Ogden Type I to III tibial tubercle fractures in skeletally immature patients: Is routine anterior compartment fasciotomy of the leg indicated?

PURPOSE: Determine the frequency of compartment syndrome of the leg after displaced, operatively treated modified Ogden I to III tibial tubercle fractures (TTFxs), evaluate the preoperative assessment and use of advanced imaging, and need for prophylactic fasciotomies. METHODS: Retrospective analysis of operatively treated, displaced modified Ogden I to III TTFxs, at our level 1 paediatric trauma centre between 2007 and 2019. Modified Ogden Type IV and V fracture patterns were excluded. Fracture patterns were determined by plain radiographs. RESULTS: There were 49 modified Ogden I to III TTFxs in 48 patients. None had signs nor symptoms of vascular compromise, compartment syndromes or impending compartment syndromes preoperatively. In all, 13 of the 49 fractures underwent anterior compartment fasciotomy at surgery; eight of the 13 had traumatic fascial disruptions, which were extended surgically. All incisions were primarily closed. There were no instances of postoperative compartment syndromes, growth arrest, leg-length discrepancy or recurvatum deformity postoperatively. All patients achieved radiographic union and achieved full range of movement. CONCLUSION: The potentially devastating complications of compartment syndrome or vascular compromise following TTFx did not occur in this consecutive series of patients over 12 years. The presence of an intact posterior proximal tibial physis and posterior metaphyseal cortex (Modified Ogden TTFx Type I to III) may mitigate the occurrence of vascular injury and compartment syndrome. Plain radiographs appear appropriate as the primary method of imaging TTFxs, with use of advanced imaging as the clinical scenario dictates. Routine, prophylactic fasciotomies do not appear necessary in Ogden I to III TTFxs, but should be performed for signs and symptoms of compartment syndrome. LEVEL OF EVIDENCE: Level IV

Impact of spinal deformity characteristics on patient-reported outcome measurement information system scores in patients with idiopathic scoliosis undergoing posterior spinal fusion

INTRODUCTION: The impact of posterior spinal fusion (PSF) on physical function and pain and mental health in pediatric patients as quantified by the Patient-Reported Outcomes Measurement Information System (PROMIS), developed by the National Institute of Health, is largely unknown. The purpose of this study is to report the changes of PROMIS scores for upper extremity (UE), pain interference (PI), mobility (MOB), and peer relationships (PR) after PSF in patients with idiopathic scoliosis (IS), compare postoperative changes in PROMIS PI and Scoliosis Research Society-30 pain scores, and evaluate associations between curve characteristics and PROMIS scores. METHODS: A retrospective cohort of 122 patients (\u3c18 years old) who underwent PSF for IS was identified through electronic medical record search. PROMIS scores were obtained preoperatively and 6 weeks, 6 months, 1 years, 2 years, and 3 years postoperatively. RESULTS: The mean age of the cohort was 14.2 ± 1.6 years, and the mean Cobb angle was 62.9 ± 13.8° at surgery. Eighty patients had preoperative PROMIS data. UE and MOB scores were statistically lower at 6 weeks and 6 months postoperatively and returned to baseline with a longer follow-up. PI scores were significantly lower at 1 and 2 years postoperatively. PR was unchanged up to 2 years postoperatively and then showed significant improvement. There was a statistically significant negative relationships between lowest instrumented vertebra and PROMIS UE and MOB scores at 6 weeks and 1 year postoperatively, but not at a longer follow-up. There were no significant differences noted in PI and PR PROMIS scores and lowest instrumented vertebra. PROMIS scores were not statistically associated with the Lenke Classification, number of vertebral levels fused, or percentage coronal correction. DISCUSSION: Changes in PROMIS functional domains (UE and MOB) postoperatively normalize at longer follow-ups. Changes in PI and PR demonstrated improvements over preoperative values at 1 to 2 years postoperatively. Preoperative coronal and sagittal measures, and the percentage correction did not correlate with any PROMIS scores

Genetic risk for aortic aneurysm in adolescent idiopathic scoliosis

BACKGROUND: Scoliosis is a feature of several genetic disorders that are also associated with aortic aneurysm, including Marfan syndrome, Loeys-Dietz syndrome, and type-IV Ehlers-Danlos syndrome. Life-threatening complications of aortic aneurysm can be decreased through early diagnosis. Genetic screening for mutations in populations at risk, such as patients with adolescent idiopathic scoliosis, may improve recognition of these disorders. METHODS: The coding regions of five clinically actionable genes associated with scoliosis (COL3A1, FBN1, TGFBR1, TGFBR2, and SMAD3) and aortic aneurysm were sequenced in 343 adolescent idiopathic scoliosis cases. Gene variants that had minor allele frequencies of <0.0001 or were present in human disease mutation databases were identified. Variants were classified as pathogenic, likely pathogenic, or variants of unknown significance. RESULTS: Pathogenic or likely pathogenic mutations were identified in 0.9% (three) of 343 adolescent idiopathic scoliosis cases. Two patients had pathogenic SMAD3 nonsense mutations consistent with type-III Loeys-Dietz syndrome and one patient had a pathogenic FBN1 mutation with subsequent confirmation of Marfan syndrome. Variants of unknown significance in COL3A1 and FBN1 were identified in 5.0% (seventeen) of 343 adolescent idiopathic scoliosis cases. Six FBN1 variants were previously reported in patients with Marfan syndrome, yet were considered variants of unknown significance based on the level of evidence. Variants of unknown significance occurred most frequently in FBN1 and were associated with greater curve severity, systemic features of Marfan syndrome, and joint hypermobility. CONCLUSIONS: Clinically actionable pathogenic mutations in genes associated with adolescent idiopathic scoliosis and aortic aneurysm are rare in patients with adolescent idiopathic scoliosis who are not suspected of having these disorders, although variants of unknown significance are relatively common. CLINICAL RELEVANCE: Routine genetic screening of all patients with adolescent idiopathic scoliosis for mutations in clinically actionable aortic aneurysm disease genes is not recommended on the basis of the high frequency of variants of unknown significance. Clinical evaluation and family history should heighten indications for genetic referral and testing