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Purpose: Pelvic sarcoma is uncommon in children and challenging to treat. This study examined different surgical approaches to treat pelvic sarcoma with the aim of assessing the oncologic, and functional outcomes., Methods: We retrospectively examined the medical records of patients younger than 21 years of age who underwent surgery for pelvic sarcoma at our institution from 1992 to 2010. The functional status of the patients was examined after a minimum follow-up of two years., Results: Twenty-six patients were included in the analysis. Nineteen (73%) patients were male and seven (27%) were female. Mean age at presentation was 12.0 ± 3.9 years. Nineteen patients had Ewing sarcoma (73%), five had osteosarcoma (19%), one had chondrosarcoma (4%) and one had rhabdomyosarcoma (4%). Iliac wing resection with no reconstruction was done in three patients. Reconstruction with free fibular graft A-frame was performed in four patients, saddle endoproshtesis in five patients, iliac autoclave in one patient, and internal hemipelvectomy in nine patients. Hindquarter amputation was performed in five patients. Median follow-up was 4.6 years (range, 2.6-16 years). Nineteen patients were alive (73%); of those, 13 were known to be without disease, three were with disease and three did not have known tumor status. Six patients were reported deceased, three had osteosarcoma and three had Ewing sarcoma. Function was assessed in 17 patients; 64% were asymptomatic and ambulatory and 36% were symptomatic and ambulatory., Conclusions: Salvage reconstruction for pelvic sarcoma can be performed through various procedures on the extent of necessary bony resection. Survival rate and functional outcomes were promising in the performed study.

Background: Aicardi syndrome (ACS) is a rare neurodevelopmental disorder that was classically characterized by the triad of agenesis of corpus callosum, infantile spasms, and chorioretinal lacunae. As new cases emerge and new common phenotypic features are being described in subsequent reports, new modified diagnostic criteria have been proposed that now classify the observed costovertebral abnormalities as supporting diagnostic features. To our knowledge there are no previous studies focusing and describing the scoliosis observed in children with ACS., Methods: We screened billing lists to identify patients seen in the Division of Orthopaedic Surgery at our institution with a diagnosis of ACS that were treated for scoliosis after 2001. A total of 5 patients were identified. Medical records and radiographs were retrospectively reviewed in all cases. In all of the patients the diagnosis of ACS had been confirmed through complete genetic evaluation and advanced imaging., Results: The mean age when scoliosis was first noticed was 3.9±4.2 years (range, 0.5 to 10.5 y) with a mean Cobb angle of 22.5±6.7 degrees (range, 10 to 27 degrees). The mean age at the first orthopedic visit was 5.8±5.0 years (range, 1.5 to 13 y) with a progressed mean Cobb angle of 39.5±17.3 degrees (range, 15 to 57 degrees). Congenital vertebral anomalies were observed in 1 patient. Three patients were treated surgically; 1 of the 3 patients had a surgical complication with loss of intraoperative neuromonitoring signals. Two patients had not undergone surgery at the last visit with a mean Cobb angle of 75.5 degrees. The mean postoperative follow-up for the surgical group (cases 1 to 3) was 3±3.6 years (range, 0.6 to 7.2 y) and the mean total follow-up for both groups was 6.6±2.5 years (range, 2.6 to 8.6 y)., Conclusions: Scoliosis in ACS can represent a clinically significant problem that is underdiagnosed and overshadowed by the other severe medical complications associated with the syndrome. Our data suggest that scoliosis in patients with ACS is rapidly progressive and bracing is ineffective; early screening, close observation, and low threshold for referral to an orthopedic surgeon are crucial., Level of Evidence: Level IV-case series.

Background: The use of the conventional halo is accompanied by the possibility of serious complications, especially in the pediatric population. Complications could include penetration of pin into the skull, pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores. The noninvasive "pinless" halo was introduced in an attempt to mitigate these problems while retaining the effectiveness of the conventional halo. The purpose of this study is to determine the indications and complications related to pinless halo application., Methods: We retrospectively reviewed 61 patients, whose treatment included the use of a pinless halo device, presenting to our institution between 2004 and 2012., Results: There were 35 male and 26 female patients with an average age of 6.04 years. Indications of pinless halo application included postoperative immobilization for congenital muscular torticollis in 38 cases, conservative management of atlantoaxial rotatory subluxation in 11 cases, postoperative immobilization following cervical fusion in 10 cases, and immobilization for occipital condyle fracture in 2 cases. The average duration of the pinless halo application was 32.68 days. Thirteen patients had complications, among which major complications were seen in 2 patients, each of whom developed a pressure sore; one on the scalp and the other on the chest. Both the pressure sores responded to local treatment; however, 1 resulted in permanent alopecia., Conclusions: The use of the noninvasive pinless halo was found to be safe with few complications in our study. The complications were infrequent and patients were compliant to treatment, indicating that this modality is patient-friendly. Effectiveness of this treatment in comparison with invasive halos and other cervical orthoses was not determined and is a limitation of this study., Level of Evidence: Level IV-Case series.

Background: Chest wall osteochondroma is a rare tumor in children. Even though the potential for malignant transformation or serious intrathoracic complications is low, it has led some centers to advocate surgical management of these bony tumors. We present our experience of the surgical management of costal osteochondromata., Methods: Between January 1, 2006 and November 1, 2012 we saw 854 patients with solitary or multiple exostoses in our clinics. By reviewing our billing lists we found 7 children who had surgical management of chest wall osteochondromata. The indications for surgery were pain (3 patients), excision for confirmation of diagnosis (2 patients), recurrent pneumothorax (1 patient), and malignancy (1 patient)., Results: All patients made a good postoperative recovery with a median hospital stay of 1.8 days (range, 0 to 4 d). There was no recurrence of exostosis on follow-up (range, 8 mo to 2.6 y). One patient required surgery for excision of another chest wall osteochondroma at an adjacent location. No patient reported scar-related pain symptoms. No malignant transformation or intrathoracic complications occurred. We found ribs as the first site of presentation of multiple hereditary exostoses in 2 young patients., Conclusions: Surgical management of thoracic osteochondroma, with excision for painful, symptomatic, malignant lesions or lesions adjudged to be at risk of intrathoracic complications, yields good outcomes in terms of symptom control, establishing histologic diagnosis, and prevention of thoracic complications., Level of Evidence: Level IV-case series.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as a public health concern since the mid-1990s. Because of the increase in reports of this pathogen, it has become increasingly tempting for clinicians to provide prophylaxis against this entity using antibiotics known to be effective against MRSA. The goal of this study was to assess the use of MRSA prophylaxis to determine whether it is safe and effective. A systematic search of the literature was performed to identify articles that examined the use of vancomycin in clean orthopedic surgery. Infection rates and adverse events were extracted, and the data were aggregated and analyzed using a DerSimonian and Laird random effects model. Publication bias and study quality were also assessed. No benefit of parenteral administration of vancomycin was identified. Local, vancomycin-impregnated cement and powder are associated with lower infection rates. Few adverse events occurred, and most of those that occurred involved infusion rate.Cost, resistance, and side effects are concerns in using vancomycin therapy in addition to standard antibiotic prophylaxis. Given the lack of efficacy of intravenous vancomycin, the authors do not recommend its routine use in clean orthopedic surgery. However, local administration appears to be safe and effective. The data are most compelling in orthopedic spine surgery in which a patient without prophylaxis is more than 4 times as likely to have a deep postoperative wound infection compared with a patient who received local vancomycin. The authors recommend the use of local antibiotics when possible in clean orthopedic surgery., (Copyright 2013, SLACK Incorporated.)

Quantity of citation is often used as a surrogate measurement of an article's importance or relevance in a given field. To date, there has been no study on citation quantity or density in pediatric orthopedics. We present such an analysis. We reviewed all articles in the ISI web of science under the subheading 'orthopedics' to find articles of relevance to pediatric orthopedic surgeons. We subsequently analyzed the characteristics of the most cited articles in terms of the level of evidence, journal of publication, and subcategory of pediatric orthopedics. The majority of the top 50 articles in pediatric orthopedics were from the 1970s and 1980s. All the articles were in English. Uncontrolled case series comprised the largest single level of evidence (level IV). We describe the top 50 articles in pediatric orthopedics by citation and citation density. The level of evidence for highly cited papers was low. Although many of these articles were written by the great thinkers of our field, a need exists for more rigorous methodology.

Study Design: Retrospective review., Objective: To report on the safety of repetitive transcranial electric stimulation (RTES) for eliciting motor-evoked potentials during spine surgery., Summary of Background Data: Theoretical concerns over the safety of RTES have hindered broader acceptance of transcranial electric motor-evoked potentials (tceMEP), despite successful implementation of spinal cord monitoring with tceMEPs in many large spine centers, as well as their apparent superiority over mixed-nerve somatosensory-evoked potentials (SSEP) for detection of spinal cord injury., Methods: The records of 18,862 consecutive patients who met inclusion criteria and underwent spine surgery with tceMEP monitoring were reviewed for RTES-related complications., Results: This large retrospective review identified only 26 (0.14%) cases with RTES-related complications; all but one of these were tongue lacerations, most of which were self-limiting., Conclusions: The results demonstrate that RTES is a highly safe modality for monitoring spinal cord motor tract function intraoperatively.

Study Design: Literature review., Objective: This article presents a critical examination of standard of care (SOC) related to intraoperative neurophysiologic monitoring during spine surgery. Definition of SOC and its applications in the surgical setting is accompanied by discussions on SOC for neuromonitoring, credentialing of neuromonitoring personnel, off-site remote monitoring, and unattended surgeon-controlled neuromonitoring devices., Methods: A literature review of neuromonitoring and SOC over the past 10 years was performed. This information, in conjunction with the author's experience and evidence-based medicine, was used to formulate a framework for critique and discussion., Conclusion: An appropriate SOC as it relates to neuromonitoring is difficult to devise because of national variance with regard to qualifications of neurophysiologic technical and professional personnel, different levels of training and certification, and anesthesia protocols. A unified group of surgeons working in collaboration with a multidisciplinary group of experienced doctoral level nonphysician and physician professional surgical neurophysiologists is needed to define a protocol for providing and interpreting such data. In addition to ensuring that only the most qualified and experienced personnel are delivering and/or interpreting neuromonitoring services, surgeons, hospital administrators, and insurance company medical directors need to understand the different service delivery models and their respective strengths and limitations with particular attention to the qualifications and competencies of all respective parties. Only then can a well-defined SOC be established, thus improving the treatment of surgical patients for whom neuromonitoring is required.

Unlabelled: Unicameral bone cysts are benign bone lesions commonly seen in pediatric patients. Several treatment methods have been described with variable results and high recurrence rates. We previously reported short-term success of a minimally invasive technique that includes combining percutaneous decompression and grafting with medical-grade calcium sulfate pellets. The purpose of this study was to review the additional long-term results with a minimum followup of 24 months (average, 37 months; range, 24-70 months). We identified 55 patients with an average age of 10.8 years (range, 1.3-18 years). Forty-one of 55 lesions occurred in the humerus and femur. Forty-four of 55 (80%) patients had a partial or complete response after initial surgery; of these, seven obtained a partial or complete response after a repeat surgery (cumulative healing rate, 94%). Two patients underwent a third surgery (cumulative healing rate, 98%). One underwent a third repeat surgery (cumulative healing rate, 100%). There were no major complications associated with the procedure. Two patients had a superficial infection that resolved with oral antibiotics. Although some patients required a repeat procedure, complete or partial response at a minimum 24 months' followup was achieved in all patients., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Study Design: Retrospective case series from a multicenter database., Objective: To evaluate the risk of neurologic injury during growing rod surgeries and to determine whether intraoperative neuromonitoring is necessary for all growing rod procedures., Summary of Background Data: Although the use of growing rod constructs for early-onset spinal deformity has become a commonly accepted treatment, the incidence of neurologic events during growing rod surgeries remains unknown., Methods: We reviewed data from a multicenter database on 782 growing rod surgeries performed in 252 patients. VEPTR devices and any constructs with rib attachments were excluded. A questionnaire was sent to all surgeons contributing cases requesting detailed information about all neurologic events associated with any growing rod surgery., Results: There were 782 growing rod surgeries performed on 252 patients including 252 primary growing rod implantations, 168 implant exchanges, and 362 lengthenings. Five hundred sixty-nine of 782 (73%) cases were performed with neuromonitoring. Only one clinical injury occurred in the series, resulting in an injury rate of 0.1% (1/782). This deficit occurred during an implant exchange while attempting pedicle screw placement, and resolved within 3 months. There were 2 cases with neuromonitoring changes during primary implant surgeries (0.9%, 2/231), 1 change during implant exchanges (0.9%, 1/116), and 1 neuromonitoring change during lengthenings (0.5%, 1/222). The single monitoring change that occurred during a lengthening was in a child with an intracanal tumor who also had a monitoring change during the primary surgery. There are anecdotal cases (outside this study group series) of neuromonitoring changes during simple lengthenings in children with uneventful primary implantations., Conclusion: Based on our study, the largest reported series of growing rod surgeries, the rate of neuromonitoring changes during primary growing rod implantation (0.9%) and exchange (0.9%) justifies the use of intraoperative neuromonitoring during these surgeries. As there were no neurologic events in 361 lengthenings in patients with no previous neurologic events, the question may be raised as to whether intraoperative neuromonitoring is necessary for simple lengthenings in these patients. However, caution should be maintained when interpreting our results as anecdotal cases of neurologic changes from simple lengthenings do exist outside of this series.

Aneurysmal bone cyst (ABC) is a benign but locally aggressive tumor-like condition. Treating children with spinal involvement poses special hazards due to the proximity of the lesion to the spinal cord and the need to preserve spinal stability and balance after surgery. Twelve children with ABC treated between 1990 and 2002 at a tertiary pediatric musculoskeletal tumor center using modern surgical techniques and technology were retrospectively reviewed. A surgical technique using a four-step approach of intralesional curettage, high-speed bur, electrocautery, and bone grafting was found to have a significantly reduced rate of recurrence (0/8 cases) compared with traditional intralesional curettage and bone grafting (4/4 cases) (P < 0.002). Short-segment spinal fusion with instrumentation was also done in five cases immediately after excision of the ABC under the same anesthesia and was a nonsignificant marker for reduced rate of recurrence (P < 0.08), likely secondary to wide exposure. Overall, at last follow-up, all 12 patients were alive and well with no evidence of disease and no significant spinal deformity. The four-step approach to treatment of ABC of the spine with appropriate spinal instrumentation and fusion is recommended for successful treatment of this aggressive lesion.

There has been an unprecedented improvement in the survival outcome of children with extremity sarcoma as well as a corresponding increase in percentage of limb-sparing surgeries being performed over the past many decades. This has been, in part, due to the improved imaging modalities, newer surgical techniques, and advences in neoadjuvant chemotherapy. Limb-sparing surgery for primary bone and soft-tissue malignancies in children is becoming an acceptable option of surgical treatment in most cases today. This article outlines the demographics, classification, clinical presentation, imaging, and molecular genetics of pediatric mosculoskeletal tumors and discusses the current treatment principles with emphasis on the state-of-the-art surgical management and limb-sparing techniques for children with extremity sarcoma., (Copyright 2004 Wiley-Liss, Inc.)

Background: Halo ring and vest application in children requires torque wrenches capable of delivering a spectrum of torque values ranging from 0.11 to 0.68 N-m (1 to 6 in-lb). Published evaluations of torque wrenches commonly used in adults have shown that the measured torque values were within 10% of the target torque in only 64% of trials. The objective of the present study was to evaluate the accuracy, reliability, and interobserver variability of halo wrenches capable of applying the lower torque levels commonly used in children., Methods: Torque wrenches from four distributors (Bremer, Jerome Medical, Mountz, and PMT) were tested with use of a calibrated torque-meter. Five wrenches of each type were tested by a single observer, with fifty trials performed at six different torque settings (0.11, 0.23, 0.34, 0.45, 0.57, and 0.68 N-m). One wrench of each type was then tested by two additional observers at a torque setting of 0.34 N-m, with each observer performing fifty trials per wrench., Results: The measured torque value was within 10% of the target value in 69.2% of the 6400 trials, including 50.7% of the trials performed with the PMT wrench, 51.8% of those performed with the Bremer wrench, 84.5% of those performed with the Mountz wrench, and 90% of those performed with the Jerome wrench. Significant variability (p < 0.05) was found between at least two, and as many as five, wrenches of the same variety at each of three torque settings used for comparison (0.23, 0.45, and 0.68 N-m). Significant interobserver variability (p < 0.05) was found between at least two observers during testing of the Jerome and Mountz wrenches, but no significant differences were shown between observers during testing of the PMT and Bremer wrenches., Conclusions: The Jerome and Mountz wrenches are more accurate and reliable at low torque settings than the PMT and Bremer wrenches are. Variability among different wrenches from the same manufacturer may be seen with any of the wrenches studied.