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Early-onset scoliosis (EOS) is defined as any spinal deformity that is present before 10 years old, regardless of etiology. Deformity must be evaluated based on the intercorrelation between the lungs, spine, and thorax. Curvatures of early-onset have increased risk of progression, cardiorespiratory problems, and increased morbidity and mortality. Progression of the deformity may produce thoracic insufficiency syndrome, where a distorted thorax is unable to support normal respiratory function or lung growth. Management and treatment of EOS should pursue a holistic approach in which the psychological impact and quality of life of the patient are also taken into consideration. Growth-friendly surgical techniques have not met the initial expectations of correcting scoliotic deformity, promoting thoracic growth, and improving pulmonary function.

Introduction: Pediatric back pain evaluation nowadays relies on patient history, physical examination, and plain radiographs to identify underlying pathologies. Constant pain, night pain, radicular pain, and abnormal neurological examination were previously recommended as clinical markers to assess the need for magnetic resonance imaging evaluation. Recent studies have challenged the use of these clinical markers, recommending further studies. This study aimed to assess pain intensity as a predictor of underlying magnetic resonance imaging pathology in children with back pain. Methods: An observational cross-sectional study of pediatric patients between 8 and 17 years with back pain for more than 4 weeks from 2009 to 2021 was conducted. A whole spine magnetic resonance imaging was performed on patients with back pain without an identifiable cause and no prior spine treatment. The numerical rating scale questionnaire was administered to each patient, and answers were divided into three groups: mild (1–3), moderate (4–6), and severe (7–10) numerical rating scale score. Student’s t-test and chi-square analysis were used to correlate differences between continuous and categorical values, respectively. Results: Of 590 patients (70% female and a mean age of 15.25 years), there were 35.1% of patients had a magnetic resonance imaging underlying pathology. No association was found between severe numerical rating scale score and the presence of underlying MRI pathology (p = 0.666). Patients with low or moderate numerical rating scale scores had similar associations to an underlying magnetic resonance imaging pathology as patients with a severe numerical rating scale score (p = 0.256; p = 0.357, respectively). Conclusions: Back pain intensity was not found to be an effective clinical marker for predicting underlying magnetic resonance imaging pathology in pediatric patients with back pain.

Restoring function to damaged peripheral nerves with a gap remains challenging, with50% of patients who undergo nerve repair surgery recovering function. Further, despite enormous efforts to improve existing techniques and develop new ones, the percentage of patients who recover function and their extent of recovery has not increased in almost 70 years. Thus, although sensory nerve grafts remain the clinical "gold standard" technique for attempting to restore function to nerves with a gap, they have significant limitations. They are effective in restoring good to excellent function only for gaps3-5 cm, repairs performed3-5 months post-trauma, and patients20-25 years old. As the value of any of these variables increases, the extent of recovery decreases precipitously, and if the values of two or all three variables increase, there is little to no recovery. Therefore, novel techniques are required that increase the percentage of patients who recover function and the extent of their recovery. This review discusses the limitations of sensory nerve grafts and other techniques currently being used to repair nerves. It also discusses the use of autologous platelet-rich plasma (PRP), which appears to be the most promising technique for inducing sensory and motor recovery even when the values of all three variables are significantly greater than when sensory nerve grafts alone are not effective. Thus, there is finally the promise that patients who presently have limited to no chance of any recovery may recover good to excellent sensory and motor function.

A spinal arachnoid web is a rare pathology that has been associated with the development of syringomyelia. Syrinx expansion can occur, which can result in the development of new symptoms. In the current literature, the farthest rostral expansion of the associated syrinx has been to the C3 spinal level.We present a 49-year-old Hispanic male with a thoracic spinal arachnoid web and an associated syrinx spanning from C1 to T7 spinal level. The patient developed upper extremities radicular symptoms that worsened over time. He underwent surgical management with T6-8 laminectomy and excision of the web. Postoperative follow-up evaluations demonstrated progressive clinical improvement with eventual resolution of symptoms and syringomyelia.Syringomyelia secondary to a thoracic spinal arachnoid web is a progressive disease that can expand rostrally to the C1 spinal level. The clinical presentation usually involves the lower extremities. However, if the upper thoracic or cervical spinal cord is involved, patients can also present symptoms in the upper extremities. Management usually involves surgical excision of the web in order to decompress the subarachnoid space and restore the normal cerebrospinal fluid (CSF) flow.Our case suggests that syringomyelia secondary to a spinal arachnoid web may continuously expand with concomitant worsening of symptoms. However, surgical resection is curative with possible remission of symptoms and normalization of spinal anatomy.

Early-onset scoliosis (EOS) is a well-known orthopaedic manifestation in patients with myelomeningocele. The rib-based growing system (RBGS) has been proposed as an alternative for these individuals because of the poor outcomes with traditional surgical techniques. We aimed to describe the effect of RBGS in patients with nonambulatory EOS myelomeningocele.We retrospectively reviewed the Pediatric Spine Study Group Multicenter Database for all patients with nonambulatory EOS myelomeningocele treated with RBGS from 2004 to 2019. Demographics, surgical data, radiographic findings, and postoperative complications were obtained. The quality-of-life parameters were assessed postoperatively using the Early-onset Scoliosis Questionnaire-24.Thirty patients (18 women; 60%) were patients with nonambulatory EOS myelomeningocele treated with RBGS. The mean age at the initial surgery was 5.3 years. The thoracic (T1-T12) spine height showed a significant increase from initial surgery to the most recent follow-up (P0.001). Spine (T1-S1) height was also significantly increased (P0.001). The postoperative complication rate was 87%. The Early-onset Scoliosis Questionnaire-24 demonstrates significant improvements in the quality-of-life scores (P = 0.037).This study demonstrated that RBGS could improve the reported quality-of-life scores in patients with nonambulatory EOS myelomeningocele when assessed with an EOS-oriented tool. Moreover, we confirmed the ability of RBGS to hold or even correct spinal deformity.

Background Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Methods Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Results Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00–3.00 cm). A weak direct relationship (R = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated (p = 0.811). Conclusion This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

Adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) usually require surveillance in the pediatric ICU (PICU). Some reports have documented evidence of hypomagnesemia following PSF at PICU. Little has been studied about relationship between AIS and postoperative serum magnesium (Mg+2) levels. The aim of this study is to determine the prevalence and risk factors of hypomagnesemia in AIS patients admitted to PICU after PSF. IRB approved the cross-sectional study of AIS patients admitted to PICU after PSF from January 2016 to May 2017. Serum electrolyte levels of phosphorous, calcium, sodium, potassium and hemoglobin were taken preoperative and 24 h postoperative and compared with postoperative magnesium levels. Blood volume reinfused from cell saver return (CSR), estimated blood loss (EBL), volume of fluids intraoperative and average of vertebra levels operated were charted and compared with postoperative magnesium levels. A total of 46 AIS patients undergoing PSF met inclusion criteria, with an average age of 15 years (78% female). Postoperatively, hypomagnesemia was reported in 24/46 patients (53%). No association was found between hypomagnesemia and serum electrolyte (phosphorous, calcium, sodium and potassium) or hemoglobin levels. In addition, no statistical association was found with age, operative time, vertebrae level fused, CSR, EBL and volume of fluids intraoperatively. Fifty-three percent of pediatric patients developed hypomagnesemia after surgical correction for AIS. Further investigation of this electrolyte disturbance will likely result in a useful clinical tool for physician in the management of AIS.

Cross-sectional comparative study. Evaluate prevalence and clinical relevance of an underlying pathology in painful adolescent idiopathic scoliosis (AIS) patients after a non-diagnostic history, physical examination and spinal X-ray using Magnetic Resonance Image (MRI) as diagnostic tool. Discrepancies regarding indications of routine MRI screening in painful AIS patients are multifactorial. Few studies have investigated relationship and practical importance of painful AIS with an underlying pathology by MRI. A total of 152-consecutive AIS patients complaining of back pain during a 36-month period were enrolled. All patients underwent whole-spine MRI after a non-diagnostic history, physical examination and spinal X-ray. Underlying pathologies were reported as neural and non-neural axis abnormalities based on MRI reports. Variables such as sex, age, constant or intermittent pain, night pain, back pain location (thoracic or lumbar pain), Cobb-angle and follow-up were evaluated as clinical markers to predict presence of underlying MRI pathologies. The presence of an underlying pathology was found by MRI in 54 painful AIS patients (35.5%). Isolated syringomyelia was the only neural axis abnormality found in 6 patients (3.9%). Non-neural axis abnormalities (31.6%) were composed by: 32 herniated nucleus pulposus, 5 vertebral disc desiccation, 4 ovarian cysts, 3 renal cysts, 2 sacral cysts, and 2 vertebral hemangiomas. There was no association with gender, age of presentation, initial coronal Cobb angle and follow up; with presence of an underlying pathology. Lumbar pain location was identified as an adequate clinical marker that correlated with presence of an underlying pathology (p = 0.01). Prevalence of underlying pathologies diagnosed by MRI in painful AIS was found high (35.5%), but it’s clinical relevance and implication are debatable. The use of MRI did not affect orthopedic management of painful AIS patients who showed an underlying pathology. A thorough evaluation must be performed by clinicians; and discussed with patients and family prior to undergo further imaging management. Level III.

Highlights • Giant cell tumor of bone (GCTB) at proximal humerus in skeletally immature (SI) patients is rare. • MRI and clinical evaluation are paramount for the GCTB diagnosis. • Tumor resection with cementation and adjuvant therapy is described as GCTB treatment. • GCTB should be suspected in all SI cases with enlarged proximal humerus lesions., Introduction Giant cell tumor of bone (GCTB) in skeletally immature (SI) patients are rare benign lesions that have locally aggressive growth pattern and high risk of recurrence. The presence of GCTB at the proximal epiphysis of humerus in SI patients has never been described in literature. Presentation of case This report shows the case of a 10-year-old SI male who presented with a GCTB at the proximal epiphysis of humerus that was treated with curettage, cement and adjuvant therapy. Discussion The presence of a lytic growing lesion at the proximal humerus in a SI patient should alert clinicians to consider GCTB in their differential diagnosis. The management of GCTB in SI patients is challenging for orthopaedic surgeons. Tumor resection with cementation and adjuvant therapy has been described as a method rationale to prevent the recurrence and preserve the joint function in SI patients with GCTB at the proximal epiphysis of humerus. Clinicians should continue to monitor these patients with radiographic imaging for possible recurrence, metastasis or growth plate injury. Conclusion Tumor resection with cementation and adjuvant therapy offers a treatment alternative to prevent the recurrence and preserve the joint function in SI patients with GCTB at the proximal epiphysis of humerus. The use of a prothesis in a SI patient should avoided if possible, to prevent implant-related complications and damage to the growth plate.

An isolated hook of hamate fracture is an extremely rare condition in skeletally immature patients. Early diagnosis and treatment are vital for the functional outcome of athletes such as baseball players. The hook of hamate fracture may be missed at initial presentation due to nonspecific symptoms and false-negative radiographs, which may eventually lead to a nonunion. Currently, there is no clear indication of surgical intervention for nonunion of the hook of hamate in a skeletally immature patient. This report presents the case of a twelve-year-old skeletally immature male with a hook of hamate fracture who underwent surgical bone fragment excision three months after initial injury due to a nonunion of the hamate bone. At the two-year postoperative visit, excellent results were obtained, and patient was able to continue his sports activity without any functional impairment.

Background & Objectives: Recently, constant and night pain has been discarded as adequate clinical markers to predict the presence of an underlying pathology in pediatric back pain. The pain intensity has been recognized as an important domain in the pain assessment. Numerical Rating Scale (NRS) is one of the most common validated tools to assess pediatric pain intensity in children above 8 years of age. The aim of this study is to assess NRS as a predictor of underlying pathologies found by magnetic resonance image (MRI) in pediatric back pain. We hypothesize that a higher NRS score is associated with a high sensitivity, specificity and likelihood ratio to identify the present of organic pathology in pediatric chronic back pain. Methodology: After obtaining Institutional Review Board approval, a retrospective electronical medical record review was conducted. All pediatric patients who reported back pain lasting > 4 weeks between 2009 to 2018 were enrolled in the study. As per regular protocol, a pediatric orthopedic surgeon evaluated all patients who presented with back pain. After a non-diagnostic history, physical examination and spinal x-ray; spine MRI was order. Pain was graded with the use of NRS from 0 to 10. Patients were divided in two groups: NRS (1-5) & NRS (6-10). Variables such as gender, age, pain frequency, night pain, neurological exam, and the presence of an underlying pathology were compared between both groups. Patients that presented with injury due to trauma, previous diagnosis of back pain or cervical pain were excluded. Results: A total of 467 patients were evaluated in the study. Mean age of subjects was 15 years; 69% being female. An underlying pathology was identified in 131/315 (41.6%) patients with NRS (6-10), and 55/152 (36.2%) patients with NRS (1-5) (P=0.27). Patients with NRS (6-10) had two times more probability of suffering constant pain (PConclusion: Evaluation and treatment of children and adolescent with chronic back pain is challenging. Our study shows a strong association between NRS high (6-10) and constant pain and/or abnormal neurological exam. However, the use of NRS of (6-10) was not found as adequate predictor for the presence of an underlying organic pathology in children and adolescent patients. Therefore, physicians should not rely only high NRS score to recommend advance imaging study to assess chronic back pain in children and adolescent patients. Summary [Table: see text]

Purpose The aim of this study was to evaluate the associated factors of patients with LSS who undergo reoperation after a PLSF in a Hispanic-American population. Methods A retrospective single-center review was performed from all non-age-related Hispanic-Americans with LSS who underwent one or two-level PLSF from 2008 to 2018. Baseline characteristics were analyzed between the reoperation and no-reoperation group using a bivariate and multivariate analyses. Results Out of 425 patients who underwent PLSF, 38 patients underwent reoperation. At a two-year follow-up, the reoperation rate was 6.1% (26/425), mostly due to pseudoarthrosis (39.5%), recurrent stenosis (26.3%), new condition (15.8%), infection (10.5%), hematoma (5.3%), and dural tear (2.6%). Patients who underwent reoperation were more likely to have a preoperative history of epidural steroid injection (ESI) (OR 5.18, P = 0.009), four or more comorbidities (OR 2.69, P = 0.028), and operated only with a posterolateral fusion without intervertebral fusion (OR 2.15, P = 0.032). Finally, the multivariable analysis showed that ESI was the only independent associated factor in patients who underwent reoperation after a PLSF in our group. Conclusion Among this population who underwent surgery, a reoperation rate at two years of follow-up was less than ten percent. Our study did not find any associated factor inherent to Hispanic-Americans, as ethnic group, who were reoperated after LSS.

The sustained use of intraoperative fluoroscopy has led to increased use of minimally invasive surgical techniques, enhanced surgeon proficiency, improved anatomic corrections, reduced patient morbidity, earlier functional recovery, and decreased length of hospital stay. As a result, orthopedic attending surgeons and residents are exposed to more radiation, increasing the risk of cancer and radiation-induced cataracts compared with the general population and those who work in other surgical specialties. The magnitude of radiation exposure depends on the susceptibility of the tissues affected, medical specialty, the position of the C-arm, distance from the radiation beam, level of difficulty of the surgical procedure, surgeon experience, level of resident training, and level of supervision by the attending surgeon. However, little information is available on the effect of supervision level on radiation exposure for orthopedic senior residents. The goal of this study was to investigate whether level of supervision by the attending surgeon affects the radiation exposure of orthopedic senior residents during surgical treatment of proximal femur fracture with cephalomedullary nail fixation. This retrospective cohort study was performed from January 2019 to March 2019. No significant relationship between supervision level and radiation exposure of senior residents was observed. Supervision level does not significantly affect radiation exposure for senior residents; therefore, the implementation of standardized training in radiation safety may be a more essential measure to decrease radiation exposure. [ Orthopedics . 2021;44(3):e402–e406.]

Tenosynovial chondromatosis (TC) is a rare progressive benign tumor from the synovial lining of tendon sheath. The TC mostly affects males between the ages 30 to 50 years old at the ventral side of wrist. There are two different forms of TC that have been proposed in previous studies: an idiopathic cause (primary TC) and a joint related diseases cause (secondary TC). Even though trauma has been written to be a common reason for TC, a case of a secondary TC affecting the dorsal wrist following a triquetrum fracture has never been written before. The aim of this report is to present a rare case of a solitary post-traumatic TC at the dorsal wrist following a triquetrum fracture. We describe the clinical presentation, imaging modalities, histopathological and treatment challenges to manage this difficult lesion.

Background/Purpose: Rib based growing system have been presented as an alternative to improve clinical status, spinal deformity and pulmonary function in patients with early onset scoliosis. The aim of this study is to evaluate respiratory and postoperative long-term outcomes in early onset scoliosis patients who undergo a rib based growing system (RBGS). Methods: Retrospective single-center study of all early onset scoliosis patients treated with a RBGS and repeated …

Case A 13-year-old female gymnast sustained a diaphyseal both-bone forearm fracture due to a grip lock injury. Conclusion This is a report of a diaphyseal both-bone forearm fracture due to a grip lock injury in a female pediatric gymnast, successfully treated with closed reduction and cast immobilization. The rare mechanism of injury, education, and treatment have been discussed.

Microvascular free-tissue transfer (M-FTT) is a surgical technique for traumatic injuries that allows tissue reconstruction based on donor tissue composition. The aim of this study is to describe the surgical experiences of M-FTT for reconstruction of complex soft tissue injuries in the lower extremities of a Hispanic population.This is a descriptive study of all M-FTT procedures performed by a single plastic surgeon from 2012 to 2016 at Puerto Rico Medical Center. Demographics, admission diagnosis, mechanism of trauma, type of free flap, co-morbidities, length of stay, donor site and complications were evaluated.Eight patients who underwent single M-FTT procedures at lower extremity were enrolled in the study. The average age at time of surgical reconstruction was 36.9+13.2 years with six males and two females. The transfer procedures were performed using donor sites of six rectus abdominis flaps and 2 radial forearm flaps. Posterior tibial artery was used in 62.5% and popliteal artery were used in 37.5% as recipient arteries. Average surgical time was 4.4+0.7 hours with an average length of hospital stay of 22.9+20.1 days. Post-operative complications were reported in three M-FTT procedures: two cases who suffered venous thrombosis and one case who suffered partial necrosis.The M-FTT offers an adequate surgical option for patients who present with complex soft tissue traumatic injuries at the lower extremities.

Introduction: There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience. Material & Methods: A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed. Results: A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons Discussion and Conclusions: This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Actinomycosis is a chronic granulomatous disease associated with the Actinomyces species. This unusual condition, especially in the musculoskeletal system, has been considered a diagnostic challenge due to its initial non-specific symptoms requiring high clinical suspicion and an adequate diagnostic approach for its identification.We present the case of a 39-year-old Hispanic female with right knee pain and associated purulent secretions for the past four years, who demonstrated persistent synovial actinomycosis despite arthrotomy with cleansing and debridement plus a long-term antibiotic regime.Actinomyces species remain a rare cause of musculoskeletal disease. Its presentation could include localized swelling, tissue fibrosis, sinus tracts, or an abscess, yet these symptoms are not specific, requiring high clinical suspicion to avoid a potential misdiagnosis. Culture in an anaerobic media and pathologic specimens are vital diagnostic tools. Among the treatment alternatives, antimicrobial therapy and surgery are usually required to manage bone and joint infections. Adequate antibiotic selection is crucial, as suboptimal treatment could promote the development of a persistent infection.This case highlights the diagnostic challenge of synovial actinomycosis, a rarely reported condition in native knee joints. High clinical suspicion is critical as early diagnosis, and adequate management is essential to avoid a persistent infectious process.

Myoepithelial tumors are under-recognized neoplasms that could be difficult to identify due to their rarity and limited comprehension. Their diverse morphology, varied cytologic features and heterogenous immunohistochemical characteristics create a significant diagnostic challenge.We report the case of a 72-year-old-male patient who received conservative treatment during one year for a popliteal mass on the right knee that showed synovial hyperplasia (benign findings) at initial open tissue biopsy. New symptoms of popliteal area enlargement and discomfort required a second incisional biopsy to reach the diagnosis of a soft tissue myoepithelial tumor through tissue analysis and immunohistochemical staining.The myoepithelial tumors represent a medical dilemma due to their heterogenic features requiring high level of suspicion and adequate immunohistochemical markers for their diagnosis.Orthopaedic surgeons should be aware of the atypical presentation of these rare neoplasms to provide an early diagnosis and adequate management.

The use of constant pain and night pain as clinical markers for predicting the presence of underlying pathology in painful adolescent idiopathic scoliosis (AIS) patients has been questioned. Pain intensity has been recognized as an important domain in pain assessment. The numerical rating scale (NRS) is one of the most commonly validated tools to assess pain intensity in children above 8 years of age. The aim of this study was to assess the NRS as a predictor of underlying pathologies found by MRI in painful AIS patients. A cross-sectional study comprising of all AIS patients with back pain lasting >4 weeks from April 2015 to April 2019 was performed. An MRI was performed on each AIS patient presenting with back pain after a nondiagnostic history, physical examination and spinal X-ray. The pain was graded using the NRS, ranging from 0 to 10. Patients were divided into three groups: NRS (1-3), NRS (4-6) and NRS (7-10). Variables, including gender, age, scoliosis magnitude and presence of underlying pathology, were compared between the groups. A total of 186 AIS patients were evaluated in the study, were 66/186 (35.5%) of them had underlying pathologies. The mean age of subjects was 14.7 years, 85% being female. An underlying pathology was identified in 4/11 (36.4%) with NRS (1-3), 28/82 (34.2%) with NRS (4-6) and 34/93 (36.6%) with NRS (7-10) (P = 0.94). The use of an NRS was not found to be an adequate predictor for identifying an underlying pathology via MRI in painful AIS patients.

This is a rare case of a 42-year-old Hispanic male with macrodactyly who presented with recurrent carpal tunnel syndrome (CTS) due to Lipofibromatous Hamartoma (LFH). A slowly growing mass in his right palm with pain and numbness, along with motor and sensory deficits in the median nerve distribution, was reported since the past year prior to visit. Previous open carpal tunnel release was performed at 16 years of age due to CTS without complications. The diagnosis of LFH was made based on ultrasound, electromyography test and physical examination. An extended open carpal tunnel release with transection of transverse ligament was performed. The 24-month postoperative evaluation showed complete resolution of symptoms. This report illustrates the management of a recurrent CTS due to LFH in a Hispanic adult patient with macrodactyly that was successfully treated with a carpal tunnel decompression.

Introduction: Demographic and socioeconomic factors are important determinants that may affect patient self-reported outcomes after acetabular fracture surgery. Hispanics, as a minority group, have an increased tendency to suffer demographic and socioeconomic disparities. At the present time, there is scant information regarding their role among Hispanic patients with acetabular fractures. The aim of this study was to investigate whether demographic or socioeconomic factors would affect satisfaction and self-reported functional outcomes in Hispanic patients who endured open reduction and internal fixation (ORIF) of posterior wall fractures of the acetabulum. Methods: A cross-sectional study of 78 patients with posterior wall fracture of the acetabulum treated with ORIF from 2011 to 2017 was performed. Data from demographics (age, sex, and body mass index [BMI]) and socioeconomic factors (household income, highest educational level achieved, employment status, type of medical insurance, workers' compensation involvement, and injury-related litigation process) were obtained and compared with the Short Musculoskeletal Form Assessment-46 (SMFA-46) questionnaire using a multivariable logistic regression analysis. Results: Unemployment was the most significant variable associated with dissatisfaction among 15 of the 46 responses of the SMFA-46 (P < 0.048). Patients who had an overweight or obese BMI and had an age of 41 years or older exhibited significantly worse outcomes in 7 of the 46 questions (P < 0.049). Finally, women were less likely to be satisfied in 1 of the 46 questions (P = 0.028). No notable difference was observed in any of the SMFA-46 responses regarding insurance plan, educational level, workers' compensation involvement, and injury-related litigation process. Discussion: A strong association exists between dissatisfaction after ORIF of posterior wall fractures of the acetabulum and employment status, BMI, and age among the Hispanic population. Addressing socioeconomic factors can be critical to overcome dissatisfaction and improve functional status among Hispanic patients with acetabular fractures.

Introduction Flexor tendon lacerations in zone II have been reported to be the most complicated of all tendon injuries. Currently, there is no consensus on treatment in surgical management for patients with flexor tendon laceration of flexor digitorum profundus and flexor digitorum superficialis (FDS). The aim of this study was to evaluate whether the repair of FDS tendons provided superior functional outcomes compared with FDS excision in Hispanic patients. Methods Total active motion, original Strickland criteria, and the disability of arm shoulder and hand questionnaire were provided postoperatively at 3 and 6 months to all consecutive Hispanic patients who underwent zone II flexor tendon repair. The cohort was divided into two groups, those who underwent FDS repair and those underwent FDS excision. Results Functional and disability outcome analysis showed a notable improvement with FDS repair using total active motion, Strickland criteria, and disability of arm shoulder and hand score at the 3 months postoperative interval. No statistical differences were identified regarding functional and disability outcomes at the 6-month evaluation between both groups. Conclusions Among Hispanics, the FDS-repaired group had similar functional and disability outcomes at their 6 months postoperative evaluation compared with the FDS-excised group. Increased awareness for tendon rerupture during the initial 3 months of index surgery is recommended for FDS-excised patients.

Spasticity is a risk factor for increased complications and decreased coronal plane correction in the management of neuromuscular Early-Onset Scoliosis with a RBGS.

The purpose of this study is to evaluate whether patients with high-tone neuromuscular early-onset scoliosis have different surgical outcome and complication rate, when compared to patients with low-tone neuromuscular early-onset scoliosis treated with a rib-to-pelvis rib-based dual growing system. This is a retrospective cohort study of 67 neuromuscular early-onset scoliosis patients, collected from a multicenter database, treated with a rib-to-pelvis rib-based dual growing system. All patients were divided into two groups: high tone and low tone. Pre-, intra- and postoperative data were compared between both groups. Complications were reported by a standardized system. Twenty-six high-tone and 41 low-tone patients were found homogeneous regarding gender, age at surgery, weight, height, estimated blood loss and surgery time. High-tone group (19/26 = 73.1%) experiences more postoperative complications than low-tone group (22/41 = 53.7%). Most common complications were infection, device migration, death and hardware failure. Permanent abandonment of rib-based growing technique and device removal was required in 21% of high-tone patients (P

Purpose Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation. Methods We performed an institutional review board–approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale–Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated. Results Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale–Revised Survey results. No hematoma block-associated complications were reported. Conclusions The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF. Type of study/level of evidence Therapeutic II.

Introduction Previous studies have suggested that most cases of pediatric back pain do not have an identifiable cause. No reliable sign or indication differentiates between a benign or serious cause of the symptom. Constant pain, night pain, and abnormal neurological examination have been suggested as adequate predictors of an identifiable cause, when plain radiographs could not explain the symptoms. The purpose of this study is to determine the sensitivity, specificity, and likelihood ratios of constant pain, night pain, and abnormal neurological examination to predict the presence of an underlying positive finding as a cause of back pain. Method From 2010 to 2016, all patients who presented with a chief complaint of back pain were included in the study. Magnetic Resonance Image was performed to all patients presenting with back pain without identifiable cause lasting >4 weeks. Patients who presented with spondylolysis were treated accordingly base on radiographic findings and were excluded as study protocol. Results A total of 388 patients were evaluated during the study period. The mean age of the subjects was 14.5 years; 69.7% being female. An underlying pathologic condition was identified in 56 of 132 (42%) of patients with constant pain, 61 of 162 (38%) with night pain, and 8 of 9 (89%) with abnormal neurological examination. Probability to have an underlying pathology correlated directly with the amount of clinical markers. Discussion An abnormal neurological examination was found as a strong predictor for an underlying pathologic condition. Further imaging of a pediatric patient with back pain without clear explanation for their symptoms on plain radiographs should not be limited to constant pain, or night pain because clinicians could be missing important diagnosis. Therefore, the clinician cannot be assured by absence of these clinical markers, that there is no underlying spinal pathology. Level of evidence Level III.

Introduction The relationship between spinal structure and respiratory function has been coined as thoracic insufficiency syndrome and is defined as the inability of the thorax to support normal respiratory function or lung growth. Little is known about what supports this relationship in untreated nonambulatory myelomeningocele patients. Methods A prospective cross-sectional study of nonambulatory myelodysplasia patients was performed. Anatomic, radiographic, and functional parameters were evaluated to validate the respiratory-spinal structure relationship. Thirty-one patients diagnosed with nonambulatory myelomeningocele fulfilled the inclusion criteria. Results The imaging study confirmed the spinal deformity. Lung functions measured in this patient population describe reduced lung volumes by CT lung volume reconstruction, reduced vital capacity by spirometry, and reduced total lung capacity by the nitrogen washout method. Together, these findings suggest moderate restrictive respiratory disease. The blood count study did not show evidence of anemia or other blood disturbances. Echocardiogram analysis did not show pulmonary hypertension in any patient. Conclusion The data validate the relationship between spinal structure and lung function. However, there is no simple structural feature that could help to diagnose thoracic insufficiency syndrome. Thus, the diagnosis continues to be based on a combination of clinical findings and radiological and respiratory function evaluations. Level of evidence Level III.

Spasticity is a risk factor for increased complications and decreased coronal plane correction in the management of neuromuscular Early-Onset Scoliosis with a RBGS.