients undergoing elective lower extremity arthroscopy. A second objective is to determine whether a targeted, standardized screening tool is both cost- and clinically effective in the identification of VTE risk factors in adolescents.

                  • Subspecialty:
                  • Pediatric Orthopaedics

                Inadvertent Radial Head Inversion During Closed Reduction of a Pediatric Radial Neck Fracture

                Management of displaced pediatric radial neck fractures can be fraught with challenges. This unique case presents an 11-year-old female with a Salter-Harris type II radial neck fracture and how her radial head overturned 180° with the articular surface facing the radial shaft rather than the capitellum during closed manipulation under anesthesia. The malreduction subsequently required open reduction and highlights the importance of a careful stepwise approach to managing markedly displaced radial neck fractures. After closed reduction, meticulous assessment of intraoperative imaging when determining proper alignment is of the utmost importance as a result of the transverse nature of Salter-Harris type I and II fractures.

                Level of Evidence:

                Level IV

                OPEN-ACCESSTRUESTATUSONLINE-ONLY

                    • Subspecialty:
                    • Pediatric Orthopaedics

                    • Spine

                  Prescription Opioid Type and the Likelihood of Prolonged Opioid Use After Orthopaedic Surgery

                  Introduction: A common belief is that some narcotic medications have a higher association with prolonged use. We assessed whether the initial opiate type prescribed to postoperative, opiate-naive orthopaedic trauma patients was associated with prolonged opioid use.

                      • Subspecialty:
                      • General Orthopaedics

                    Cost Comparison of Femoral Distraction Osteogenesis With External Lengthening Over a Nail Versus Internal Magnetic Lengthening Nail

                    Introduction: Femoral lengthening is performed by distraction osteogenesis via lengthening over a nail (LON) or by using a magnetic lengthening nail (MLN). MLN avoids the complications of external fixation while providing accurate and easily controlled lengthening. However, the increased cost of implants has led many to question whether MLN is cost-effective compared with LON.

                        • Subspecialty:
                        • General Orthopaedics

                      Comparing Standard Versus Extended Culture Duration in Acute Hip and Knee Periprosthetic Joint Infection

                      Introduction: Periprosthetic joint infection (PJI) is a devastating complication of hip and knee arthroplasties. Surgical cultures are essential for the diagnosis and treatment of PJI. Yet, the ideal culture duration remains unclear. This study compares culture yield, organism profile, and treatment success between standard (5 days) and extended (14 days) cultures in acute hip and knee PJI.

                          • Subspecialty:
                          • Adult Reconstruction

                        Predicting Discharge Disposition After Shoulder Arthroplasty in the United States

                        Introduction: Postdischarge management for shoulder replacement continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. The goal of this study was to develop a nomogram to preoperatively predict a patient's discharge disposition after elective shoulder arthroplasty.

                            • Subspecialty:
                            • Shoulder and Elbow

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