Publications by authors named "Arun R Hariharan"

5 Publications

  • Page 1 of 1

Orthopaedic Manifestations of Transverse Myelitis in Children.

J Pediatr Orthop 2021 May 13. Epub 2021 May 13.

Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE Seton Hall Orthopaedics, St. Joseph's University Medical Center, Paterson, NJ Icahn School of Medicine at Mount Sinai, New York, NY Department of Orthopaedic Surgery, Nemours Children's Specialty Care, Jacksonville, FL.

Background: Transverse myelitis (TM) is a rare inflammatory disorder of the spinal cord. It can have a heterogeneous presentation with sensory, motor, and autonomic dysfunction. Neurological sequelae of TM include autonomic dysfunction, motor weakness, and/or spasticity. Studies describing orthopaedic deformities and treatments associated with TM are nonexistent. This purpose of this study was to describe the orthopaedic manifestations of TM in children.

Methods: A multicenter retrospective review was conducted of patients, 0 to 21 years of age, with TM presenting over a 15-year period at 4 academic children's hospitals. Those with confirmed diagnosis of TM and referred to an orthopaedic surgeon were included. Demographics, orthopaedic manifestations, operative/nonoperative treatments, and complications were recorded. Descriptive statistics were used for data reporting.

Results: Of 119 patients identified with TM, 37 saw an orthopaedic surgeon. By etiology, 23 were idiopathic (62%), 10 infectious (27%), 3 (8%) inflammatory/autoimmune, and 1 (3%) vascular. The mean age at diagnosis was 6.7 (SD: 5.5) years and at orthopaedic presentation was 8.4 (SD: 5.2) years. Orthopaedic manifestations included scoliosis in 13 (35%), gait abnormalities in 7 (19%), foot deformities in 7 (19%), upper extremity issues in 7 (19%), symptomatic spasticity in 6 (16%), lower extremity muscle contractures in 6 (16%), fractures in 6 (16%), hip displacement in 3 (8%), pain in 2 (5%), and limb length discrepancy in 2 (5%) patients. Seven children (19%) were seen for establishment of care. In all, 14 (38%) underwent operative intervention, mainly for soft-tissue and scoliosis management. Four patients had baclofen pump placement for spasticity management. Postoperative complications occurred in 36% of cases, most commonly because of infection. Neither topographic pattern nor location of lesion had a significant relationship with need for hip or spine surgery.

Conclusions: This report describes the orthopaedic manifestations associated with TM in children, nearly 40% of whom required operative intervention(s). Understanding the breadth of musculoskeletal burden incurred in TM can help develop surveillance programs to identify and treat these deformities in a timely manner.

Level Of Evidence: Level IV.
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May 2021

Transphyseal Humeral Separations: What Can We Learn? A Retrospective, Multicenter Review of Surgically Treated Patients Over a 25-Year Period.

J Pediatr Orthop 2020 Jul;40(6):e424-e429

Department of Orthopaedics, University of Maryland Medical Center.

Purpose: Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. This multicenter study aimed to assess the various patient characteristics, injury patterns, treatments, outcomes, and complications in a large series of these injuries.

Methods: A retrospective review was conducted at 5 pediatric institutions to identify TPHS that were treated surgically in patients 0 to 3 years of age over a 25-year period. Patient demographics, mechanisms of injury, Child Protective Services involvement, diagnostic modalities, time to surgery, pin size and configuration, time to fracture union, and complications were recorded.

Results: A total of 79 patients aged 0 to 46 months, with a mean of 17.6 months, were identified and followed for a median of 57 days postoperatively. The most common mechanism of injury was accidental trauma (n=49), followed by nonaccidental trauma (n=21), cesarean section (n=6), and vaginal delivery (n=3). Child Protective Services were involved in 30 cases (38%). Additional injuries were reported in 19 of the patients; most commonly additional fractures including the humerus, rib, and skull fractures. All patients had elbow radiographs, whereas 4 patients had an elbow ultrasound and/or a magnetic resonance imaging. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intraoperatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), averaging utilization of 2.2 pins, and 2 patients underwent an open reduction. In total, 11 complications (14%) were noted, including decreased range of motion (n=4), cubitus varus/valgus (n=6), and need for additional surgery (n=1). No cases of avascular necrosis or physeal arrest were found. No losses of reduction were noted.

Conclusions: This multicenter review provides the largest known demographic and outcomes data on TPHS. TPHS have excellent outcomes in the vast majority of patients when treated surgically. Nonaccidental trauma accounted for 27% of these injuries so it needs to remain high on the differential diagnosis.

Level Of Evidence: Level III-retrospective cohort study.
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July 2020

A Metaphyseal Corner Fracture that Wasn't: A Case Report of Osteitis from Congenital Syphilis.

JBJS Case Connect 2020 Jan-Mar;10(1):e0557

Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware.

Case: Congenital syphilis (CS) is an infrequently seen condition in the United States; however, rates of CS have been on the rise. We present a case of an infant with a lesion of the radius that was initially diagnosed as a metaphyseal corner fracture and treated as such until maternal syphilis testing was noted to be positive. Ultimately, the child was diagnosed with CS. She is now undergoing treatment with penicillin and recovering well.

Conclusion: Although CS is rare, the incidence is on the rise and should remain on the differential of lytic lesions of bone in young children.
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January 2021

Cost Analysis of Treating Pediatric Supracondylar Humerus Fractures in Community Hospitals Compared With a Tertiary Care Hospital.

J Am Acad Orthop Surg 2020 May;28(9):377-382

From the Department of Orthopaedics, University of Maryland School of Medicine (Dr. Shasti, Case, Dr. Hariharan, Dr. Jauregui, and Dr. Abzug), and Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine (Dr. Li), Baltimore, MD.

Objective: In the current healthcare environment, providing cost-efficient care is of paramount importance. One emerging strategy is to use community hospitals (CHs) rather than tertiary care hospitals (TCHs) for some procedures. This study assesses the costs of performing closed reduction percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures (SCHFs) at a CH compared with a TCH.

Methods: A retrospective review of 133 consecutive SCHFs treated with CRPP at a CH versus a TCH over a 6-year period was performed. Total encounter and subcategorized costs were compared between the procedures done at a CH versus those done at a TCH.

Results: Performing CRPP for a SCHF at a CH compared with a TCH saved 44% in costs (P < 0.001). Cost reduction of 51% was attributable to operating room costs, 19% to anesthesia-related costs, 16% to imaging-related costs, and 7% to supplies.

Discussion: Performing CRPP for a SCHF at a CH compared with a TCH results in a 44% decrease in direct cost, driven largely by surgical, anesthesia, and radiology-related savings.
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May 2020

Branching patterns and localization of the common fibular (peroneal) nerve: an anatomical basis for planning safe surgical approaches.

Surg Radiol Anat 2014 Oct 30;36(8):821-8. Epub 2013 Nov 30.

University of Michigan Medical School, Ann Arbor, MI, 48104, USA.

Purpose: Given the severity and incidence of injury to the common fibular (peroneal) nerve (CFN), there is a need to further clarify its anatomical location and branching patterns. This project attempts to consolidate current anatomical understanding of this nerve and provide physicians with reproducible measurements regarding the CFN and its branches.

Methods: Dissections were performed on 50 specimens (28 cadavers), both fresh and preserved. The CFN was dissected from its emergence from the fibular tunnel to its anterior tibial recurrent nerve (ATRN), superficial fibular nerve (SFN), and deep fibular nerve (DFN) branches. The CFN branching patterns were assessed and all variations were categorized into four types.

Results: Several significant relationships were identified between observable traits and key anatomical characteristics of the CFN. A significant correlation was found between fibular length and distance from the tip of the fibula to the DFN/ATRN branch, as well as between fibular length and distance from the tibial tuberosity to the SFN/DFN and DFN/ATRN branches. An association was identified between length of exposed sub-cutaneous CFN and height. Thickness of the biceps femoris tendon correlated significantly with BMI.

Conclusions: These findings allow physicians to better assess a patient's individual CFN anatomy based on correlations with measureable physical traits and will contribute to anatomic education and successful completion of various surgical, anesthetic, and physical therapy procedures.
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October 2014