JAAOS, Volume 26, No. 12

Management of Pediatric Femoral Neck Fracture

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

      • Subspecialty:
      • Trauma

      • Pediatric Orthopaedics

    Basic Science and Clinical Application of Reamed Sources for Autogenous Bone Graft Harvest

    Autologous bone graft remains the only clinically available source of graft material with osteogenic, osteoinductive, and osteoconductive properties. Although iliac crest autologous bone graft has long served as the benchmark, reamed autogenous bone graft offers several advantages. Reamed autograft has a biochemical and cellular profile that is at least equivalent, and perhaps superior, to that of iliac crest autograft. In addition, larger volumes of reamed autograft can be obtained via less-invasive techniques, giving surgeons an accessible source of mesenchymal stem cells that can be reliably and repeatedly harvested. Early clinical experience involving reamed autogenous bone graft in the management of nonunion, bone defects, and arthrodesis has been encouraging and has demonstrated the necessary properties to warrant regular consideration of reamed graft for these applications.

        • Subspecialty:
        • Basic Science

      Lateral Patellar Instability in the Skeletally Mature Patient: Evaluation and Surgical Management

      Lateral patellar instability is a common disease process that affects all types of patients. Depending on the patient’s anatomy and the results of preoperative imaging, surgical management options include medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, and sulcus-deepening trochleoplasty. Medial patellofemoral ligament reconstruction or repair is useful for almost all patients, whereas tibial tubercle osteotomy is helpful to correct a lateralized tibial tubercle and the associated elevated lateral pull of the extensor mechanism. For a select subset of patients with severe trochlear dysplasia, a sulcus-deepening trochleoplasty can be a useful option to prevent future patellar instability. Many technical considerations exist for each procedure, and in most situations, no consensus exists to direct surgeons on the superior technique.

          • Subspecialty:
          • Knee

          • Adult Reconstruction

        Lower Extremity Megaprostheses in Orthopaedic Oncology

        The megaprosthesis is designed to reproduce the form and function of a removed or lost large segment of bone and accompanying soft tissues. Slow but substantial improvements in the design and surgical implementation of these devices have advanced the capacity to restore patients’ functional abilities. The essential challenges include identifying the ideal materials, bonding these materials to bone and soft tissues, reproducing functional anatomy, and adapting to the growing skeleton. Failure of these devices can result from soft-tissue insufficiency, aseptic loosening, structural failures, infection, and tumor recurrence. The history of the use of megaprostheses in the pelvis, proximal femur, distal femur, total femur, and proximal tibia has shown that each anatomic area presents unique challenges. Improvements that have been made over the years will guide the development of the next generation of devices. Despite early high complication rates, these devices are a reasonable choice in the right patient.

            • Subspecialty:
            • Foot and Ankle

          Radiographic Resource Utilization in the Initial Referral and Evaluation of Patients With Adolescent Idiopathic Scoliosis

          Introduction: The dangers of radiation exposure in children have been well studied, with assessment of adolescent idiopathic scoliosis (AIS) documented as having the potential for notable patient exposure. The purposes of this study were to evaluate a consecutive series of patients referred to a tertiary care pediatric hospital for AIS and to assess the type and quality of imaging obtained before referral for specialist evaluation.

          Methods: We performed a prospective study of consecutive patients referred over a 6-month period to a pediatric orthopaedic practice at a large, free-standing, urban children's hospital for evaluation of AIS. We assessed prereferral radiographic exposure, evaluating the utilization and adequacy of these radiographs.

          Results: Of a total of 131 patients enrolled in the study, 79 had received radiographs before the visit; of these, only 59 patients (75%) brought the previously obtained radiographs to the specialist consultation, and 45 patients (76%) of this subset were found to be adequate for evaluation of AIS. Of the total cohort, 56 patients (43%) required repeat radiographs because of missing or inadequate radiographs.

          Discussion: We found a large number of missing or inadequate radiographs, leading to repeat radiation exposure in this cohort. Improvements in the utilization of radiographs before orthopaedic referral could decrease unnecessary patient radiation exposure.

              • Subspecialty:
              • Pediatric Orthopaedics

              • Spine

            Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training

            Introduction: We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not.

            Methods: We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non–trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment.

            Results: A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001).

            Discussion: We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group.

            Level of Evidence: Level III

                • Subspecialty:
                • Ankle

                • Trauma

                • Foot and Ankle