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Background: At many centers, double-leg spica casting is the treatment of choice for diaphyseal femoral fractures in children two to six years old. We hypothesized that such patients can be effectively treated with single-leg spica casting and that such treatment would result in easier care and better patient function during treatment.Methods: In a prospective, randomized controlled study, fifty-two patients two to six years old with a diaphyseal femoral fracture were randomly assigned to be treated immediately (after consent was obtained) with a single-leg (twenty-four patients) or double-leg (twenty-eight patients) spica cast. Serial radiographs were evaluated for maintenance of fracture reduction with respect to limb length, varus/valgus angulation, and procurvatum/recurvatum angulation. After cast removal, the performance version of the Activities Scale for Kids questionnaire and a custom-written survey were administered to the parents so that they could evaluate the ease of care and function of the children during treatment. Means were compared between treatment groups with use of Student t tests. P values of <0.05 were considered significant.Results: All limbs healed in satisfactory alignment. The children treated with a single-leg spica cast were more likely to fit into car seats (p < 0.05) and fit more comfortably into chairs (p < 0.05). Caregivers of patients treated with a single-leg cast took less time off work (p < 0.05). There were no major complications.Conclusions: Treatment of pediatric femoral fractures with a single-leg spica cast is effective and safe, and postfracture patient care is facilitated.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: In light of the increasing rate of obesity among children in the United States, this study examines whether obese children have an increased rate of complications following surgical treatment of femoral shaft fractures.Methods: A retrospective review of the charts of children between six and fourteen years of age who were treated operatively for a femoral shaft fracture was performed, and complications were identified.Results: One hundred and three children (104 fractures), with a mean age at the time of injury of 9.3 years, were identified. Fifty-nine fractures were treated with external fixation, and forty-five were treated with an intramedullary rod. Six children (6%) were considered obese, with a weight for age at the 95th percentile or higher. An additional four children were extremely heavy at the 90th to the 94th percentile of weight for age. Three complications occurred in the six obese children, and one complication occurred in the four extremely heavy children. Eleven (12%) of the remaining ninety-three children had a complication. When examined according to treatment groups, the complication rate for heavier children was higher for both the group managed with an intramedullary rod and the group that had external fixation (p = 0.004).Conclusions: Obese children have an increased rate of postoperative complications compared with children who are not obese. Therefore, parents of obese children should be warned that such children may have a potentially increased risk of complications associated with surgical management of a femoral fracture. [ABSTRACT FROM AUTHOR]

Background: Documentation of the clinical course of a compartment syndrome is critical to effective treatment; however, such documentation often is found to be inadequate.Methods: Notes and consent forms for thirty consecutive patients with adequate follow-up who had undergone fasciotomy for the treatment of compartment syndrome were reviewed for legibility, notation of the time and date, and documentation of the presence of core physical examination and history findings, including pain, paresthesias, tenseness, pain on passive stretch, sensory deficit, motor deficit, pulses, compartment pressures, and diastolic blood pressure.Results: Documentation was inadequate for twenty-one patients (70%): the notes and consent forms were not timed or not dated (or both) for nine patients (30%), and the notes were at least partially illegible for sixteen patients (53%). The documentation was incomplete with regard to the presence of paresthesias in eleven patients, pain on passive stretch in ten, sensory deficit in nine, motor deficit in eight, pulses in seven, pain in five, and tenseness in three. The documentation was incomplete with regard to the blood and compartment pressures for sixteen and six patients, respectively.Conclusions: The documentation of the core history and physical examination findings was inadequate in this series of patients with compartment syndrome. On the basis of the results of this study, and through an organizational systems approach, we have instituted for our residents, nursing staff, and faculty an educational program on the documentation of compartment syndrome in patients who are at risk for this condition. [ABSTRACT FROM AUTHOR]

Background: Compared with other orthopaedic subspecialties, pediatric orthopaedic surgeons are thought to be at greater risk for malpractice claims; however, there is scant research on this topic. The purpose of our study was to characterize publicly available malpractice cases pertaining to pediatric orthopaedics to determine the (1) most common specialties of the physicians implicated, (2) most common diagnoses involved, (3) rate of verdicts in favor of the plaintiff, (4) amount of indemnity payments resulting from all verdicts versus verdicts in which only an orthopaedic surgeon was involved, and (5) outcomes of cases that were appealed., Methods: The Westlaw legal database was queried for jury verdicts, settlements, and appellate cases using the search terms "pediatric" AND "orthopaedic" from December 31, 1984, to January 1, 2016, yielding 176 appellate court cases and 189 jury reports/settlements. After excluding duplicate cases and those involving patients aged 21 years or older, 36 appellate and 84 jury reports/settlement cases remained for analysis., Results: Lawsuits against orthopaedic surgeons and pediatricians were most common, in cases involving fracture diagnosis and misdiagnosis of developmental dysplasia of the hip, respectively. Of the 84 cases, 43 rulings favored the plaintiffs. The median (interquartile range) indemnity payment was $900,000 ($1.9 million), and for cases in which only the orthopaedic surgeon was named as the defendant, the median (interquartile range) indemnity payment was $675,000 ($827,000). Of the 34 appellate cases, 16 cases initially ruled in favor of the defendant were upheld and 13 were reversed/remanded. Five cases initially ruled in favor of the plaintiff were upheld, and none was reversed/remanded., Conclusions: Malpractice lawsuits named orthopaedic surgeons and pediatricians more often than physicians in other specialties. Orthopaedic surgeons were sued most often for management of fractures and pediatricians for mismanagement of developmental dysplasia of the hip. Nearly 51% of malpractice cases were ruled in favor of the plaintiff, with high indemnity payments. However, when cases that were ruled in favor of the physician were appealed, most verdicts were upheld., Level of Evidence: Level IV.

Background: Thoracolumbar kyphosis (TLK) is common in infants with achondroplasia. Our goals were to examine the natural history of TLK and identify factors associated with persistent TLK., Methods: We reviewed records of patients with achondroplasia seen by a board-certified orthopaedic surgeon at a tertiary care medical center between 1997 and 2013. Inclusion criteria were minimum 2-year follow-up and radiographs taken at time of presentation, within 6 months of walking age, and within 6 months of the first anniversary of walking age. We defined TLK as kyphosis of ≥20 degrees centered at T12 and L1. We assessed patient demographic characteristics, radiographic parameters (Cobb angle, apical vertebral translation, and apical vertebral wedging for vertebral height and width), and clinical parameters (developmental motor delay, hydrocephalus, presence of a ventriculoperitoneal shunt, and foramen magnum decompression). Developmental motor delay was defined as the inability to sit or ambulate independently by age 14 or 30 months, respectively. Associations between these factors and persistent TLK (ie, unresolved at final follow-up) were evaluated using logistic regression and χ, Fisher exact, and independent t tests. Significance was set at P<0.05., Results: A total of 60 patients were included. Mean values were as follows: age at presentation, 10.9±7.0 months; length of follow-up, 5.7±3.6 years; initial curve, 43.8±11.0 degrees; independent sitting age, 12.6±5.5 months; and independent walking age, 21.1±7.8 months. At walking age and 1 year after walking age, 15% and 58% of patients, respectively, had spontaneous TLK resolution. In total, 30% of patients had persistent TLK at final follow-up. Apical vertebral translation (P=0.001), percentage of apical vertebral wedging for vertebral height (P=0.031), and developmental motor delay (P=0.043) were associated with unresolved TLK., Conclusions: In patients with achondroplasia, TLK resolved at walking age in 15% of patients and after a year of walking in 58% of patients. Earlier bracing may slow TLK progression in patients with achondroplasia and developmental motor delay. Patients with kyphotic curves between 20 and 40 degrees should be examined intermittently for progressive deformity or worsening symptoms of spinal cord compression., Level of Evidence: Level II.

Objective: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion., Patients and Methods: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication., Results: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001)., Conclusion: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury., (Copyright © 2018. Published by Elsevier B.V.)

Study Design: Review of techniques and description of institutional clinical experience., Objective: To provide a historical review and description of key neuromonitoring concepts, focusing on neurogenic motor-evoked potentials and descending neurogenic evoked potentials, and to review the authors' experience with neuromonitoring techniques in children and adults undergoing spinal deformity surgery., Summary of Background Data: The original form of neuromonitoring, the Stagnara wake-up test, remains the "gold standard" for detecting true neurological deficits. Multiple newer modalities involving cortical and muscular monitoring, such as somatosensory evoked potentials and motor evoked potentials, have been developed and are widely used. Descending and neurogenic evoked potentials are becoming more common for neuromonitoring in patients undergoing spinal deformity surgery., Methods: A PubMed search for literature related to "neuromonitoring" was performed, and recent, as well as historical, articles were reviewed. Clinical experience regarding the use of neuromonitoring in adult and pediatric spinal deformity surgery was obtained from institutional experts., Results: Although not regularly used, the Stagnara wake-up test remains the gold standard for detecting neurological injury. Somatosensory evoked potentials measure signals transmitted from the periphery to the cortex and have historically been widely used but are limited by delay, poor localization, and the inability to detect damage to motor tracts. Motor evoked potentials continue to be used widely and measure muscular activity after cortical stimulation, but they are difficult to interpret in patients with underlying motor disorders and cannot be continuously monitored. Newer techniques such as descending neurogenic evoked potentials and neurogenic motor evoked potentials monitoring are used at some high-volume centers., Conclusions: Familiarity with the history of neuromonitoring in spinal deformity surgery and an understanding of the physiological systems used for neuromonitoring provide a framework from which spine surgeons can select appropriate monitoring for their patients.

Introduction: Numerous factors associate with health disparities. The extent to which such factors influence health-related quality of life (HRQOL) among adults with short stature skeletal dysplasias (SD) is unknown. In an effort to update and clarify knowledge about the HRQOL of adults with SD, this study aimed to quantify HRQOL scores relative to the American average and assess whether specific indicators are associated with lower scores., Methods: Members (>18 years) of Little People of America were invited to complete an online survey assessing HRQOL using the SF-12 supplemented with indicator-specific questions. SF-12 components (Physical Component Summary, PCS; Mental Component Summary, MCS) were compared to the standardized national American mean. Scores were divided at the median to identify factors associated with lower scores using multivariable logistic regression, adjusting for age, gender, race, education, and employment., Results: A total of 189 surveys were completed. Mean and median PCS and MCS were below the national mean of 50 (p < 0.001). Advancing decade of age corresponded to a significant decline in PCS (p < 0.001) but not MCS (p = 0.366). Pain prevalence was high (79.4%); however, only 5.9% visited a pain specialist. Significant factors for lower PCS included age >40 years (p = 0.020), having spondyloepiphyseal dysplasia congenita (SED) or diastrophic dysplasia relative to achondroplasia (p = 0.023), pain (p < 0.001), and "partial" versus "full" health insurance coverage (p = 0.034). For MCS, significant factors included a lack of social support (p = 0.002) and being treated differently/feeling stigmatized by health care providers (p = 0.022)., Conclusions: Individuals with SD face documented disparities and report lower HRQOL. Further research and interventions are needed to modify nuanced factors influencing these results and address the high prevalence of pain.

Background: Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation., Methods: From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications., Results: Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05)., Conclusions: Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation., Level of Evidence: Level III-Therapeutic.

Background: Anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries and their subsequent reconstructions are common in the general population, but there has been no research regarding ACL or PCL injuries in patients with achondroplasia, the most common skeletal dysplasia. Our goals were to (1) evaluate the prevalence of ACL and PCL injuries in adolescents and adults with achondroplasia, (2) compare this prevalence with that reported for the general population, (3) determine how many patients with ACL or PCL injuries underwent ligament reconstruction as treatment, and (4) determine patient activity levels as they relate to the rate of ACL/PCL injuries and reconstructions., Methods: We reviewed medical records of 430 patients with achondroplasia seen in the senior author's clinic from 2002 through 2014. Demographic data were reviewed, as well as any documentation of ACL or PCL injury or reconstruction. We called all 430 patients by telephone, and 148 agreed to participate in our survey, whereas 1 declined. We asked these patients about their history of ACL or PCL injury or reconstruction, as well as current and past physical activity levels., Results: No ACL or PCL injuries were found on chart review. One patient reached by telephone reported an ACL injury that did not require reconstruction. This yielded a theoretical prevalence of 3/430 (0.7%). Of the 148 patients surveyed, 43 (29%) reported low physical activity, 75 (51%) reported moderate physical activity, and 26 (17%) reported high physical activity. There was no significant difference in the rate of ACL injury when stratified by physical activity level (P=0.102)., Conclusions: ACL and PCL injuries and reconstructions are extremely rare in patients with achondroplasia, which cannot be completely ascribed to a low level of physical activity. One possible explanation is that patients with achondroplasia, on an average, have a more anterior tibial slope compared with those without achondroplasia, which decreases the force generated within the ACL and may protect against ACL injury. Further research is needed to explore possible causes., Level of Evidence: Level IV-retrospective review.

Background: Genu recurvatum, a posterior resting position of the knee, is a common lower extremity deformity in patients with achondroplasia and has been thought to be secondary to ligamentous laxity. To the best of our knowledge, the role of the tibial slope has not been investigated, and no studies describe the tibial slope in patients with achondroplasia. Our goals were to characterize the tibial slope in children and adults with achondroplasia, explore its possible role in the development of genu recurvatum, and compare the tibial slope in patients with achondroplasia to that in the general population., Methods: We reviewed 252 lateral knee radiographs of 130 patients with achondroplasia seen at our clinic from November 2007 through September 2013. Patients were excluded if they had previous lower extremity surgery or radiographs with extreme rotation. We analyzed patient demographics and, on all radiographs, the tibial slope. We then compared the mean tibial slope to norms in the literature. Tibial slopes >90 degrees had an anterior tibial slope and received a positive prefix. Statistical analysis included intraclass and interclass reliability, Pearson correlation coefficient, and the Student t tests (significance, P<0.05)., Results: The overall mean tibial slope for the 252 knees was +1.32±7 degrees, which was significantly more anterior than the normal slopes reported in the literature for adults (7.2 to 10.7 degrees, P=0.0001) and children (10 to 11 degrees, P=0.0001). The Pearson correlation coefficient for mean tibial slope and age showed negative correlations of -0.4011 and -0.4335 for left and right knees, respectively. This anterior tibial slope produces proximal and posterior vector force components, which may shift the knee posteriorly in weightbearing., Conclusions: The mean tibial slope is significantly more anterior in patients with achondroplasia than in the general population; however, this difference diminishes as patients' age. An anterior tibial slope may predispose to a more posterior resting knee position, also known as genu recurvatum., Level of Evidence: Level IV-retrospective case series.

Lateral condylar humeral fractures are the second most common elbow injury in children and commonly occur between the ages of 5 and 10 years. There are several systems for classification of this fracture, including those of Milch (fracture line location) and Jakob et al. (displacement). Although nonoperative management is indicated for nondisplaced or minimally displaced fractures (<2 mm), operative fixation is indicated for greater displacement. Traditionally, open reduction and internal fixation has been the method used to ensure adequate reduction. However, closed reduction and internal fixation techniques for displaced fractures have been receiving increasing attention, with recent studies showing promising results. Several constructs (multiple smooth pins, a single lag screw, and threaded pins) for closed reduction and internal fixation have been described. Smooth-pin fixation has the advantage of a small diameter and easy removal, whereas threaded pins combine a small diameter with compressive properties. Compression of these small, articular fractures is important, and the optimal mode of fixation for maintaining fracture reduction is debated. Fixation with a partially threaded lag screw works by achieving metaphyseal compression, preventing loss of reduction of the distal fragment. In our experience, the compressive abilities of smooth and threaded pins are limited in the soft osteocartilaginous lateral condyle. Partially threaded lag screw fixation is indicated for pediatric patients with a substantially displaced (Jakob type-II or III) lateral condylar fracture. The major steps of the procedure are (1) preoperative planning with anteroposterior, lateral, and oblique radiographs; (2) supine positioning of the patient with the shoulder in abduction; (3) closed reduction with manual pressure; (4) guide-pin insertion through the lateral column of the distal part of the humerus; and (5) exchange of the guide pin with a lag screw. Postoperatively, the elbow is immobilized with a bivalved long-arm fiberglass cast or a posterior splint. The cast or splint is removed after interval healing is demonstrated on radiographs, and the lag screw is removed after complete fracture union is demonstrated. Complications are rare, and patients are expected to have decreased infection and open-reduction rates compared those treated with pin fixation.

Background Context: Perioperative visual loss (POVL) after spinal deformity surgery is an uncommon but severe complication. Data on the incidence and risk factors of this complication after corrective surgery in the pediatric population are limited., Purpose: The present study aimed to investigate nationwide estimates of POVL after corrective surgery for pediatric scoliosis., Study Design: This is a retrospective study that uses a nationwide database., Patient Sample: The sample includes 42,339 patients under the age of 18 who underwent surgery for idiopathic scoliosis., Outcome Measures: The outcome measures were incidence of POVL and risk factors., Methods: Patients under the age of 18 who underwent elective surgery for idiopathic scoliosis between 2002 and 2011 were identified using the Nationwide Inpatient Sample database. The incidence of POVL (ischemic optic neuropathy, central retinal artery occlusion, or cortical blindness) was estimated after application of discharge weights. Demographics, comorbidities, and operative parameters were compared between patients with and without visual loss. A multivariate logistic regression was performed to identify significant risk factors for POVL development. No funds were received in support of this work., Results: The incidence of POVL was 1.6 per 1,000 procedures (0.16%). Patients with visual loss were significantly more likely to be younger and male, have Medicaid as insurance, and undergo fusion of eight or more spinal levels compared with patients without visual loss. Following multivariate analysis, older patients (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.77-0.91) and female patients (OR: 0.08; 95% CI: 0.04-0.14) were significantly less likely to develop POVL compared with younger and male patients. On the other hand, having Medicaid as insurance (OR: 2.13;95% CI: 1.32-3.45), history of deficiency anemia (OR: 8.64; 95% CI: 5.46-14.31), and fusion of eight or more spinal levels (OR: 2.40; 95% CI: 1.34-4.30) were all independently associated with POVL., Conclusions: In this nationwide study, the incidence of POVL after scoliosis surgery in patients under the age of 18 was estimated at 0.16%, similar to the rate reported in adult patients. Cortical blindness accounted for all cases of POVL in the present study. Younger patients, patients with history of deficiency anemia, and patients undergoing long-segment fusions may be at increased risk of POVL after corrective surgery for pediatric scoliosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Design: Retrospective chart review, case series., Objectives: To determine the prevalence of scoliosis and kyphosis in patients with achondroplasia., Summary of Background Data: There is little published research on the prevalence of scoliosis and thoracolumbar kyphosis in patients with achondroplasia., Methods: The authors retrospectively reviewed charts of 459 patients with achondroplasia who were seen by the senior author, an orthopedic surgeon, from 1999 through 2013, at a tertiary referral center. After excluding patients who presented after spinal surgery and those who were referred for specific non-spinal issues, 326 patients were included (71%). Cobb angles were measured on lateral and posteroanterior radiographs. Scoliosis was defined as curvature on posteroanterior radiographs greater than 10°; thoracolumbar kyphosis was defined as any kyphotic curvature with an apex between T11 and L2. These data were then stratified by sex, age group (0-2, 3-12, 13-19, 20-40, and >40 years), and severity: within normal limits (≤10°), mild (>10°-25°), moderate (26°-50°), and severe (>50°)., Results: The study population consisted of 176 males and 150 females with a mean age of 18 years. Scoliosis was observed in 60%. Thoracolumbar kyphosis was observed in 79%, with 52% exhibiting moderate to severe curvature., Conclusions: In these patients, the rates of scoliosis and kyphosis were 60% and 79%, respectively, which are much higher than the rates reported in the literature for the general population of children., Level of Evidence: Level 3 or 4., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Implant design may affect risk of fracture, especially in the proximal femur, which has been shown to have the highest risk of implant-related fracture (IRF). Blade plate (BPL) and screw-side plate (SSP) implants are used to stabilize proximal femoral osteotomies (PFOs). Our goal was to compare BPL and SSP constructs with regard to the rate, location, and timing of IRF in children undergoing PFOs., Methods: We retrospectively reviewed clinical and radiographic records from 1 pediatric orthopaedic practice from 1995 through 2010. We identified 734 children 18 years or younger who underwent PFO with a BPL (480 patients) or an SSP (254 patients). Manufacture and style of implants were consistent throughout this period. There were no significant differences between the 2 groups in terms of mean age, sex, race, or diagnosis. The 2 groups were compared with respect to the rate, location, and timing of IRF. The t, Z, χ, and Fisher exact tests were used to analyze the data (statistical significance, P<0.05 for all analyses)., Results: The IRF rates were 2.9% and 1.6% in the BPL and SSP groups, respectively (P=0.27). The overall rate of IRF in all patients was 2.5%. Fractures distal to the implant occurred in 7 of 14 patients in the BPL group and 3 of 4 patients in the SSP group. There was no significant difference between the 2 groups in location of fracture with respect to the implant (P=0.78). The mean times to fracture were 3.8±2.9 and 2.4±2.3 years (P=0.39) in the BPL and SSP groups, respectively., Conclusions: The risk of IRF in children after PFO is substantial. Despite differences in design, there was no significant difference between BPL and SSP implants with respect to IRF risk., Level of Evidence: Level III.

Orthopedic surgeons frequently encounter short statured patients. A systematic approach is needed for proper evaluation of these children. The differential diagnosis includes both proportionate and disproportionate short stature types. A proper history and physical examination and judicious use of plain film radiography will establish the diagnosis in most cases. In addition to the orthopedic surgeon, most of these patients will also be evaluated by other specialists, including endocrinologists and geneticists. This article provides an overview of the evaluation of the child with short stature and offers several illustrative examples., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Cervical spine fractures with spinal cord injury (CFSCI) can be devastating. We describe the epidemiology of children and adolescents with CFSCI., Methods: Using the Nationwide Inpatient Sample (NIS) database, we identified 4418 patients (≤18 years old) who had CFSCI from 2000 through 2010. Outcomes of interest were patient characteristics (age, sex), injury characteristics [fracture location, spinal cord injury (SCI) pattern], economic variables (duration of hospital stay, total hospital charges), and mortality., Results: Upper cervical fractures (UCFs) occurred half as often (31.4 %) as lower cervical fractures (LCFs; 68.8 %). Among patients <8 years old, 73.6 % had UCFs; among patients ≥8 years old, 72.3 % had LCFs. Overall, 68.7 % had incomplete SCI, 22.4 % had complete SCI, 6.6 % had central cord syndrome, and 2.3 % had anterior cord syndrome. Patients with complete SCI had the longest hospital stays and highest hospital charges. The overall in-hospital mortality rate was 7.3 %, with a sixfold higher rate in patients <8 (30.6 %) vs. those ≥8 (5.1 %) years old (p < 0.001). There was a threefold higher mortality rate in patients with upper (13.5 %) vs. lower (4.3 %) cervical fractures (p < 0.001). Patients with complete SCI had a 1.85-fold higher mortality rate than patients with other cord syndromes (p < 0.001)., Conclusions: Patients <8 years old were more likely than older patients to sustain UCFs. Patients with UCFs had a significantly higher mortality rate than those with LCFs. Patients with complete SCI had the longest duration of hospital stay and highest hospital charges and in-hospital mortality rate.

Background: This manuscript describes the clinical and operative characteristics of achondroplastic children who undergo multilevel thoracolumbar decompressions using either the high-speed drill or the ultrasonic bone curette (BoneScalpel)., Methods: We retrospectively reviewed 30 thoracolumbar decompressions in achondroplastic patients at a single institution between 2008 and 2013. Patients were classified into either the high-speed drill cohort or the BoneScalpel cohort, depending on which instrument was utilized to perform the decompression. A technical note on the role of the ultrasonic bone curette in decompressing stenotic achondroplastic spines is also provided., Results: In comparison with the high-speed drill cohort, the BoneScalpel cohort experienced less overall perioperative complications, including durotomy, cerebrospinal fluid leak, pseudomeningoceles, wound infection, and wound dehiscence. Although 45.0% of patients experienced a durotomy in the high-speed drill cohort, only 30.0% of patients experienced a durotomy in the BoneScalpel cohort (P = 0.694). In the high-speed drill cohort, the number of patients complaining of sensory disturbances, back pain, ataxia, incontinence, neurogenic claudication, radiculopathy, ataxia, and/or weakness decreased postoperatively. Similar results were observed in the BoneScalpel cohort., Conclusions: Although spinal decompression provides symptomatic resolution in patients with achondroplasia, intraoperative complications, in general, and durotomies, in particular, are common. Here, we report a decreased incidence in intraoperative durotomy and overall perioperative complication rates in the BoneScalpel cohort, although this did not reach the level of statistical significance. Nonetheless, the data demonstrate that the BoneScalpel is a safe and efficacious alternative to the high-speed drill in these challenging patients., Level of Evidence: Level II-retrospective study.

Purpose: There is limited literature on nonoperative treatment of open type I pediatric fractures. Our purpose was to evaluate the rate of infection in pediatric patients with type I open fractures treated nonoperatively at our institution without admission from the emergency department (ED)., Methods: We performed a retrospective chart review of all patients who sustained a type I open fracture of the forearm or tibia from 2000 through 2013. Forty patients fit the inclusion criteria: <18 years old with type I open fracture treated nonoperatively with irrigation and debridement, followed by closed reduction and casting of the fracture under conscious sedation in the ED. All patients were discharged home. The primary outcome was presence of infection. Secondary outcomes included occurrence of a delayed union, time to union, complications, and residual angulation., Results: There were no reported or documented infections. There was one case of a retained foreign body (<1 cm) in a mid-diaphyseal forearm fracture, which was removed in clinic at 4 weeks after the patient developed a granuloma with no infectious sequela. There was one case of a delayed union; all patients eventually had complete bony union. There was minimal residual angulation in both upper and lower extremities at last follow-up., Conclusions: Nonoperative treatment of type I open fractures in pediatric patients can be performed safely with little risk of infection. This preliminary evidence may serve as a foundation for future prospective studies.

Study Design: Prospective study., Objectives: To prospectively evaluate bone allografts during spinal fusion surgery for 1) the rate of contamination as a result of perioperative preparation, and 2) the types of bacterial organisms that may be transmitted through the contaminated bone allograft., Summary of Background Data: Bone allografts are routinely used to enhance spinal arthrodesis procedures. Ready availability and lack of donor site morbidity make them valuable alternatives to iliac crest bone grafts. Reports of disease transmission of such organisms as hepatitis C, the human immunodeficiency virus, and a variety of bacterial pathogens through allograft bone implants raise concerns for patient and practitioner safety., Methods: Our study population consisted of 50 consecutive (20 male and 30 female) patients (mean age at surgery, 15 years; range, 3-51 years) undergoing spinal deformity correction from May 2010 through October 2010, by 1 surgeon at 1 institution. The mean operative time was 297 minutes (range, 81-444 minutes), and the most commonly fused spinal levels were T5 to L4. During the procedure, the researchers prospectively obtained intraoperative microbial culture swabs from a container with freeze-dried allograft and from an empty identical control container. Aerobic and anaerobic bacterial culture growth was assessed for 7 days postoperatively. Each patient was observed for 6 weeks after surgery to ascertain any evidence of surgical-site infection., Results: Microbial cultures showed bacterial growth in 4 cases: 1 allograft specimen (day 4, very light Staphylococcus aureus) and 3 control specimens (day 3, very light Enterococcus; day 4, very light S aureus; and day 6, Propionibacterium acnes). No patient showed signs of infection in the perioperative or 6-week postoperative period., Conclusions: Intraoperative allograft preparation is not a major source of bone allograft contamination during spinal surgery., (Copyright © 2013 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective comparison., Objective: To compare complications and radiographic and functional outcomes of patients undergoing revision spinal deformity surgery, who were 40-64 years of age and 65 years of age or older., Summary of Background Data: The effect of age on radiographic and functional outcomes has not been well established in the literature for patients undergoing revision adult deformity surgery. The hypothesis was that the complications and radiographic and functional outcomes of younger and older adult patients would be comparable., Methods: The authors retrospectively reviewed prospectively collected data on 109 consecutive patients (84 women and 25 men) undergoing revision spinal deformity surgery who were 40 years of age or older. All surgeries were performed at 1 institution by the senior author. Patients were divided into groups based on age: younger than 65 years of age (70 patients) or 65 years of age or older (39 patients), and complications and radiographic and functional outcomes were compared. All patients had at least 2 years' clinical follow-up. Hotelling's t 2 test and the χ 2 test were used to compare differences; statistical significance was set at p < .05., Results: There was no significant difference between the 2 groups in major complications (p = .62), minor complications (p = .34), or reoperation rate (p = .08). Major correction was achieved in the coronal and sagittal planes in both groups after surgery. By final follow-up, patients in both groups had significant improvements from baseline in Oswestry disability index (p < .05) and in all Scoliosis Research Society-22 domains (p < .001); there was no significant difference in any domain score between groups (p > .05)., Conclusions: Older adult patients undergoing revision deformity correction surgery achieved functional outcome benefits comparable to those in younger adults without significantly more complications. Surgeons should be aware of these factors when counseling patients regarding revision surgery for deformity correction., (Copyright © 2013 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective review., Objective: To report and analyze the perioperative complications, radiographical results, and functional outcomes in elderly patients undergoing pedicle subtraction osteotomy (PSO) and/or vertebral column resection (VCR) procedures for spinal deformity correction., Summary of Background Data: To our knowledge, no studies have focused on 3-column osteotomies in the elderly., Methods: We retrospectively reviewed prospectively collected data for 51 consecutive patients 60 years or older undergoing 3-column osteotomies for spinal deformity correction (PSO, 36 patients; VCR, 13 patients; PSO and VCR, 2 patients) and who had at least 2 years' follow-up. We analyzed the perioperative complications; the preoperative, postoperative, and final follow-up radiographical measurements; and the preoperative, postoperative, and final follow-up functional outcome scores (using the Scoliosis Research Society-22 questionnaire and Oswestry Disability Index). Hotelling's t2 test and the χ2 test were used for analysis (statistical significance, P < 0.05)., Results: There were 9 (18%) major complications (5 with PSO and 4 with VCR) and 20 (39%) minor complications (14 with PSO and 6 with VCR). Compared with preoperative values, improvement at 6 weeks after surgery averaged 16° (range, 0°-42°) in thoracic scoliosis, 14° (range, 2°-25°) in lumbar scoliosis, 9° (range, 5°-35°) in thoracic kyphosis, -24° (range, -12° to -68°) in lumbar lordosis, 2.4 cm (range, 0-12 cm) in coronal balance, and 6.9 cm (range, -2 to 20 cm) in sagittal balance. At final follow-up, improvements in the coronal and sagittal balance were maintained. By final follow-up, compared with preoperative state, there were significant improvements in all 5 Scoliosis Research Society-22 domains and in the Oswestry Disability Index., Conclusion: In the elderly patient, PSO and VCR can achieve significant restoration of sagittal and coronal balance and significant improvement in quality of life. However, both techniques can lead to serious complications and should be selectively used.

The 22 modifier is a Current Procedural Terminology code modifier that allows surgeons to receive additional reimbursement for complex procedures. The goal of this study was to evaluate the rate of, time to, and factors affecting reimbursement for 22-modifier cases filed by orthopedic surgeons. The authors reviewed the charts and billing data of the 150 noncharity spine and total joint replacement cases filed with a 22 modifier at 1 academic institution from 2004 through 2011. Of those 150 cases, 63 (42%) were reimbursed at a rate higher than the fee schedule. For all 150 cases, the mean amount and mean percentage of additional reimbursement were -$86±$1966 (P=.7) and 5.5%±37% (P=.04), respectively. The mean reimbursement time for private and public payers was 138±126 days (P<.001) and 118±129 days (P<.001), respectively (standard time, 30 and 15 days, respectively). The mean present values of the amount and percentage received compared with the fee schedule were -$144±$1966 (P=.8) and 4.1%±37% (P=.09), respectively (discount rate, 5%). Anatomic variant was the only cited reason that increased the probability of additional reimbursement (P=.016). Citing that the case required additional time had no bearing on additional reimbursement. The authors conclude that additional reimbursement with the 22 modifier is inconsistent, has significant payment delays, and is not worth the effort for total joint replacement or spine surgery., (Copyright 2012, SLACK Incorporated.)

Background: To our knowledge, there are no comprehensive clinical studies of implant-related fractures in children. Our goal was to identify the incidence, skeletal location, and associated diagnoses of implant-related fractures., Methods: We reviewed our institutional database to identify cases of implant insertion (7584 cases) in patients less than 18 years old from January 1, 1995 through December 31, 2009. We calculated the overall incidence of these fractures and stratified the incidence by skeletal location and preoperative diagnoses. Fisher exact test was used to ascertain differences in fracture incidence. Risk ratios were calculated when appropriate. Significance was set at P<0.05., Results: There were 25 cases of implant-related fractures: 22 in the femur, 2 in the tibia, and 1 in the radius. The overall incidence of implant-related fracture was 0.33%; the incidence by skeletal location was: femur, 0.89%; tibia, 0.1%; and radius, 0.14%. Associated diagnoses were cerebral palsy (9 cases), hip dysplasia (3 cases), spina bifida (2 cases), and avascular necrosis (1 case); 10 cases were associated with "other diagnoses," which included various skeletal syndromes (5 cases) and traumatic fractures (5 cases). The incidences of implant-related fractures by diagnoses were: cerebral palsy, 1.1%; hip dysplasia, 1.1%; spina bifida, 1.3%; and avascular necrosis, 0.35%. The incidence of implant-related fracture in the "other diagnoses" group was 0.16%, and the incidence of fracture in otherwise healthy patients was 0.084%. The femur was 15.2 times more likely to fracture than other bones (P<0.001). Diagnoses of cerebral palsy, hip dysplasia, spina bifida, and avascular necrosis were 6.1 times more likely to be associated with implant-related fractures than the "other diagnoses" (P<0.001). The mean time to fracture in the study was 2.8 years. The overall implant removal rate at our institution was 24.3%, and it varied significantly by patient diagnosis (P<0.01)., Conclusions: Skeletal location and preoperative diagnosis should be factors of consideration in a surgeon's decision about removing implants to prevent implant-related fractures., Level of Evidence: Prognostic Level III.

Object: Spinopelvic parameters in children with achondroplasia have not been described. Because they observed a unique sagittal spinopelvic phenotype in some achondroplastic children with very horizontal sacrums, the authors sought to quantify the spinopelvic parameters in a pediatric patient population., Methods: A retrospective review was performed to identify all children (age range 1 month-10 years) with a diagnosis of achondroplasia between 2004 and 2009. Clinical and radiographic data were analyzed for age, sex, lumbar lordosis (LL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Differences among these variables were analyzed using a 2-tailed, unpaired Student t-test., Results: Forty children, 23 males and 17 females, with achondroplasia were identified during the study period. The mean age was 2.6 years. Two groups of patients were identified based on PT (that is, negative or positive tilt and horizontal or not horizontal sacrum). A negative PT was identified in all children with an extremely horizontal sacrum. Seventeen children had a negative PT (mean -16.6°), and the mean parameters in this group were 65.4° for LL, 31.7° for TLK, 18.5° for TK, 43.3° for SS, and 26.4° for PI. Twenty-three children had a positive PT (mean 17.9°), and the mean parameters in this group were 53.4° for LL, 41.5° for TLK, 9.6° for TK, 30.8° for SS, and 43.8° for PI. A statistically significant difference was observed for LL (p = 0.01), TLK (p = 0.05), SS (p = 0.006), PT (p = 0.006), and PI (0.0002)., Conclusions: Spinopelvic parameters in achondroplasia are potentially dichotomous. The future implications of this observation are not known and will need to be explored in future long-term studies that follow pediatric patients with achondroplasia through adulthood.

Object: The aim of this study was to assess the natural history of pain associated with spinal stenosis in individuals with achondroplasia and to characterize pain patterns and associated functional and psychological effects., Methods: The authors measured pain severity, spatial distribution of pain, functional disability, psychological distress, physical symptoms other than pain, and healthcare utilization in 181 individuals with achondroplasia. They also assessed low back and/or lower extremity pain at the initial visit and 1-year follow-up via self-rated patient questionnaires, calculated composite scores from responses via component analyses, and used repeated measures linear regression analyses for score changes (significance, p < or = 0.05)., Results: At the follow-up, back pain severity was unchanged. Patients reported significant progression of pain toward involvement of the lower extremities and significant increases in lower extremity pain severity overall. There were also significant increases in healthcare utilization overall. Compared with patients with back pain only, those with back pain and proximal or distal leg pain had higher self-rated pain severity; higher functional disability; and more bowel and bladder dysfunction symptoms, sleep disturbances, extremity numbness, and psychological distress., Conclusions: Individuals with achondroplasia and symptomatic spinal stenosis often experience back pain, which may progress to lower extremity pain and debilitating consequences. A more thorough understanding of the progression of spatial pain characteristics and pain severity may aid clinical decision making regarding the optimal timing for intervention.

Purpose: The Wilkins-modified Gartland classification of pediatric supracondylar humerus fractures does not consider coronal or sagittal obliquity. The purposes of our study were (1) to identify and describe fracture characteristics with unique properties and (2) to propose a fracture classification system that can be reproduced reliably., Methods: We retrospectively studied 203 consecutive displaced pediatric extension-type supracondylar humerus fractures treated operatively from January 1998 to January 2003. Fracture characteristics (eg, coronal and sagittal obliquity, postoperative alignment), type of surgical treatment, outcome, and complications were assessed and analyzed statistically with Student t test and a receiver operating characteristic curve. Significance was defined as P < 0.05. We incorporated significant cutoff values for fracture obliquity into our classification scheme and tested the classification's interobserver and intraobserver reliability., Results: We identified 4 coronal (typical transverse, medial oblique, lateral oblique, and high fractures) and 2 sagittal (low sagittal and high sagittal) subtypes with significantly different characteristics and outcome. Compared with fractures with coronal obliquity of less than 10 degrees, fractures with coronal obliquity of 10 degrees or greater were associated with significantly more comminution and rotational malunion. Compared with fractures with sagittal obliquity of less than 20 degrees, fractures with sagittal obliquity of 20 degrees or greater were associated with a significantly higher incidence of additional injuries and were more likely to result in extension malunion. Analysis of the interobserver and intraobserver reliability for our system identified correlation coefficients ranging from 0.772 to 0.907 and 0.860 to 0.899, respectively., Conclusions: Because pediatric extension-type supracondylar humerus fractures vary significantly in terms of characteristics, identification of sagittal oblique and coronal oblique angles may have an important role in surgical decision making and may impact outcomes.

To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.

Background: Lumbar decompressive surgery can be complicated by dural tears, infection, nerve root injury, deep venous thrombosis, and epidural hematoma. However, perioperative complications of multilevel laminectomies in patients with achondroplasia rarely are reported. Our objective was to determine the perioperative complication rates associated with laminectomies in patients with achondroplasia., Methods: We reviewed the medical records of the initial laminectomies for all ninety-eight patients with achondroplasia at our institution, which included twenty-eight patients who had had previous spine surgeries at other institutions, and determined the rates of complications in the following categories: neurologic, pulmonary, cardiovascular, and gastrointestinal complications; intraoperative dural tears; infections at the incision site; and mortality., Results: Sixty (61%) of ninety-eight patients had at least one perioperative complication. By category, these included intraoperative dural tears, which occurred in 37% (thirty-six patients); neurologic complications, in 23% (twenty-three patients); infections at the incision site, in 9% (nine patients); deep venous thrombosis, in 3% (three patients); pulmonary complications, in 3% (three patients); and gastrointestinal complications, in 3% (three patients). The only death was caused by a pulmonary embolism., Conclusions: Perioperative complications are common in patients with achondroplasia undergoing multilevel laminectomies, and the perioperative care team should be aware of these complications when caring for these patients.

Obesity is a widespread and potentially serious health problem in individuals with achondroplasia. In addition to obesity, such individuals commonly experience lumbar spinal stenosis. Although laminectomies have long been the method of choice for thorough lumbar decompression, to the best of our knowledge, the relationship between body mass index (BMI) and surgical outcomes after laminectomy in patients with achondroplasia has not been investigated in a large patient population. Through a retrospective medical record review of the initial laminectomies of all individuals with achondroplasia at our institution for whom adequate records were available, we evaluated the influence of BMI on surgical outcomes after laminectomy via four criteria: (1) change in Rankin score; (2) change in walking distance; (3) intra-operative and post-operative complications; and (4) need for subsequent revision laminectomies. The 49 individuals (mean BMI: 31.5 kg/m(2) at the time of laminectomy) were stratified into the standard BMI categories: normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), obese Class I (30-34.9 kg/m(2)), and a combined obese Class II (35-39.9 kg/m(2)) and obese Class III (>40 kg/m(2)). Our analysis indicated that there was no statistical difference between these groups in terms of the four criteria. When the study group was categorized into non-obese (normal weight and overweight) and obese (obese Classes I and II/III) groups, there was also no statistically significant improvement difference in terms the same four criteria. Our data suggest that obesity does not pose additional risks to laminectomy in individuals with achondroplasia.

Object: Achondroplasia is a hereditary form of dwarfism caused by a defect in endochondral bone formation, resulting in skeletal abnormalities including short stature, shortened limb bones, macrocephaly, and small vertebral bodies. In the pediatric population, symptomatic spinal stenosis occurs at all spinal levels due to the abnormally narrow bone canal. In this study, clinical outcomes were assessed in children with achondroplasia after spinal canal decompression., Methods: A retrospective review was conducted involving pediatric patients with heterozygous achondroplasia and symptomatic stenosis after decompressive procedures at the authors' institution within a 9-year period. Measured outcomes included resolution of symptoms, need for repeated surgery, presence of fusion, development of deformity, and complications. Forty-four pediatric patients underwent a total of 60 decompressive procedures. The average patient age at surgery was 12.7 years (range 5-21 years). Forty-nine operations were performed for initial treatment of stenosis, and 11 were performed as revision surgeries on previously operated levels. A large proportion of patients (> 60%) required additional cervicomedullary decompressions, most often preceding the symptoms of spinal stenosis. Of the initial procedures, decompression locations included 32 thoracolumbar (65%), 10 lumbar (20%), four cervical (8%), two cervicothoracic (4%), and one thoracic (2%). Forty-three of the decompressive procedures (72%) included spinal fusion procedures. Of the 11 revisions, five were fusion procedures for progressive deformity at levels previously decompressed but not fused (all thoracolumbar), five were for decompressions of symptomatic junctional stenosis with extension of fusion, and one was for repeated decompression at the same level due to recurrence of symptomatic stenosis., Conclusions: Decompression of the spinal canal in pediatric patients with achondroplasia can be accomplished safely with significant clinical benefit. Patients with a history of cervicomedullary compression may be at an increased risk of developing symptomatic stenosis prior to adolescence. Fusion procedures are recommended in patients with a large decompression overlying a thoracolumbar kyphosis to avoid progressive postoperative deformity.

One third of patients with achondroplasia develop spinal stenosis requiring surgical intervention. However, this condition rarely develops before the age of 15 years. The goal of the current study was to identify anatomical factors and clinical symptoms associated with early presentation of lumbar stenosis in such patients. The charts of 22 pediatric patients with achondroplasia who developed lumbar spinal stenosis requiring surgery (subjects) were reviewed retrospectively, focusing on clinical presentation, physical examination findings, and radiographic data. These findings were compared with those of a group of patients who had not developed stenotic symptoms (controls). Analysis was performed using chi2 test. Significance was set at P < 0.05. All 22 subjects presented with neurogenic claudication (weakness, pain, and/or numbness), and 77% had bladder incontinence. Compared radiographically with controls, the subjects had a significantly larger average percentage decrease in the transverse interpedicular distance from T12 to L5 (-8% vs -19%, respectively) and a significantly greater thoracolumbar kyphosis angle (24.2-degree angle vs 14.1-degree angle, respectively). These features were associated with an increased likelihood of developing symptomatic stenosis. The study indicated that 6 patients (32%) of the control group had caudal widening of the lumbar spine from T12 to L5.

Mallet fingers are difficult to treat, especially in surgeons, who need to sterilize their hands continuously and who have constant strains placed on their fingers. We successfully treated a nondominant, fifth-digit, nonbony mallet finger in a surgical resident with a splint method composed of a bent, semitubular, small-fragment plate and Steri-strips (3-M, St. Paul, MN). This splinting method allowed the resident to continue performing surgeries while the injury healed.

The etiology of genu varum in achondroplasia is the subject of much speculation. The purpose of the current study was to investigate the association between fibular overgrowth and genu varum in achondroplasia. A retrospective analysis was performed on the long-leg radiographs of 48 pediatric patients with achondroplasia. All patients were skeletally immature, and the average age was 7.7 years (range, 3-16 years). Boys were significantly more likely to have varus mechanical tibiofemoral angles than girls (Fisher exact test, P=0.038 for the right leg and P=0.008 for the left leg). The distance from the proximal and distal fibula to the proximal tibia knee and ankle joint orientation lines, respectively, was not associated with the alignment of the lower extremity. We conclude that fibular overgrowth does not correlate with the severity of genu varum.

Study Design: Retrospective prognostic study., Objective: To evaluate the safety and efficacy of cervical arthrodesis for cervical instability in patients with skeletal dysplasia., Summary of Background Data: Individuals with certain skeletal dysplasias have a high incidence of cervical instability, which can lead to compression of the spinal cord and subsequent severe spinal cord symptoms, progressive neurologic decline, quadriplegia, and death., Materials and Methods: The charts of 25 patients with skeletal dysplasia (spondyloepiphyseal dysplasia, spondyloepimetaphyseal dysplasia, pseudoachondroplasia, Morquio, or Kniest) who had undergone cervical arthrodesis to treat instability were reviewed for evidence of fusion, neurologic improvement, and complications., Results: Of the 25 patients, 23 (92%) achieved a solid bony fusion, and 5 (20%) experienced surgery-related complications. One of the two patients who did not achieve fusion had a stable pseudarthrosis without neurologic complications, and additional surgical intervention was unnecessary; the second patient is contemplating revision surgery. Of 16 patients with preoperative neurologic manifestations, 14 (88%) experienced improvement., Conclusion: Cervical arthrodesis can be a safe and effective treatment for patients with skeletal dysplasia and cervical instability, despite the inherent complications associated with a dysplastic skeleton. The procedure can preserve and/or improve neurologic function while minimizing the risk of neurologic injury from spinal cord compression.

Study Design: Retrospective review., Objectives: To determine the risk of postlaminectomy thoracolumbar kyphosis in skeletally immature achondroplasts and evaluate the need for concurrent fusion at multilevel decompression., Summary of Background Data: Spinal stenosis is a relatively common complication of achondroplasia. Although most achondroplasts do not develop symptomatic spinal stenosis until the third or fourth decades, some patients become symptomatic before skeletal maturity. While postlaminectomy kyphosis typically does not occur in the adult achondroplast, it is not known if it occurs in the skeletally immature achondroplast., Methods: The charts and radiographs of 10 consecutive skeletally immature achondroplasts that underwent surgical treatment for symptomatic spinal stenosis during a 10-year period were retrospectively reviewed. The average age of the 6 male and 4 female patients at surgery was 9.2 years (range 6-16). All patients had preoperative lateral radiographs. Decompression consisted of multilevel (5-8) thoracolumbar laminectomies. More than 50% of each medial facet was preserved bilaterally to maintain spinal stability., Results: Postlaminectomy thoracolumbar kyphoses developed in all 10 patients (100%). The postlaminectomy kyphoses ranged from 78 degrees to 135 degrees (mean 94 degrees ). All patients underwent spinal fusions with instrumentation, performed from 10 months to 2.6 years after the decompressions, to stabilize the kyphoses., Conclusions: Skeletally immature achondroplasts are at high risk for developing postlaminectomy thoracolumbar kyphoses. Therefore, concurrent spinal fusion is indicated in skeletally immature achondroplasts who undergo thoracolumbar laminectomies of at least 5 levels.

Study Design: Retrospective radiograph and chart review., Objectives: To assess the safety, efficacy, and complications after posterior spinal arthrodesis with instrumentation for thoracolumbar kyphosis in the pediatric achondroplast., Summary of Background Data: The conventional approach of anterior and posterior arthrodesis has achieved minimal correction, avoided instrumentation, and had a high risk of neurologic deterioration. To the current authors' knowledge, there are only two reports of successful instrumentation with pedicle screw fixation for kyphosis in pediatric achondroplasts; the outcome of such procedures remains largely unknown., Methods: The current authors evaluated the results of posterior spinal arthrodeses with instrumentation performed between 1998 and 2001 on 12 consecutive patients (mean age, 12 years). Indications for arthrodesis were concomitant laminectomy for neurologic symptoms or progressive deformity. Arthrodesis methods included anterior and posterior arthrodesis (5 patients) and posterior arthrodesis only (7 patients). Intraoperative somatosensory-evoked potentials, pedicle screw stimulation, and/or a wake-up test were used to confirm neurologic status in all patients., Results: Successful fusion was obtained in all patients. No intraoperative or postoperative neurologic deterioration was encountered. Mean improvement in kyphotic deformity was 50%. Complications included three instrumentation fractures (2 patients) and one dural leak. Parents rated outcome as excellent (4), good (6), and fair (2). No patients have subsequently experienced deformity progression., Conclusions: Spinal arthrodesis with vertebral body and/or pedicle screw instrumentation was a reliable technique for treating thoracolumbar kyphosis in achondroplasia and did not precipitate any of the neuromonitoring difficulties or neurologic deficits that have been reported in previous studies.

Persistent thoracolumbar kyphosis in patients with achondroplasia is typically prevented with sitting modifications and bracing. When the kyphosis persists and progresses despite bracing, spinal fusion is indicated to prevent further progression and neurologic complications. Previous reports have suggested that instrumentation in such patients carries a high risk of neurologic injury. The purpose of this study was to evaluate the safety and efficacy of a two-stage procedure to control progressive kyphosis in the patient with achondroplasia. The authors treated four such patients (4-8 years old) surgically. The first stage involved an anterior spinal fusion with instrumentation and a posterior spinal fusion, and the second stage involved an additional posterior fusion. There were no neurologic complications. Correction ranged from 23.0% to 31.25%. All patients achieved a solid fusion. These results suggest that when nonoperative treatments fail, this procedure for thoracolumbar kyphosis in the achondroplastic patient can be done safely and effectively.

Patients with substantial skeletal dysplasia and hip arthritis are poor candidates for noncustom total hip arthroplasty (THA) because of hip size and deformity. To determine the efficacy of THA via modified prostheses and surgical techniques in this population, the authors analyzed 9 consecutive THAs in 7 small-stature adults (mean height, 118.6 cm; mean weight, 47.5 kg). The Student t-test was used to test for significant (P < 0.05) differences in outcome variables. Seven hips received custom femoral components based on imaging studies. Five hips required extensive soft-tissue releases secondary to severe contractures. Follow-up radiographs (range, 24-56 months) showed adequate position of all prostheses and no loosening. Follow-up mean pain and function scores (Harris Hip Score and WOMAC Arthritis Index) showed significant improvement from preoperative levels.