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  • 1
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    Online Resource
    Sagittal Plane Considerations During Long Cephalomedullary Nailing: Optimal Distal Positioning and the Role of Intraoperative Nail Bending
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Journal of Orthopaedic Trauma Vol. 33, No. 11 ( 2019-11), p. 553-558
    Details
    In: Journal of Orthopaedic Trauma, Ovid Technologies (Wolters Kluwer Health), Vol. 33, No. 11 ( 2019-11), p. 553-558
    Abstract: To retrospectively review a large population of long cephalomedullary nails with special attention to distal implant position in the sagittal plane and assess the ability to avoid anterior cortical contact (ACC) by bending the distal tip of the nail intraoperatively. Design: Retrospective review of single surgeon experience. Setting: Single Level 1 trauma center. Outcomes: Radiographic position of the cephalomedullary nail with respect to the anterior femoral cortex and the effects of intraoperative bending of the distal tip of the nail. Patients: A total of 215 patients who underwent long cephalomedullary nailing for peritrochanteric hip fractures between 2007 and 2017 were reviewed. Results: In the period between 2007 and October 2013, ACC of the distal portion of the nail in the sagittal plane was a common finding. Its incidence significantly decreased after intraoperative bending of long cephalomedullary nails was incorporated into practice in cases where sagittal plane impingement was detected ( P 〈 0.0001). ACC was more prevalent if the final nail position was proximal to the level of the patella. Conclusion: Careful attention should be paid to sagittal plane anatomy and distal ACC during insertion of a long cephalomedullary nail. One strategy to prevent anterior impingement or perforation may be intraoperative bending of the distal end of the nail. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Type of Medium: Online Resource
    ISSN: 0890-5339
    URL: Article
    DOI: 10.1097/BOT.0000000000001577
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 2
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    Proximal Humeral Nonunion Treated With an Intramedullary Tantalum Cylinder
    SLACK, Inc. ; 2013
    In:  Orthopedics Vol. 36, No. 12 ( 2013-12)
    Details
    In: Orthopedics, SLACK, Inc., Vol. 36, No. 12 ( 2013-12)
    Abstract: Nonunion is uncommon after proximal humerus fracture surgery. There is no agreement about preferred method of treatment. Traditional approaches have included laterally based locking plates, autogenous grafting, and endosteal support to provide improved biomechanical stability. Open reduction and internal fixation (ORIF) of proximal humeral nonunion has been performed with various methods, including blade plates and bone grafting, as well as intramedullary support with autologous or allogenic grafts. Both malunion and nonunion have occurred after ORIF with locking plates. Endosteal support in the form of a fibular allograft incorporated into the locking plate construct can increase mechanical stability in selected cases. An ideal implant for proximal humeral nonunion provides medial column mechanical support and osteoconductive and osteoinductive properties. Porous intramedullary tantalum metal may play a role in nonunion surgery as an alternative to fibular allograft because of its versatility of use and salutary biological effects. It offers many material advantages for use in nonunion surgery. Tantalum is extensively porous (75%–80%), has a stiffness close to that of native bone, and offers the possibility of being a carrier for osteoinductive materials. It may also be suitable for patients who refuse allograft material. This article describes a 65-year-old woman with recalcitrant proximal humeral nonunion who was successfully treated with revision ORIF with intramedullary tantalum cylinder augmentation with a lateral-based locking plate and autogenous cancellous bone grafting. At 5-year follow-up, she had excellent motion and clinical and radiographic union.
    Type of Medium: Online Resource
    ISSN: 0147-7447 , 1938-2367
    URL: Article
    DOI: 10.3928/01477447-20131120-22
    Language: English
    Publisher: SLACK, Inc.
    Publication Date: 2013
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  • 3
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    Short-term causal effects of common treatments in ambulatory children and young adults with cerebral palsy: three machine learning estimates
    Springer Science and Business Media LLC ; 2022
    In:  Scientific Reports Vol. 12, No. 1 ( 2022-05-12)
    Details
    In: Scientific Reports, Springer Science and Business Media LLC, Vol. 12, No. 1 ( 2022-05-12)
    Abstract: Orthopedic and neurological impairments (e.g., muscle contractures, spasticity) are often treated in children and young adults with cerebral palsy (CP). Due to challenges arising from combinatorics, research funding priorities, and medical practicalities, and despite extensive study, the evidence base is weak. Our goal was to estimate the short-term effectiveness of 13 common orthopedic and neurological treatments at four different levels of outcome in children and young adults diagnosed with CP. The outcome levels considered were body structures, specific gait kinematic deviations, overall gait kinematic deviations, and functional mobility. We used three well-establish causal inference approaches (direct matching, virtual twins, and Bayesian causal forests) and a large clinical gait analysis database to estimate the average treatment effect on the treated (ATT). We then examined the effectiveness across treatments, methods, and outcome levels. The dataset consisted of 2851 limbs from 933 individuals (some individuals underwent multiple treatment episodes). Current treatments have medium effects on body structures, but modest to minimal effects on gait and functional mobility. The median ATT of 13 common treatments in children and young adults with CP, measured as Cohen’s D, bordered on medium at the body structures level (median [IQR] = 0.42 [0.05, 0.60] ) and became smaller as we moved along the causal chain through specific kinematic deviations (0.21 [0.01, 0.33]), overall kinematic deviations (0.09 [0.03, 0.19] ), and functional mobility (-0.01 [-0.06, 0.13]). Further work is needed to understand the source of heterogeneous treatment effects, which are large in this patient population. Replication or refutation of these findings by other centers will be valuable to establish the generalizability of these results and for benchmarking of best practices.
    Type of Medium: Online Resource
    ISSN: 2045-2322
    URL: Article
    DOI: 10.1038/s41598-022-11875-5
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2022
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  • 4
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    A model for understanding the causes and consequences of walking impairments
    Public Library of Science (PLoS) ; 2022
    In:  PLOS ONE Vol. 17, No. 12 ( 2022-12-28), p. e0270731-
    Details
    In: PLOS ONE, Public Library of Science (PLoS), Vol. 17, No. 12 ( 2022-12-28), p. e0270731-
    Abstract: Walking is an important skill with positive impacts on health, function, and well-being. Many disorders impair walking and its positive impacts through a variety of complex and interrelated mechanisms. Any attempt to understand walking impairments, or the effects of interventions intended to treat these impairments, must respect this complexity. Therefore, our main objectives in conducting this study were to (1) propose a comprehensive model for quantifying the causes and consequences of walking impairments and (2) demonstrate the potential utility of the model for supporting clinical care and addressing basic scientific questions related to walking. To achieve these goals, we introduced a model, described by a directed acyclic graph, consisting of 10 nodes and 23 primary causal paths. We gave detailed descriptions of each node and path based on domain knowledge. We then demonstrated the model’s utility using a large sample of gait data (N = 9504) acquired as part of routine care at a regional referral center. We analyzed five relevant examples that involved many of the model’s nodes and paths. We computed causal effect magnitudes as Shapley values and displayed the overall importance of variables (mean absolute Shapley value), the variation of Shapley values with respect to underlying variables, and Shapley values for individual observations (case studies). We showed that the model was plausible, captured some well-known cause-effect relationships, provided new insights into others, and generated novel hypotheses requiring further testing through simulation or experiment. To aid in transparency, reproducibility, and future enhancements we have included an extensively commented Rmarkdown file and a deidentified data set.
    Type of Medium: Online Resource
    ISSN: 1932-6203
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    DOI: 10.1371/journal.pone.0270731
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    Language: English
    Publisher: Public Library of Science (PLoS)
    Publication Date: 2022
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  • 5
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    Displaced Distal Radius Fractures in Children: To Reduce or Not to Reduce? To Pin or Not to Pin?
    Elsevier BV ; 2020
    In:  Journal of the Pediatric Orthopaedic Society of North America Vol. 2, No. 2 ( 2020-08), p. 77-
    Details
    In: Journal of the Pediatric Orthopaedic Society of North America, Elsevier BV, Vol. 2, No. 2 ( 2020-08), p. 77-
    Type of Medium: Online Resource
    ISSN: 2768-2765
    URL: Article
    DOI: 10.55275/JPOSNA-2020-77
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2020
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  • 6
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    Demonstrating the utility of Instrumented Gait Analysis in the treatment of children with cerebral palsy
    Public Library of Science (PLoS) ; 2024
    In:  PLOS ONE Vol. 19, No. 4 ( 2024-4-9), p. e0301230-
    Details
    In: PLOS ONE, Public Library of Science (PLoS), Vol. 19, No. 4 ( 2024-4-9), p. e0301230-
    Abstract: Instrumented gait analysis (IGA) has been around for a long time but has never been shown to be useful for improving patient outcomes. In this study we demonstrate the potential utility of IGA by showing that machine learning models are better able to estimate treatment outcomes when they include both IGA and clinical (CLI) features compared to when they include CLI features alone. Design We carried out a retrospective analysis of data from ambulatory children diagnosed with cerebral palsy who were seen at least twice at our gait analysis center. Individuals underwent a variety of treatments (including no treatment) between sequential gait analyses. We fit Bayesian Additive Regression Tree (BART) models that estimated outcomes for mean stance foot progression to demonstrate the approach. We built two models: one using CLI features only, and one using CLI and IGA features. We then compared the models’ performance in detail. We performed similar, but less detailed, analyses for a number of other outcomes. All results were based on independent test data from a 70%/30% training/testing split. Results The IGA model was more accurate than the CLI model for mean stance-phase foot progression outcomes (RMSE IGA = 11 ∘ , RMSE CLI = 13 ∘ ) and explained more than 1.5 × as much of the variance (R 2 IGA = .45, R 2 CLI = .28). The IGA model outperformed the CLI model for every level of treatment complexity, as measured by number of simultaneous surgeries. The IGA model also exhibited superior performance for estimating outcomes of mean stance-phase knee flexion, mean stance-phase ankle dorsiflexion, maximum swing-phase knee flexion, gait deviation index (GDI), and dimensionless speed. Interpretation The results show that IGA has the potential to be useful in the treatment planning process for ambulatory children diagnosed with cerebral palsy. We propose that the results of machine learning outcome estimators—including estimates of uncertainty—become the primary IGA tool utilized in the clinical process, complementing the standard medical practice of conducting a through patient history and physical exam, eliciting patient goals, reviewing relevant imaging data, and so on.
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    ISSN: 1932-6203
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    DOI: 10.1371/journal.pone.0301230
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    Language: English
    Publisher: Public Library of Science (PLoS)
    Publication Date: 2024
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  • 7
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    Lengthening of the Humerus Using a Motorized Lengthening Nail: A Retrospective Comparative Series
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Journal of Pediatric Orthopaedics Vol. 40, No. 6 ( 2020-07), p. e479-e486
    Details
    In: Journal of Pediatric Orthopaedics, Ovid Technologies (Wolters Kluwer Health), Vol. 40, No. 6 ( 2020-07), p. e479-e486
    Abstract: Lengthening of the humerus has traditionally been accomplished by the use of external fixation. Intramedullary motorized lengthening nails are now frequently used for lower limb lengthening, and this technology is slowly being adopted for use in the humerus. Methods: A retrospective, single-surgeon experience of pediatric humeral lengthenings was performed. The time period surveyed included use of external fixation (EF) for lengthening, and the use of a motorized nail (MN) for lengthening. The primary outcome measures were lengthening magnitude achieved, duration of lengthening, frequency and type of complications encountered, or further procedures required, during each lengthening. Results: From 1999 to 2018, 13 humeral lengthenings were performed in 9 patients. Six lengthenings were performed using the MN technique and 7 using the EF technique. The average absolute lengthening achieved was 8.5±1.3 cm in the EF group and 6.6±2.3 cm in the MN group. The duration of lengthening averaged 114 days in the MN group and 103 days in the EF group. The average duration of EF time was 215 days. Two patients underwent an initial EF lengthening of a humerus and then underwent a second lengthening using the MN technique. Two of 6 (33%) MN lengthenings and 3 of 7 (43%) EF lengthenings experienced complications during treatment. Two patients in the MN group underwent planned reversal and redeployment of their motorized nails to attain the planned lengthening magnitude. Conclusions: Humeral lengthening using motorized intramedullary nails is a safe technique that mitigates some of the complications of EF including pin site infection. It is well tolerated by patients. For lengthenings of a large magnitude, reversal and reuse of MN can be considered.
    Type of Medium: Online Resource
    ISSN: 0271-6798
    URL: Article
    DOI: 10.1097/BPO.0000000000001453
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 8
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    Extramedullary Motorized Lengthening of the Femur in Young Children
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Journal of Pediatric Orthopaedics Vol. 40, No. 10 ( 2020-11), p. e978-e983
    Details
    In: Journal of Pediatric Orthopaedics, Ovid Technologies (Wolters Kluwer Health), Vol. 40, No. 10 ( 2020-11), p. e978-e983
    Abstract: Limb lengthening by distraction osteogenesis is now achievable via motorized intramedullary devices, mitigating many complications of lengthening by external fixation. In young patients, antegrade intramedullary nailing of the femur risks avascular necrosis of the femoral head. A method of extramedullary placement of a motorized expandable intramedullary nail has been employed by the senior author to safely achieve femoral lengthening without the use of an external fixator in young patients. Methods: Eleven skeletally immature patients with lower limb length discrepancy were reviewed who underwent extramedullary placement of a magnetic, expandable intramedullary nail for lengthening of the femur. Surgical details, lengthening parameters, and complications were reviewed and classified according to the modified Clavien-Dindo Classification. Results: Average lengthening was 32.3 mm (range: 27 to 40 mm) comprising an average 14.8% of femoral segment length. The average lengthening duration was 6.3 weeks, and average full weight-bearing began at 12.6 weeks. All but 1 patient underwent early removal of the device at an average of 4.5 months, and 5 had immediate plating of the femur. Complications rates were comparable to other methods of femoral lengthening, including varus or procurvatum through the regenerate, and unplanned reoperation in 3 of 11 cases. Preoperative considerations included careful planning of implant length due to short femoral segments and protection of the knee joint from contracture or iatrogenic instability. Conclusions: Extramedullary placement of a magnetic expandable intramedullary lengthening nail can achieve lengthening of the femur without the use of external fixation. Considerations with this technique include careful planning of implant length relative to trochanteric-physeal distance, protection against knee subluxation during lengthening, and mitigating deformity of the regenerate. Off-label, extramedullary use of these devices can be considered to decrease the burdens of external fixation in young children. The technique begs the advent of future all-internal technology specifically designed for safe limb lengthening in this age group. Level of Evidence: Level IV—retrospective case series.
    Type of Medium: Online Resource
    ISSN: 0271-6798
    URL: Article
    DOI: 10.1097/BPO.0000000000001593
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 9
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    Intraoperative Neurological Monitoring in Lower Limb Surgery for Patients With Mucopolysaccharidoses
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Journal of Pediatric Orthopaedics Vol. 41, No. 3 ( 2021-03), p. 182-189
    Details
    In: Journal of Pediatric Orthopaedics, Ovid Technologies (Wolters Kluwer Health), Vol. 41, No. 3 ( 2021-03), p. 182-189
    Abstract: There are reports of spinal cord injury (SCI) occurring after lower extremity (LE) surgery in children with mucopolysaccharidoses (MPS). Intraoperative neurological monitoring (IONM) has been adopted in some centers to assess real-time spinal cord function during these procedures. The aim of this investigation was to review 3 specialty centers’ experiences with MPS patients undergoing LE surgery. We report how IONM affected care and the details of spinal cord injuries in these patients. Methods: All pediatric MPS patients who underwent LE surgery between 2001 and 2018 were reviewed at 3 children’s orthopaedic specialty centers. Demographic and surgical details were reviewed. Estimated blood loss (EBL), surgical time, positioning, use of IONM, and changes in management as a result of IONM were recorded. Details of any spinal cord injuries were examined in detail. Results: During the study period, 92 patients with MPS underwent 252 LE surgeries. IONM was used in 83 of 252 (32.9%) surgeries, and intraoperative care was altered in 17 of 83 (20.5%) cases, including serial repositioning (n=7), aggressive blood pressure management (n=6), and abortion of procedures (n=8). IONM was utilized in cases with larger EBL (279 vs. 130 mL) and longer operative time (274 vs. 175 min) compared with procedures without IONM. Three patients without IONM sustained complete thoracic SCI postoperatively, all from cord infarction in the upper thoracic region. These 3 cases were characterized by long surgical time (328±41 min) and substantial EBL (533±416 mL or 30.5% of total blood volume; range, 11% to 50%). No LE surgeries accompanied by IONM experienced SCI. Conclusions: Patients with MPS undergoing LE orthopaedic surgery may be at risk for SCI, particularly if the procedures are long or are expected to have large EBL. One hypothesis for the etiology of SCI in this setting is hypoperfusion of the upper thoracic spinal cord due to prolonged intraoperative or postoperative hypotension. IONM during these procedures may mitigate the risk of SCI by identifying real-time changes in spinal cord function during surgery, inciting a change in the surgical plan. Level of Evidence: Level III—retrospective comparative series.
    Type of Medium: Online Resource
    ISSN: 0271-6798
    URL: Article
    DOI: 10.1097/BPO.0000000000001720
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 10
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    What’s New in Limb Lengthening and Deformity Correction
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Journal of Bone and Joint Surgery Vol. 103, No. 16 ( 2021-8-18), p. 1467-1472
    Details
    In: Journal of Bone and Joint Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 103, No. 16 ( 2021-8-18), p. 1467-1472
    Type of Medium: Online Resource
    ISSN: 0021-9355 , 1535-1386
    URL: Article
    DOI: 10.2106/JBJS.21.00584
    RVK:
    XA 52200.A
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 220625-0
    detail.hit.zdb_id: 1473137-X
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