Rib-on-Pelvis Deformity and Reported Pain in Neuromuscular Early-Onset Scoliosis.

BACKGROUND: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL. METHODS: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded. RESULTS: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency (P<0.001) and severity (P<0.001) of pain. ROP was associated with worse general health (P=0.01), increased difficulty with vocalization (P=0.02), increased frequency of shortness of breath (P=0.002), and increased difficulty sitting upright (P=0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function (P<0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency (P=0.004) and severity (P=0.001) of pain than the patients without preoperative ROP at 2 years postoperatively. CONCLUSIONS: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention. LEVEL OF EVIDENCE: Level III.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database.

BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.

Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative Osteomyelitis: Results From the CORTICES Multicenter Database.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Novel Uses of Traditional Algorithms for Septic Arthritis.

BACKGROUND: Pediatric musculoskeletal infection (MSKI) is a bacterial infection of the bone, joint, and/or muscle that can be difficult to diagnose. The Kocher and Caird algorithms were developed to distinguish septic arthritis (SA) from transient synovitis (TS) in the hip. These algorithms have been applied to all patients presenting with painful, swollen monoarticular joints regardless of suspicion for SA. The aim of this analysis was to assess the test performance of Kocher and Caird to distinguish MSKI among all pediatric patients presenting with monoarticular joint pain. A secondary aim was to validate the original algorithms. METHODS: We conducted a secondary analysis of a prospective cohort study evaluating the test performance of procalcitonin for suspected SA in a pediatric emergency department. Patients aged 0 to 16 years old who presented with a painful or swollen monoarticular joint were considered for enrollment. We compared the test performance of the traditional algorithms in an expanded population of MSKI versus alternate joint pain using sensitivity, specificity, and area under the curve (AUC). As a sensitivity analysis, missing data for predictors like temperature, erythrocyte sedimentation rate, C-reactive protein, and inability to bear weight were multiply imputed using the Stata program, mi impute, for changed equations. RESULTS: The Caird algorithm had better test performance compared to the Kocher in all populations. Both algorithms were most discriminative in comparing SA to TS in all joints (AUC: 0.84 Caird and 0.75 Kocher). However, the Caird criteria performed almost as well discriminating MSKI from other causes of monoarticular joint pain in all joints (AUC: 0.79; 95% confidence interval: 0.72, 0.85) and nonhip joints (AUC: 0.80; 95% confidence interval: 0.71, 0.88). CONCLUSION: Based on the findings of this study, it is clinically reasonable to apply the Caird algorithm to pediatric patients presenting with monoarticular joint pain of medium and large joints such as the knee, ankle, shoulder, elbow, and wrist, in addition to the hip. LEVEL OF EVIDENCE: Level III-retrospective study of novel applications of SA algorithms.

Prioritizing Elective Surgical Cases During a Pandemic or Global Crisis: The Elective-Pediatric Orthopedic Surgical Timing (E-POST) Score.

BACKGROUND: As the first wave of the COVID-19 pandemic stabilized and resources became more readily available, elective surgery was reinitiated and hospitals realized that there was little guidance on how to prioritize elective cases. METHODS: A prioritization tool was formulated based on clinically relevant elements and previous literature. Nine pediatric orthopaedic surgeons from North American institutions evaluated 25 clinical scenarios on 2 occasions separated in time. Intra-rater and inter-rater reliability were calculated [intraclass correlation coefficient (ICC)]. Surgeons also ranked the importance of each element and how confident they were with scoring each factor. RESULTS: Intra-rater ICC for total score showed good to excellent consistency; highest at 0.961 for length of stay (LOS) and lowest at 0.705 for acuity. Inter-rater ICC showed good to excellent agreement for American Society of Anesthesiologists score, LOS, duration of surgery, and transfusion risk and moderate agreement for surgical acuity and personal protective equipment (PPE) use. Transfusion risk and duration of surgery were deemed least important, and surgeons were least confident in scoring PPE and transfusion risk. Based on findings, the novel Elective-Pediatric Orthopedic Surgical Timing (E-POST) score for prioritizing elective cases was developed, consisting of 5 factors: surgical acuity, global health status, LOS, duration of surgery, and PPE requirement. CONCLUSIONS: The E-POST numeric total score or subscore may help objectively prioritize elective cases during a global crisis. LEVEL OF EVIDENCE: Level V.

Refracture Rate of Both Bone Forearm Fractures: A Retrospective Comparison of Casting Alone Versus Casting and Extended Functional Bracing.

BACKGROUND: One of the most common pediatric fractures is a midshaft both bone forearm fracture. The preferred nonoperative treatment is cast immobilization for 6 to 8 weeks; however, 4% to 8% refracture within 6 months. There are no comparative studies evaluating the efficacy of bracing after cast immobilization. We hypothesized that children treated with prolonged functional bracing would have a lower rate of refracture than casting alone or short-term bracing. METHODS: This is a retrospective review of children younger than 15 years of age treated nonoperatively following radius and ulnar shaft fractures treated at 3 tertiary pediatric hospitals. We excluded distal radius/ulna fractures, isolated fractures of the radius/ulna, and fractures near the elbow. Logistic regression analysis on casting plus functional bracing was run to determine if age, translation, or the number of days in brace were associated with refracture. The incidence of refracture was compared between groups. RESULTS: A total of 1549 patients were screened and 426 were included in the study [111 casting only (CO), 259 casting plus functional brace <8 wk (CFB <8 wk), 56 casting plus functional brace ≥8 wk (CFB ≥8 wk)]. In comparing the groups, CO was the youngest (4.4 y vs. 6.3 and 8.4 y). The initial translation and angulation of the radius and ulna were significantly greater in the CFB ≥8 weeks group. Regression analyses shows no association between refracture and initial fracture characteristics including age, translation, or the number of days in brace. The CO group had 3 refractures (2.7%), the CFB <8 weeks group had 13 (5%) and the CFB ≥8 weeks group had 1 (1.8%); demonstrating no statistical significance. CONCLUSION: Extended fracture bracing, following a period of cast immobilization, did not lead to a statistically significant difference in refracture rate. Contrary to previous cases series, the benefit of bracing seems nominal. Larger, prospective studies are needed to better understand targets for treatment. LEVEL OF EVIDENCE: This is the first level III retrospective comparison study of its kind.

Outcomes and Complications in Management of Congenital Myopathy Early-Onset Scoliosis.

BACKGROUND: Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients. METHODS: This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications. RESULTS: Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P<0.01), with no significant increase in T1-S1 height or maximum kyphosis(P>0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P<0.01). Fifty-four (55.7%) CP patients experienced a total of 105 complications at 2 years. There was no evidence that the risk of complication or radiographic outcomes differs between cohorts at 2 years, though CP EOS patients experienced significant improvement in all measurements at 2 years. CONCLUSIONS: EOS CM children face a high risk of complication after growing instrumentation, with similar curve correction and risk of complication to CP patients. LEVEL OF EVIDENCE: Level III.

Socioeconomic Status and Analgesia Provision at Discharge Among Children With Long-Bone Fractures Requiring Emergency Care.

BACKGROUND: Inadequate treatment of painful conditions in children is a significant and complex problem. The objective of this study was to examine the effect of socioeconomic status on the provision of analgesic medicines at discharge in children treated emergently for a long-bone fracture. METHODS: A retrospective review of all patients during a 1-year period with a long-bone fracture treated in 2 urban pediatric emergency departments (EDs) was performed. RESULTS: Eight hundred seventy-three patients were identified who met our inclusion criteria. Sixty percent of patients received a prescription for an opioid-containing medicine, and 22% received a prescription for an over-the-counter analgesic medicine at ED discharge. Socioeconomic status had no effect on opioid analgesic prescriptions at discharge. Patients in the lowest-income group were younger, presented to the ED longer after an injury, were likely nonwhite, and had higher rates of over-the-counter analgesic medicine prescriptions provided at discharge. Higher-income patients were likely white and non-Hispanic, presented to the ED sooner, and were less likely to receive a prescription for a nonopioid analgesic medicine. CONCLUSIONS: Socioeconomic status is associated with different nonopioid analgesic prescription patterns in children treated in the ED for a long-bone fracture, but had no effect on opioid analgesic prescriptions.

Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection.

OBJECTIVES: Septic arthritis (SA) is responsible for 20% of pediatric musculoskeletal infections (MSKI) and can have significant consequences. Early detection of SA is critical, and procalcitonin (PCT) has emerged as a promising biomarker. This study assessed the test performance of PCT and traditional biomarkers for suspected SA. METHODS: We conducted a prospective study at two pediatric emergency departments (ED). Data collected measured serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and PCT. Box and whisker plots were generated to compare the of the biomarkers by positive MSKI or a non-MSKI diagnosis. The diagnostic performance of biomarkers was examined using the area under the receiver operating characteristic curve (AUC), and optimal cut -points were identified using the Liu method. RESULTS: Procalcitonin performed reasonably well for detection of MSKI (AUC, 0.72; confidence interval [95% CI], 0.59-0.84). However, CRP and ESR performed better (AUC, 0.88 and 0.78, respectively). White blood cell count was not predictive of MSKI. Patients with a PCT value >0.1 ng/mL, ESR values >19.5 mm/h, and a temperature higher than 99.0°F were more than twice as likely to have acute MSKI. A high CRP level was most predictive of acute MSKI, and patients with levels >2.38 mg/dL were 3.5 times more likely to have acute MSKI. CONCLUSIONS: Procalcitonin is a potential biomarker for the clinical differential of MSKI in the pediatric ED. Additional research is warranted to establish the optimal diagnostic level for PCT, to increase sample size, and to examine any impact on cost.

Displaced Distal Radius Fracture Treatment: A Survey of POSNA Membership.

BACKGROUND: Distal radius fractures (DRFs) are the most common pediatric orthopaedic fracture, of which 20% are displaced injuries. Displaced metaphyseal DRFs are often treated with sedated or anesthetized reduction. The necessity of reduction treatment of displaced fractures to achieve good clinical outcomes is unclear. The purpose of this investigation was to determine the treatment preferences for DRFs among pediatric orthopaedic surgeons and to determine whether they were uncertain enough in their decisions to randomize treatment. METHODS: Twenty-eight DRF scenarios in children aged 3 to 10 years were constructed in an electronic survey to represent a spectrum of age, angulation in sagittal and coronal planes, and displacement. The survey was disseminated to the full membership of the Pediatric Orthopaedic Society of North America (POSNA). Respondents could select either a treatment of (a) attempt anatomic reduction with sedation or (b) nonsedated immobilization. Respondents also denoted whether they would be willing to randomize the treatment of each injury scenario. Patient, fracture, and surgeon characteristics were analyzed to develop predictors of treatment recommendations and willingness to randomize treatment. RESULTS: A total of 319 surgeons responded (23% of POSNA membership). Respondents were a characteristic representation of POSNA membership (well distributed by years in practice, 78% academic, 91% whose work is >80% pediatrics, and 84% work with residents). Predictors of sedated reduction were complete displacement [odds ratio (OR), 9.23; 95% confidence interval (CI), 2.27-37.51; P=0.002] and coronal angulation (per 1-degree increase, OR, 1.09; 95% CI, 1.02-1.17; P=0.016), Willingness to randomize was inversely related to larger coronal plane angulation (per 1-degree increase, OR, 0.96; 95% CI, 0.93-0.99; P=0.01). A majority of surgeons were willing to randomize 7 of the 8 scenarios involving complete displacement and shortening, and >64% of surgeons were willing to randomize 5 of these 8 scenarios. CONCLUSIONS: POSNA members recommend sedated reduction of DRFs primarily based on existence of complete displacement. Although most completely displaced DRFs would undergo reduction, most surgeons would be willing to randomize the treatment of these injuries. This suggests that most POSNA members do not know whether their recommended treatment for displaced DRFs is necessary or correct. This survey establishes the groundwork for a randomized, prospective trial comparing nonsedated immobilization with sedated/anesthetized reduction in the treatment of displaced pediatric DRFs. LEVELS OF EVIDENCE: Level II-survey study.

What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis.

BACKGROUND: Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment. METHODS: A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review. RESULTS: The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis. CONCLUSIONS: Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance. LEVEL OF EVIDENCE: Level IV-literature review.

Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database.

BACKGROUND: Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS: A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS: A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. CONCLUSIONS: Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. LEVEL OF EVIDENCE: Level III-case series, database study.

Should Proximal Femoral Implants be Removed Prophylactically or Reactively in Children With Cerebral Palsy?

BACKGROUND: Implants are commonly used to stabilize proximal femoral osteotomies in children with cerebral palsy (CP). Removal of implants is common practice and believed to avoid infection, fracture, or pain that might be associated with retained hardware. There is little evidence to support a prophylactic strategy over a reactive approach based on symptoms. The aim of this study was to compare the outcomes of prophylactic and reactive approaches to removal of proximal femoral implants in children with CP. METHODS: An intention-to-treat model was used to compare 2 institutions that followed a prophylactic (within ∼1 y) and reactive (following complication/symptoms) approach to hardware removal, respectively. Patients with CP who had femoral implants placed at or before age 16, and had ≥2-year postsurgical follow-up were included. Demographics, surgical details, reasons for removal, and complications were recorded. χ and t tests were used. RESULTS: Six hundred twenty-one patients (prophylactic=302, reactive=319) were followed for an average of 6 years (range, 2 to 17 y). Two hundred eighty-seven (95%) implants were removed in the prophylactic group at 1.2 years. In the reactive group, 64 (20%) implants were removed at an average of 4.2 years. Reasons for removal included pain; infection; fracture; or for repeat reconstruction. The rate of unplanned removals due to fracture or infection was higher in the reactive group (4.7% vs. 0.7%, P=0.002), but there was no difference in the rate of complications during/after removal between the 2 groups (1.7% vs. 3.1%; P=0.616). No specific risk factor associated with unplanned removal could be identified; but children under 8 years old seemed more likely to undergo later removal (odds ratio 1.98; 95% confidence interval, 0.99-3.99). CONCLUSIONS: Eighty percent of patients in the reactive removal strategy avoided surgery. This group did have a 4% higher rate of fracture or infection necessitating unplanned removal but these were successfully treated at time of removal with no difference in complication rates associated with removal between both groups. One would need to remove implants from 25 patients to avoid 1 additional complication, providing some support for a reactive approach to removal of proximal femoral implants in this population. LEVEL OF EVIDENCE: Level III-therapeutic.

Utilization of a Wide Array of Nonvalidated Outcome Scales in Pediatric Orthopaedic Publications: Can't We All Measure the Same Thing?

PURPOSE: Clinical changes are best evaluated with standardized, validated outcomes, including both patient-reported outcome measures and surgeon-reported outcome measures (PROMs and SROMs). The purpose of this study was to describe the spectrum of outcome measures used in pediatric orthopaedic publications over the past 10 years and to determine the proportion that are in fact age-appropriate, validated, and appropriately applied in terms of condition and population. METHODS: The Journal of Bone and Joint Surgery, The Bone and Joint Journal, Journal of Pediatric Orthopaedics A and B, and Journal of Children's Orthopaedics were systematically searched for studies including children aged 18 and below, over a 10-year period from January 2005 to December 2014. Economic evaluations, letters, editorials, review articles, and clinical guidelines were excluded. SROMs and PROMs used were extracted, as were details on subject age and condition for which they were used. Each outcome scale was assessed for validity, and the proportion of scales used appropriately was calculated. Cochrane-Armitage test of trend was used to determine changes in PROM and SROM utilization over the study period. RESULTS: A total of 4614 articles were identified, of which 2251 met inclusion and exclusion criteria. In total, 259 (11.5%) of studies used a PROM, whereas 326 (14.5%) used a SROM. A total of 230 different outcome scales were identified; 115 were patient reported and 115 were surgeon reported. However, only 18.7% of SROMs and 38.3% of PROMs were applied to an age and disease-appropriate demographic. Overall, there was a significant increase in the overall utilization of PROMs during the study period (P=0.004), but no corresponding increase in pediatric-validated PROMs (P=0.164). SROM utilization did not significantly change over the study period (P=0.337). CONCLUSIONS: Within the field of pediatric orthopaedics, an expansive variety of outcome scales are used, many of which have not been validated in children. Improved uniformity in reporting of outcomes and use of disease and age-validated outcomes scales is essential to improve multicenter research collaboration and data quality to generate appropriate evidence-based conclusions and treatment strategies in pediatric orthopaedics. LEVEL OF EVIDENCE: Level IV-systematic review.

What's New in Pediatric Spine Growth Modulation and Implant Technology for Early-Onset Scoliosis?

BACKGROUND: Early-onset scoliosis (EOS) affects roughly 1 to 2 out of 10,000 live births per year. Because this subset of patients has a yet to achieve a majority of their skeletal growth, a number of treatment challenges need to be addressed before surgical intervention. If left untreated, EOS can cause a number of problems throughout the patient's lifespan, particularly in regards to the growth of the thorax and pulmonary development. A wide variety of surgical systems and techniques are available to the treating surgeon. METHODS: A review of the orthopaedic literature from 2010 to 2015 relating to pediatric spine growth modulation was performed. Ninety-eight papers were identified and, following exclusion criteria, a total of 31 papers were selected for further review. RESULTS: This paper summarizes the recently published literature regarding growth-friendly spinal implants, the status of their Food and Drug Administration approval labeling as well as the indications, applications, and complications associated with their implementation. CONCLUSIONS: There are a growing number of options at the surgeon's disposal when treating patients with EOS. As surgeons, we must continue to be vigilant in our demand for sound clinical evidence as we strive to provide optimal care for our patients. The rapidly advancing field of spinal growth modulation is exciting. More work must be done to further enhance our ability to predictably modulate growth in the pediatric spine.

Patterns of injury and management of children with pelvic fractures at a non-trauma center.

BACKGROUND: Pelvic injuries in young children are rare, and it has been difficult to establish clinical guidelines to assist providers in managing blunt pelvic trauma, especially in non-Level 1 trauma centers. OBJECTIVE: Our aim was to describe the relationship among clinical findings, mechanism of injury, and the radiographic resources utilized in children with pelvic fractures presenting to a non-Level 1 trauma center. METHODS: A retrospective review of patients with a pelvic fracture treated in two urban pediatric Level 3 emergency departments was performed. RESULTS: Between 2001 and 2010, a total of 208 patients were identified. Avulsion/iliac wing fractures were the most common fractures (58.7%), and sports-related injuries were the most common mechanism of injury (50.0%). Children with sports-related injuries were more likely to sustain an avulsion fracture (p<0.001), less likely to have a computed tomography scan obtained in the emergency department (p<0.001), and less likely to have an associated injury (p<0.001) than other children. Children struck by a motor vehicle (p<0.001) or involved in a motor vehicle accident (p<0.001) were more likely to receive a computed tomography scan (p<0.001) and have associated head and extremity injuries (p<0.001). Mechanism of injury was associated with abnormal computed tomography scans. Nearly all patients were treated nonoperatively (98.1%) and no deaths were reported in this study. CONCLUSIONS: Patterns of injury, based on mechanism of injury, have been reported to assist the assessment and management of children with minor pelvic injuries.

Morphological alterations of lumbar intervertebral discs in patients with adolescent idiopathic scoliosis.

BACKGROUND CONTEXT: Etiology of adolescent idiopathic scoliosis (AIS) is still unknown. Prior in vitro research suggests intervertebral disc pathomorphology as a cause for the initiation and progression of the spinal deformity, however, this has not been well characterized in vivo. PURPOSE: To quantify and compare lumbar disc health and morphology in AIS to controls. STUDY DESIGN/SETTING: Cross-sectional study. METHODS: All lumbar discs were imaged using a 3T MRI scanner. T2-weighted and quantitative T2* maps were acquired. Axial slices of each disc were reconstructed, and customized scripts were used to extract outcome measurements: Nucleus pulposus (NP) signal intensity and location, disc signal volume, transition zone slope, and asymmetry index. Pearson's correlation analysis was performed between the NP location and disc wedge angle for AIS patients. ANOVAs were utilized to elucidate differences in disc health and morphology metrics between AIS patients and healthy controls. α=0.05. RESULTS: There were no significant differences in disc health metrics between controls and scoliotic discs. There was a significant shift in the NP location towards the convex side of the disc in AIS patients compared to healthy controls, with an associated increase of the transition zone slope on the convex side. Additionally, with increasing disc wedge angle, the NP center migrated towards the convex side of the disc. CONCLUSIONS: The present study elucidates morphological distinctions of intervertebral discs between healthy adolescents and those diagnosed with AIS. Discs in patients diagnosed with AIS are asymmetric, with the NP shifted towards the convex side, which was exacerbated by an increased disc wedge angle. CLINICAL SIGNIFICANCE: Investigation of the MRI signal distribution (T2w and T2* maps) within the disc suggests an asymmetric pressure gradient shifting the NP laterally towards the convexity. Quantifying the progression of these morphological alterations during maturation and in response to treatment will provide further insight into the mechanisms of curve progression and correction, respectively.

How do implants overlying the spine influence "The Law of Diminishing Returns" in early-onset scoliosis patients?

PURPOSE: The "law of diminishing returns" (LODR) in early-onset scoliosis (EOS) is well-known. We hypothesized that previously observed variations between constructs may be related to the lateral distance that each construct lies from the spine. We therefore sought to determine whether the curve magnitude improvement and spinal length gains for distraction-based constructs in EOS are positively correlated with the collinearity of the spine and the convex-sided implant on posteroanterior radiographs. METHODS: A prospectively-collected, multicenter EOS registry was queried for all patients who underwent non-fusion, distraction-based instrumentation surgery. Post-index radiographs were graded from 1 to 5 based on amount of overlap between the convex-sided rod and the apical vertebra. Grade 1: convex rod is lateral to convex-sided pedicle; Grade 2: overlaps the convex-sided pedicle; Grade 3: lies between pedicles; Grade 4: overlaps concave-sided pedicle; Grade 5: medial to concave-sided pedicle. ANOVA assessed the correlations between post-index overlap grade and change in (a) curve magnitude and (b) T1-T12 height. Multivariable regression modeling further assessed these associations. RESULTS: 284 patients met all selection criteria and were included. On ANOVA, post-index grade was associated with curve magnitude (p <0.001) and T1-12 height (p = 0.028) change. Better curve correction and height change were associated with higher grade. On regression modeling, curve correction (R = 0.574) and T1-T12 height change (R = 0.339) remained significantly associated with grade when controlling for time, anchor locations, age, underlying diagnosis, and pre-index curve magnitude. CONCLUSION: More apical overlap by the convex rod was associated with better spinal deformity control and improved height gain. LEVEL OF EVIDENCE III: Therapeutic.

Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy.

PURPOSE: To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP). METHODS: We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated. RESULTS: 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. CONCLUSIONS: To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood. LEVEL OF EVIDENCE: III.