Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND: Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. METHODS: Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. RESULTS: Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. CONCLUSION: COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. LEVEL OF EVIDENCE: Level III-prognostic study.

Telehealth Potential in Pediatric Orthopaedics and Sports Medicine Care is Comparable to In-Person Care But Disparities Remain.

BACKGROUND: Understanding the challenges and potential of telehealth visits (THVs) in a large population can inform future practice and policy discussion for pediatric orthopaedic and sports medicine (OSM) care. We comprehensively assess telehealth challenges and potential in a large pediatric OSM population based on access, visit completion, patient satisfaction, and technological challenges. METHODS: Demographics, address, insurance, visit information, patient feedback, experience with video visits, and technical challenges of all 2019 to 2020 visits at our hospital were assessed (3,278,006 visits). We evaluated the differences in rate of telehealth utilization, rate of patient adherence, disparities in care access and patient satisfaction, and technological issues. RESULTS: Compared with in-person prepandemic visits, THVs had lower ratios of non-White patients (by 5.8%; P <0.001), Hispanic patients (by 2.8%; P <0.001) and patients with public insurance (by 1.8%; P <0.001), and a higher mean distance between the patient's residence and clinic (by 18.8 miles; P <0.001). There were minimal differences in median household income (average $2297 less in THV; P <0.001) and social vulnerability index (average 0.01 points lower in THV; P <0.001) between groups. THVs had comparable patient satisfaction to in-person visits. Non-White patients, Hispanics, and those with public insurance had lower ratings for both in-person visits and THVs and had more technical difficulties during their THV. CONCLUSIONS: Telehealth is a viable method of care for a range of pediatric OSM conditions, providing a similar quality of care as in-person visits with a greater geographic reach. However, in its current format, reduced disparities were not observed in pediatric OSM THVs. LEVEL OF EVIDENCE: Level III.

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

BACKGROUND: Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. METHODS: All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. RESULTS: In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. CONCLUSIONS: Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. LEVEL OF EVIDENCE: Level III.

Femoral Neck Stress Fractures in Children Younger Than 10 Years of Age.

BACKGROUND: Femoral neck stress fractures are rare in healthy children, with only 9 cases previously reported. The present article reviews our institutional experience with femoral neck stress fractures in children younger than 10 years of age, to highlight the unique features of this condition. METHODS: We undertook a retrospective review of clinical records of patients who had been treated at our institution for an idiopathic femoral neck stress fracture between 2000 and 2014. To focus on children rather than adolescents, the World Health Organization's definition of adolescent as a person between 10 and 19 years of age was used; we thereby limited our analysis to patients younger than 10 years of age. RESULTS: The study included 6 patients (3 males, 3 females) treated for an idiopathic femoral neck stress fracture, with a mean age at diagnosis of 7.7 years (range, 5.2 to 8.9 y). All patients presented with a limp, which worsened with activity and had persisted for a mean of 5 weeks (range, 2 to 9 wk). None of the patients had experienced an increase in activity level or sporting volume before symptom onset. On examination, 3 patients experienced pain with terminal hip flexion and 3 patients demonstrated pain-free hip range of motion. Plain radiography demonstrated inferior femoral neck cortical disruption, suggesting a compression-type stress fracture mechanism. The diagnosis was confirmed by cross-sectional imaging in all cases. All patients were initially treated with 6 to 8 weeks of non-weight-bearing followed by 4 to 6 weeks of partial weight-bearing, leading to complete healing in 4 patients. Two patients demonstrated incomplete healing and were managed with spica casting for an additional 6 weeks. CONCLUSIONS: Our case series illustrates the unique features of this rare condition in children, with a history and examination profile distinct from those of adolescents and adults. Compliance with weight-bearing restrictions is difficult in this population and hip spica casting may be required to permit complete healing. LEVEL OF EVIDENCE: Level IV-case series.

Surgical Reconstruction of Metatarsal Type Preaxial Polydactyly Using an Amalgamating Osteotomy.

BACKGROUND: Polydactyly of the foot is a relatively common condition. Approximately 15% of cases are preaxial, with one third of these cases involving duplication of the metatarsal [metatarsal type preaxial polydactyly (MTPP)].Surgical reconstruction of polydactyly is indicated to improve shoe tolerance. Reconstruction of MTPP has traditionally involved resection of the hypoplastic lateral ray in addition to soft tissue reconstruction to correct hallux varus. Poor postoperative results have frequently been reported, primarily due to residual hallux varus. We present a novel surgical technique for the treatment of children with MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy that permits retention of the stable medial metatarsotarsal joint while avoiding the complication of residual hallux varus. METHODS: This was a retrospective case series describing the surgical technique of an amalgamating osteotomy in the treatment of patients with MTPP and a cosmetic lateral hallux. The surgical technique involves corresponding metatarsal osteotomies of the medial and lateral halluces, with amalgamation of the metatarsals and ablation of the residual medial hallux, without the need for extensive soft tissue reconstruction. Clinical and radiologic outcomes were evaluated at a minimum of 2 years postoperatively in 2 patients who underwent this technique. RESULTS: Two children, 1 female and 1 male, underwent an amalgamating osteotomy at the age of 31 and 18 months, respectively. At latest follow-up, 7.3 and 2.8 years after osteotomy, respectively, both patients displayed an excellent functional result according to the Phelps and Grogan clinical outcome scale. Plain radiographs in both cases demonstrated a well-aligned first ray with no growth abnormality and no hallux varus. CONCLUSIONS: We have presented a novel surgical technique for the reconstruction of MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy without extensive soft tissue reconstruction. This simple technique maintains the stable medial metatarsotarsal joint, permits ongoing longitudinal metatarsal growth, and avoids the complication of hallux varus. LEVEL OF EVIDENCE: Level IV-case series.

Quality, Safety, Value: From Theory to Practice Management What Should We Measure?

Over the past 35 years the health care community and in particular orthopaedic surgery, has undergone a transformation from retrospective case-series-based expert opinion to randomized prospective clinical trials. During this transition, orthopaedic surgeons have become very skilled in the measurement of physician-derived outcomes (radiographic angles, complications, recurrences, and mortality); however, these are not patient-centered outcomes and they are of little importance to our patients' satisfaction. Moving forward outcome measurement needs to be restructured to focus more on patient-reported outcomes. This paper outlines why outcome measurement is important, reviews outcome strategies that have been used historically, introduces a new outcome measurement tool and identifies strategies for future implementation and measurement of health care quality and value within pediatric orthopaedics.

Occipital condyle fracture in the pediatric population: A management algorithm and systematic review.

Purpose: This study aims to develop an accessible stepwise management algorithm for pediatric presentations of occipital condyle fractures (OCFs) based on a systematic review of the published literature regarding diagnostic evaluation, treatment, and outcomes. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric OCFs. Data extraction of clinical presentation, management strategies, imaging, and treatment outcome was performed. Results: A total of 15 studies reporting on 38 patients aged 18 years and younger presenting with OCFs were identified. Loss of consciousness (LOC), depressed level of consciousness, neck pain, decreased neck range of motion (ROM), and cranial nerve injury were the most common presenting symptoms. Diagnostic imaging included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and functional radiographs to assess cervical stability. Treatment options varied and included soft collar, hard collar, and halo vest. All studies resulted in a complete healing of the OCF, with resolution of associated pain. Conclusion: The proposed treatment algorithm suggests a framework for the management of pediatric OCFs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a stepwise approach should be utilized in the management of isolated pediatric OCFs.

Utility of postoperative laboratory testing after posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: With advancements to blood management strategies, risk of perioperative transfusion following surgical treatment of adolescent idiopathic scoliosis (AIS) has diminished. We hypothesize that routine laboratory testing on postoperative-day 1 (POD1) and beyond is unnecessary. The purpose of this study is to determine necessity of POD1 labs, particularly hematocrit and hemoglobin levels, following surgical management of AIS. METHODS: We performed a retrospective cohort study of consecutive AIS patients aged 11-19 who underwent posterior spinal fusion (PSF) at a single institution. Univariable logistic regression was utilized to determine factors associated with hematocrit ≤ 22% on POD1 or a postoperative transfusion. Firth's penalized logistic regression was used for any separation in data. Youden's index was utilized to determine the optimal point on the ROC curve that maximizes both sensitivity and specificity. RESULTS: 527 patients qualified for this study. Among the eight total patients with POD1 hematocrit ≤ 22, none underwent transfusion. These patients had lower last intraoperative hematocrit levels compared to patients with POD1 hematocrit > 22% (24.1% vs 31.5%, p < 0.001), and these groups showed no difference in preoperative hematocrit levels (38.2% vs 39.8%, p = 0.11). Four patients underwent postoperative transfusion. Both preoperative hematocrit levels (34.0% vs 39.9%, p = 0.001) and last intraoperative hematocrit levels (25.1% vs 31.4%, p = 0.002) were lower compared to patients without transfusion. Intraoperative hematocrit < 26.2%, operative time of more than 35.8 min per level fused, or cell salvage > 241 cc were significant risk factors for postoperative transfusion. CONCLUSION: Transfusion after PSF for AIS is exceedingly rare. POD1 labs should be considered when last intraoperative hematocrit < 26%, operative time per level fused > 35 min, or cell salvage amount > 241 cc. Otherwise, unless symptomatic, patients do not benefit from postoperative laboratory screening.

The Troubling Rise of Scurvy: A Review and National Analysis of Incidence, Associated Risk Factors, and Clinical Manifestations.

INTRODUCTION: In the era of modern medicine, scurvy has been thought of as a rare disease of ancient times because of improved emphasis on diet and nutrition; however, isolated case reports are plentiful. This investigation presents a comprehensive review of scurvy, including an analysis on its rising incidence, with specific focus on its orthopaedic manifestations and commonly associated diagnoses. METHODS: This comprehensive review includes a retrospective analysis of 19,413,465 pediatric patients in the National Inpatient Sample database from 2016 through 2020. Patients with scurvy were identified by the ICD-10 code, and an estimated incidence of scurvy in the inpatient pediatric population was calculated. Concurrent diagnoses, musculoskeletal reports, and demographic variables were collected from patient records. Comparisons were made using analysis of variance or chi-square with Kendall tau, where appropriate. RESULTS: The incidence of scurvy increased over the study period, from 8.2 per 100,000 in 2016 to 26.7 per 100,000 in 2020. Patients with scurvy were more likely to be younger (P < 0.001), male (P = 0.010), in the lowest income quartile (P = 0.013), and obese (P < 0.001). A majority (64.2%) had a concomitant diagnosis of autism spectrum disorder. Common presenting musculoskeletal reports included difficulty walking, knee pain, and lower limb deformity. Burden of disease of scurvy was markedly greater than that of the average inpatient population, with these patients experiencing greater total charges and longer hospital stays. CONCLUSION: Clinicians should be aware of the increasing incidence of scurvy in modern medicine. In cases of vague musculoskeletal reports without clear etiology, a diagnosis of scurvy should be considered, particularly if risk factors are present. TRIAL REGISTRATION NUMBER: NA.

Evaluation and Management of Pediatric Humeral Shaft Fractures.

Diaphyseal humerus fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity, and size. Treatment strategies include closed reduction with various immobilization techniques, flexible nails, uniplanar or multiplanar external fixation, or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, and the multiplanar motion of the shoulder joint can accommodate for greater variations in alignment than many other long bone fractures. Complications such as radial nerve palsy are possible with both open and closed injuries, and mal/nonunions, although rare, can occur. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

Vascular Injury After Scoliosis Correction in Ehlers-Danlos Syndrome: Proceed With Caution.

Ehlers-Danlos syndrome (EDS) is a rare inherited connective tissue disorder characterized by collagen synthesis disruption, resulting in joint hyperlaxity, skin and vascular fragility, and bleeding diathesis. Patients with EDS are susceptible to spinal deformities, with scoliosis accounting for up to 23.4% of musculoskeletal abnormalities. Conservative management is often trialed initially; however, severe scoliosis can lead to significant sagittal imbalance and cardiopulmonary compromise. Surgical intervention for scoliosis correction in patients with EDS presents unique challenges because of tissue fragility and an increased risk of vascular and wound complications. This case report discusses a 20-year-old man with type II EDS and scoliosis, who experienced retroperitoneal compartment syndrome, significant left lower extremity weakness, and loss of sensation after scoliosis correction surgery. The report also provides an overview of the existing literature on scoliosis surgery outcomes in patients with EDS, highlighting the need for heightened vigilance and cautious surgical approaches.

Spinal osteoid osteoma in the pediatric population: A management algorithm and systematic review.

Purpose: The purpose of this study is to develop an accessible step-wise management algorithm for the management of pediatric spinal osteoid osteomas (OOs) based on a systematic review of the published literature regarding the diagnostic evaluation, treatment, and outcomes following surgical resection. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric spinal OOs. Data extraction of clinical presentation, management strategies and imaging, and treatment outcomes were performed. Results: Ten studies reporting on 85 patients under the age of 18 years presenting with OOs were identified. Back pain was the most common presenting symptom, and scoliosis was described in 8 out of 10 studies, and radicular pain in 7 out of 10 studies. Diagnostic, intraoperative, and postoperative assessment included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), bone scans, and frozen section. Treatment options varied, including conservative management, open surgical resection with or without intraoperative imaging, and percutaneous image-guided treatment. All included studies described partial or complete resolution of pain in the immediate postoperative period. Conclusions: The proposed algorithm provides a suggested framework for management of pediatric spinal OOs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a step-wise approach should be utilized in the management of pediatric spinal OOs.

Disparities in cannabis use and documentation in electronic health records among children and young adults.

The legalizations of medical and recreational cannabis have generated a great deal of interest in studying the health impacts of cannabis products. Despite increases in cannabis use, its documentation during clinical visits is not yet mainstream. This lack of information hampers efforts to study cannabis's effects on health outcomes. A clear and in-depth understanding of current trends in cannabis use documentation is necessary to develop proper guidelines to screen and document cannabis use. Here we have developed and used a natural language processing pipeline to evaluate the trends and disparities in cannabis documentation. The pipeline includes a screening step to identify clinical notes with cannabis use documentation which is then fed into a BERT-based classifier to confirm positive use. This pipeline is applied to more than 23 million notes from a large cohort of 370,087 patients seen in a high-volume multi-site pediatric and young adult clinic over a period of 21 years. Our findings show a very low but growing rate of cannabis use documentation (<2%) in electronic health records with significant demographic and socioeconomic disparities in both documentation and positive use, which requires further attention.

Socioeconomic Status Affects Postoperative Time to Union in Pediatric Patients with a Surgically Treated Fracture.

Fractures account for 10% to 25% of all pediatric injuries, and surgical treatment is common. In such cases, postoperative healing can be affected by a number of factors, including those related to socioeconomic status (SES). The purpose of this study was to investigate the relationship between time to fracture union and SES, which was measured with use of the median household income (MHI) and Child Opportunity Index (COI). Methods: A retrospective review was conducted of pediatric patients with a long-bone fracture that had been surgically treated at a Level-I pediatric trauma center between January 2010 and June 2020. Demographic and relevant medical data were collected. Patients were sorted into union and nonunion groups. The ZIP code of each patient was collected and the MHI and COI of that ZIP code were identified. Income brackets were created in increments of $10,000 ranging from $20,000 to $100,000, with an additional category of >$100,000, and patients were sorted into these groups according to MHI. Comparisons among the income groups and among the union status groups were conducted for each of the collected variables. A multiple regression analysis was utilized to determine the independent effect of each variable on time to union. Results: A total of 395 patients were included in the final sample, of whom 51% identified as Hispanic. Patients in the union group had a higher mean COI and MHI. Nonunion occurred in only 8 patients. Patients who achieved fracture union in ≤4 months had a significantly higher mean COI and MHI. When controlling for other demographic variables, the time to union increased by a mean of 9.6 days for every $10,000 decrease in MHI and increased by a mean of 6.8 days for every 10-unit decrease in the COI. Conclusions: The present study is the first, to our knowledge, to investigate the relationship between SES and time to fracture union in pediatric patients. When controlling for other demographic factors, we found a significant relationship between SES and time to union in pediatric patients with a surgically treated fracture. Further investigations of the relationship between SES and time to union in pediatric patients are needed to determine potential mechanisms for this relationship. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteochondroma of the Tibial Tubercle Masquerading as Osgood-Shlatter Disease: A Case Report.

Background: Osteochondromas are a relatively common primary bone tumor, which may share common clinical features with Osgood-Schlatter disease (OSD). A limited number of cases have described tumors misdiagnosed as OSD. Case Presentation: We report the case of an 11-year-old male with a sessile osteochondroma of the tibial tubercle and concomitant involvement of the distal extension and attachment of the patellar tendon into the tibial periosteum. A prior diagnosis OSD had been made. The lesion was resected and repair of the extensor mechanism was required at the time of surgery. The patient was followed for 20 months postoperatively and had restoration of knee function with minimal pain, as demonstrated by a PEDI-IKDC score of 94.6 at 19-month. Conclusion: This is a rarely reported case of benign tumor masquerading as OSD requiring excisional biopsy with extensor mechanism repair.

Marijuana in Orthopaedics: Effects on Bone Health, Wound-Healing, Surgical Complications, and Pain Management.

¼: Marijuana use is on the rise in the United States, and there is a paucity of information on the effects of cannabis and its chemical constituents on bone health, wound-healing, surgical complications, and pain management. ¼: Current evidence suggests that cannabidiol (CBD) may enhance bone health and metabolism, while Δ9-tetrahydrocannabinol (Δ9-THC), the major psychoactive component in marijuana, has an inhibitory effect. ¼: Marijuana users are at higher risk for delayed bone-healing, demonstrate lower bone mineral density, are at increased risk for fracture, and may experience postoperative complications such as increased opioid use and hyperemesis.

Intact PCL is a potential predictor of ACL graft size in the skeletally immature knee and other anatomic considerations for ACL reconstruction.

PURPOSE: To develop a method for using an intact posterior cruciate ligament (PCL) as a predictor of anterior cruciate ligament (ACL) graft size and examine possible differences in tunnel length based on all-epiphyseal drilling method. METHODS: One hundred one patients 5-18 years of age with magnetic resonance imaging (MRI) of the knee at an outpatient pediatric orthopaedic clinic from 2008 to 2020 were included. ACL and PCL coronal, sagittal, and length measurements were made in all patients. Tunnel length measurements were made in patients with open physes. Statistical analyses were performed to evaluate potential associations in patient bony or ligamentous measurements. RESULTS: PCL sagittal width and PCL coronal width were statistically significant predictors of ACL sagittal width and ACL coronal width, respectively (p = 0.002, R = 0.304; p = 0.008, R = 0.264). The following equations were developed to calculate ACL coronal and sagittal width measurements from the corresponding measurement on an intact PCL; ACL Coronal Width (mm) = 6.23 + (0.16 x PCL Coronal Width); ACL Sagittal Width (mm) = 5.85 + (0.53 x PCL Sagittal Width). Mean tibial maximum oblique length (27.8 mm) was longer than mean tibial physeal sparing length (24.9 mm). Mean femoral maximum oblique length (36.9 mm) was comparable to mean femoral physeal sparing length (36.1 mm). Both were longer than mean femoral straight lateral length (32.7 mm). CONCLUSION: An intact PCL is a predictor of native ACL size. Tunnel length differs based on chosen drilling method in all-epiphyseal technique. LEVEL OF EVIDENCE: Diagnostic Level III.

The Effects of Body Mass Index and Spine Flexibility on Surgical Outcomes for Patients With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the relationship between body mass index (BMI), spine flexibility index (FI), and their combined effects on adolescent idiopathic scoliosis (AIS) surgical outcomes. BACKGROUND: BMI and FI are two factors considered during presurgical planning for AIS correction, but there is sparse research about their relationship. We hypothesize that AIS patients with increased BMI may be associated with decreased FI-a combination which could lead to worsened surgical outcomes. MATERIALS AND METHODS: AIS patients ages 11 to 19 at surgery, who underwent posterior fusion at a single center from 2011 to 2017, were reviewed. Patients without proper radiographs to assess FI, or a previous spine surgical history, were excluded. FI was categorized as stiff (FI<50) or flexible (FI≥50), and patients were separated by major curve region. BMI was categorized as underweight (less than fifth percentile), healthy weight (fifth-85th percentile), overweight (85th-95th percentile), or obese (>95th percentile). Regression analysis was conducted to test BMI and FI's effects on intraoperative, immediate postoperative, and two-year postoperative outcomes. RESULTS: A total of 543 patients (82% female), with an average age of 14.9 years, were included. In all, 346 patients had available two-year data. A 10% increase in BMI was associated with a 1.3% decrease in FI for patients with major thoracolumbar/lumbar curves ( P =0.01). Obese patients were most likely to have a postoperative complication ( P =0.003) or a two-year complication ( P =0.04). Revision surgery occurred after 58% of postoperative complications (15/26) and 80% of two-year complications (4/5). FI was negatively associated with initial curve magnitude ( P <0.001), operative time ( P =0.02), and blood loss ( P =0.02). Overweight patients with flexible curves were 10.0 times more likely to sustain a postoperative complication than healthy weight patients with stiff curves ( P =0.001). CONCLUSIONS: Elevated BMI was associated with decreased FI in patients with major thoracolumbar/lumbar curves. Patients with a high BMI and high FI were associated with the greatest risk of postoperative complication.

Antegrade Elastic Intramedullary Nailing Insertion Technique Results in Higher Incidence of Symptomatic Implants in Pediatric Ulnar Fractures.

Retrograde and antegrade nailing techniques are the two options available to a surgeon when using elastic stable intramedullary nailing; however, the literature comparing these two nailing techniques is scarce. Thus, we conducted a retrospective review of all pediatric and adolescent ulnar fractures treated with elastic stable intramedullary nailing at our facility. We hypothesize that the clinical outcomes (implant and wound complications) and the time between surgery and radiographic union will be similar for both techniques. Methods: A retrospective chart review of pediatric ulnar fracture patients treated at our facility was performed. Demographic and health information associated with the injury were collected, and the clinical outcomes of the two techniques were compared. Results: A total of 53 patients with 54 fractures were included in this study. Antegrade nail insertion was used to treat 59.2% fractures. Radiographic union was achieved in all patients. Nail insertion technique was not associated with postoperative wound complications, time to radiographic union or implant removal, or significant deficits in upper extremity rotation (P > 0.05). Antegrade nailing resulted in a symptomatic implantation 3.97 times more frequently than compared with retrograde nailing (P = 0.036). Discussion: Antegrade nailing demonstrates a similar healing profile but higher implant complications compared with the retrograde nailing technique in pediatric ulnar fractures.

Inequalities in Pediatric Fracture Care Timeline Based on Insurance Type.

INTRODUCTION: Socioeconomic and insurance status are often linked with limited access to health care. Despite several government-funded projects aimed at curtailing these barriers, pediatric orthopaedic patients continue to experience delays in receiving timely care for fracture treatments. This delay has been well-identified within the orthopaedic literature but, to our knowledge, has never been characterized based on timeline. Thus, the goal of this study is to evaluate the role of ethnicity, socioeconomic status, and insurance type on the timeline of pediatric patients to obtain orthopaedic care within our community. METHODS: Pediatric patients presenting to our clinic for the treatment of one of 21 most common fractures were included. Patient demographics and the timeline of patient care were collected by retrospective chart review. RESULTS: Government-funded insurance accounted for 60.6% of the 413 patients. These patients experienced significant (P < 0.001) delays in access to care when compared with commercial insurance patients; the time between injury and referral as well as the overall time from injury to orthopaedic evaluation was 2.8 and twofold greater at 4.4 days and 9.2 days, respectively. A strong correlation was established between income levels and insurance type. DISCUSSION: Pediatric patients with a lower socioeconomic status are more likely to rely on government-funded insurance and experience delays in fracture evaluation.