Is Next-day Discharge Safe After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

OBJECTIVE: While the implementation of enhanced recovery after surgery protocols and improvements in pain control have decreased the length of stay (LOS) after scoliosis surgery, adolescents are typically hospitalized for several days after posterior spinal instrumented fusion (PSF). The purpose of this study was to determine whether next-day discharge after PSF for adolescent idiopathic scoliosis (AIS) had an equivalent safety profile compared with longer LOS. The secondary purpose was to examine perioperative factors associated with next-day discharge. METHODS: We performed a retrospective study of all patients who underwent PSF for AIS at a single institution from 2017 to 2022. We compared patients based on postoperative LOS with an early discharge group consisting of those who were discharged on the first postoperative day 1 (POD1; n = 40) and a standard discharge group consisting of those who were discharged after POD1 (n = 71). We documented preoperative variables, including patient demographics and curve characteristics, intraoperative variables, including levels fused, implant density, operative time, and blood loss, and postoperative variables, including emergency department (ED) visits within 30 days and hospital readmissions within 90 days. RESULTS: One hundred eleven patients were included with a mean curve magnitude of 67 degrees. Forty patients (36%) were discharged on POD1. There were one (3%) ED visit and 2 (5%) readmissions in the early discharge group and 3 (4%) ED visits and 2 (3%) readmissions in the standard discharge group (P = 0.64 and 0.55, respectively). Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1 (P = 0.02). There were no other significant differences in perioperative variables between the two groups including: BMI, distance from home to hospital, magnitude of main curve, curve flexibility, number of levels fused, estimated blood loss, implant density, operative time, or postoperative pain scores. CONCLUSIONS: Next-day discharge after PSF for AIS has an equivalent safety profile compared with longer LOS. Over one-third of patients were discharged on POD1, and there was no statistically significant difference in ED visits or hospital readmissions between the groups. Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1. CLINICAL RELEVANCE: In a retrospective study of posterior spinal fusions for AIS, we found no increase in ED visits or hospital readmissions for those discharged the next day. LEVEL OF EVIDENCE: Level III.

Academic Faculty Demonstrate Weak Agreement in Evaluating Orthopaedic Surgery Residents.

Background: As objective metrics fade, subjective elements of orthopaedic surgery applicants carry increasing importance during recruitment. Academic orthopaedic surgeons believe they can select for high-performing orthopaedic residents. However, can they agree? The purpose of this study was (1) to analyze an academic orthopaedic surgery department to determine whether they agree on which residents performed best during residency and; (2) to correlate preresidency and intraresidency factors with postresidency evaluations of resident performance. Methods: With Institutional Review Board [IRB] approval, an orthopaedic surgery department completed surveys to evaluate residency performance for 10 years of graduated residents (2012-2022). Faculty determined (1) Post-Residency Class Rank (PRCR)-ranked from the highest (1) to lowest performing resident (5) relative to their class based on faculty perspective of performance-and (2) Rank List Score (RLS)-ranked based off the 5-point AOA SLOR used during recruitment interviews. RLS assessed how likely the department would have graduates in the program again based on residency performance. Free marginal Cohen's kappa statistics assessed faculty inter-rater agreement. Preresidency metrics (United States Medical Licensing Exam [USMLE] 1 and 2 scores, research publications, etc) were correlated with Orthopaedic In-Training Exam (OITE) scores, research productivity, American Board of Orthopaedic Surgery (ABOS) scores, and faculty-derived rankings. Linear regressions with forward variable entry (p < 0.05) were used to determine factors associated with excellent resident performance. Results: Eighteen of 25 faculty members (72%) provided survey responses evaluating 46 residents. Faculty agreed 37% and 38% of the time for PRCR (kappa 0.26) and RLS (kappa 0.23), respectively. Step 2 score was the only preresidency factor significantly associated with PRCR (p = 0.03, r2 = 0.15) and RLS (p = 0.02, r2 = 0.3). The only intraresidency factor significantly correlated with PRCR (p = 0.002, r2 = 0.50) and RLS (p = 0.01, r2 = 0.39) was PGY-4 OITE score. Conclusions: An academic orthopaedic surgery department is able to come to a consensus on evaluations of residency performance relative to peers in the same year of training (PRCR) and an objective standard (RLS). Step 2 and Post-Graduate Year (PGY)-4 OITE scores were the only preresidency and intraresidency factors with significant association to higher postresidency, faculty-derived performance scores. Level of Evidence: III.

Fishtail Deformity after Type 2 Supracondylar Humerus Fracture with Development of Symptomatic Loose Body: A Case Report.

Introduction: Supracondylar humerus fractures are one of the most common fractures in children and have been reported to represent up to 16% of all pediatric fractures. While most fractures heal uneventfully with appropriate treatment, there are several known complications that can occur including loss of motion, malunion, and neurovascular injury. One uncommon, yet significant, complication is termed the "Fishtail" deformity. This is represented radiographically with apparent proximal migration of the trochlea, which is thought to be secondary to avascular necrosis and resulting growth arrest. Case Report: This case describes a 11-year-old male who developed a fishtail deformity at age 5, 5 months after percutaneous pinning of a Type II supracondylar humerus fracture. Initially demonstrating a tolerable loss of elbow range of motion (ROM) and being lost to follow-up, he returned 7-years postoperatively, demonstrating diffuse elbow degenerative changes and worsening mechanical symptoms secondary to a loose body which necessitated arthroscopic debridement and loose body removal. Conclusion: This case illustrates the rare fishtail deformity in a Type II supracondylar humerus fracture with acute onset mechanical symptoms of the elbow secondary to a large loose body. Patients with history of supracondylar humerus fractures can develop acute or worsening changes in elbow ROM secondary to the development of osteochondral loose bodies even in the setting of previously known motion deficits secondary to fishtail deformities.

The Costs of Interfacility Transfers for Nonurgent Pediatric Supracondylar Fractures.

BACKGROUND: Unnecessary transfers of nonemergent pediatric musculoskeletal injuries to regional trauma centers can be costly. The severity of fracture displacement in supracondylar humerus fractures dictates the risk of complications, the urgency of transfer and the need for surgical treatment. The purpose of this study is to examine the transfer patterns of Gartland type II pediatric supracondylar humerus fractures to identify strategies for improving patient care, improving health care system efficiency, and reducing costs. We hypothesize that there will be a high rate of unnecessary, emergent transfers resulting in increased cost. METHODS: We retrospectively identified all pediatric patients that underwent treatment for a supracondylar humerus fracture between 2013 and 2018. Patient demographics, injury characteristics, chronological data, and surgical data were collected and analyzed from ambulance run sheets, transferring hospital records, and electronic medical records. Transfer distances were estimated using Google-Maps, while transfer costs were estimated using Internal Revenue Service (IRS) standard mileage rates and the American Ambulance Association Medicare Rate Calculator. A student t test was used to evaluate different treatment groups. RESULTS: Sixty-two patients had available and complete transfer data, of which 44 (71%) patients were safely transferred via private vehicle an average distance of 51.8 miles, and 18 (29%) patients were transferred via ambulance on an average distance of 55.6 miles ( P =0.76). The average transfer time was 4.1 hours by private vehicle, compared with 3.9 hours by ambulance ( P =0.56). The average estimated cost of transportation was $28.23 by private vehicle, compared with $647.83 by ambulance ( P =0.0001). On average, it took 16.1 hours after injury to undergo surgery and 25.7 hours to be discharged from the hospital, without a significant difference in either of these times between groups. There were no preoperative or postoperative neurovascular deficits. CONCLUSION: Patients with isolated Gartland type II supracondylar humerus fractures that are transferred emergently via ambulance are subjected to a significantly greater financial burden with no demonstrable improvement in the quality of their care, since prior research has shown these injuries can safely be treated on an outpatient basis. Potential options to help limit costs could include greater provider education, telemedicine and improved coordination of care. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Outpatient Bryant's Overhead Traction Does Not Affect the Rate of Open Reduction or Avascular Necrosis in Developmental Dislocation of the Hip.

BACKGROUND: The efficacy of preliminary traction to increase the likelihood of closed reduction and/or decrease the incidence of avascular necrosis in the management of developmental dysplasia of the hip (DDH) is controversial. We sought to document compliance with and effectiveness of Bryant's outpatient traction in patients with idiopathic DDH. METHODS: Patients presenting between 6 and 24 months of age with idiopathic irreducible DDH were prospectively enrolled in the study. Prereduction outpatient traction was prescribed at participating surgeons' preference and parents' expressed willingness to comply with a traction protocol of at least 14 hours/day for 4 weeks. Traction hours were documented using a validated monitor; parents also reported average daily usage. Rate of successful closed reduction and evidence of capital epiphyseal growth disturbance 1 year' and 2 years' postreduction were documented. RESULTS: Ninety-six patients with 115 affected hips were enrolled. Reliable recorded traction hours were obtained in 31 patients with 36 affected hips. Defining compliance as 14 hours/day average use, 14 of 31 patients (45.2%) were compliant, 2 (6.5%) admitted noncompliance, while 15 (48.2%) claimed to be compliant, but were not. Overall, 68/115 hips (59.0%) were closed reduced. Age at treatment was the only demographic characteristic associated with an increased incidence of closed reduction (11.7 vs. 14.6 mo, P<0.01). Successful closed reduction was achieved in 10/16 hips (62.5%) of compliant patients, 12/20 (60.0%) of noncompliant patients, and 43/72 (59.7%) of no-traction patients. Irregular ossific nucleus development was noted 1-year postindex reduction in 5/16 (31.3%) of complaint-patient hips and 25/92 (27.2%) of noncomplaint and no-traction hips. Distorted proximal femoral epiphysis was noted at 2 years postreduction in 2/15 hips (13.3%) of compliant patients and 15/52 hips (28.8%) in noncompliant and no-traction patients. None of these differences was statistically significant. CONCLUSIONS: Parent-reported use of outpatient traction is unreliable. Four weeks of outpatient overhead Bryant's traction did not affect the rate of closed reduction or avascular necrosis in late-presenting DDH in this cohort. LEVEL OF EVIDENCE: Level II-prospective cohort.

Assessment of Lateral Rotation Percentage and Rotational Deformity of the Elbow in Type 3 Supracondylar Humerus Fractures: A Biomechanical Study.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common elbow fractures in children. Historically, displaced (Gartland type 3) SCH fractures have been treated with closed reduction and percutaneous pinning. Fluoroscopic imaging is used intraoperatively in order to assess adequate reduction of the fracture fragments before pinning. On lateral fluoroscopic and radiographic images, a lateral rotation percentage (LRP) can be estimated in order to assess rotational deformity. The purpose of this study was to determine the true rotational deformity of distal humerus fracture fragments in SCH fractures based upon the LRP using a clinically relevant laterally based pinning technique. METHODS: In this study, a sawbones model was used to examine the correlation between calculated LRP and the true degree of rotational deformity with 3 of the most common extension-type SCH fracture types (low transverse, high transverse, and lateral oblique). Because fracture stability was not the focus of this study, a single pin was used to hold the construct and allow for fragment rotation along a fixed axis. In this study, 2 of the authors independently measured rotational deformity and compared this with LRP on fluoroscopic lateral imaging of a sawbones model at 0 to 45 degrees of rotational deformity. RESULTS: The LRP of all 3 patterns demonstrated a near linear increase from 0 to 45 degrees with maximum LRP measured at 45 degrees for each of the 3 patterns. Univariate linear regression demonstrated an increase in LRP for the low transverse pattern of 2.02% for every degree of rotation deformity (R2=0.97), 2.29% for the lateral oblique pattern (R2=0.986), and 1.17% for the high transverse pattern (R2=0.971). Maximum LRP was measured at 45 degrees for all 3 patterns with a mean of 53.5% for the high transverse pattern, 93.5% for the low transverse pattern, and 111.2% for the lateral oblique pattern. A higher LRP was measured with increasing degrees of rotational displacement in the low transverse and lateral oblique patterns for all degrees of rotational deformity compared to the high transverse pattern. CONCLUSION: There is a near linear correlation between the degree of malrotation and the LRP with more superior metaphyseal fracture patterns demonstrating a lower LRP than inferior fracture patterns. CLINICAL RELEVANCE: Using our data one can estimate the degree of malrotation based on the LRP on radiographs in the clinical setting. LEVEL OF EVIDENCE: Not applicable (basic-science article).

Preoperative supine traction radiographs often result in higher Lenke classifications than supine bending radiographs in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective chart and radiographic review. OBJECTIVE: The purpose of this study is to determine if both traction and side-bending radiographs yield the same Lenke classification. Supine side-bending radiographs are used to evaluate curve flexibility and assign Lenke classification in Adolescent Idiopathic Scoliosis (AIS). Supine traction radiographs are another tool used by treating surgeons to gauge flexibility and appropriate levels for spinal fusion in AIS. METHODS: Retrospective chart and radiographic review were performed on AIS patients that underwent a posterior spinal fusion from 2008 to 2017. Cobb angles and Lenke classifications were determined on all upright posterioanterior (PA) spine radiographs, supine traction radiographs, and four supine bending radiographs. Statistical analysis using independent t tests and chi-square tests as appropriate were compared between patients with or without discordant Lenke classifications with p value set at < 0.05 for statistical significance. RESULTS: 184 patients met inclusion criteria, 36 males and 148 females. The average Cobb angle for the proximal thoracic (PT) curve was 27.2°, main thoracic (MT) curve was 60.5°, and thoracolumbar/lumbar (TL/L) curve was 48.0°. Significantly less curve correction was found with supine traction radiographs compared with bending radiographs: PT (23.1° vs 18.9°, p < 0.001), MT (38.9° vs 37.9°, p = 0.015), and TL/L (25.9° vs. 18.0°, p < 0.001). Lenke Classification was found concordant in 151/184 (82.1%). Traction views in the discordant Lenke classification group demonstrated less curve correction than those in the concordant group: PT (27.4° vs. 22.1°, p = 0.011), MT (45.3° vs. 37.5°, p < 0.001), and TL/L (29.3° vs 25.1°, p = 0.019). CONCLUSION: Supine traction and supine bending radiographs provided a concordant Lenke classification 82.1% of the time. However, supine traction radiographs demonstrate less curve correction, a higher Lenke classification, and underestimated the TL/L curve correction to a greater degree. A single supine traction film is not an adequate substitute to side-bending radiographs when determining Lenke classification in patients with Adolescent Idiopathic Scoliosis. LEVEL OF EVIDENCE: III.

ACGME Operative Case Log Accuracy Varies Among Surgical Programs.

OBJECTIVE: This study evaluates the accuracy of reported the Accreditation Council for Graduate Medical Education (ACGME) operative case logs from graduated residents compared to institutional operating room electronic records (ORER). We hope this will help guide review committees and institutions develop complete, accurate resident case logs. DESIGN: This is a retrospective, cross-sectional study of general surgery (GS), neurosurgery (NS), and orthopedic surgery (OS) resident physicians. ACGME and ORER cases from 2009 to 2010 were analyzed and each case and current procedural terminology (CPT) code directly compared (ORER vs. ACGME). SETTING: Single academic tertiary-care medical center (University of Kentucky, Lexington, KY). PARTICIPANTS: Eleven thousand nine hundred and twenty-three cases for 46 residents among the 3 residency programs were analyzed. RESULTS: There was an overall logging accuracy of 72% for ORER cases reflected in the ACGME case logs. OS residents had a higher rate of logging accuracy (OS 91%, GS 69%, NS 58%, chi-square p = 0.014) and mean annual number of cases compared to the other 2 programs (OS 452, GS 183, NS 237, ANOVA p = 0.001). NS residents had higher accuracy of CPT codes than post-graduate years 2 to 5 in other programs (p < 0.017). There was a strong positive correlation between the number of cases completed per resident and case logging accuracy, (rho = 0.769, p < 0.001) consistent for NS and GS, but not OS. CONCLUSIONS: This study shows only 72% of a residents' operative experience is captured in the ACGME case log across 3 surgical programs. There is significant variability among surgical programs and among post-graduate year cohorts regarding case log and CPT code accuracy. There is a strong correlation with the total number of cases performed and increasing case log accuracy. Low case log accuracy may reflect individual resident behavior instead of program operative exposure. Further studies are needed to determine if ORER may serve as a more complete assessment of the operative experience of a resident and program.

Pulling the Trigger: Recommendations for Surgical Care of the Pediatric Trigger Thumb.

BACKGROUND: Despite being a common pediatric hand condition, there are few clear guidelines regarding the optimal management of pediatric trigger thumb. Our primary aim was to help guide surgical management of this disorder by establishing a treatment algorithm on the basis of our institution's experience. METHODS: This is an institutional review board-approved retrospective study of all patients with idiopathic trigger thumbs from 2005 to 2015 at a single institution. Demographics and treatment course were recorded for all patients including duration of follow-up, observation, surgical intervention, and complications. All children were classified according to the Sugimoto classification. RESULTS: A total of 149 patients with 193 thumbs met inclusion and exclusion criteria. 16.5% of patients had stage II thumbs, 10.3% of patients with stage III, and 73% of patients with stage IV thumbs. Of all patients with stage IV thumbs, 3.5% were locked in extension for an overall incidence of 2.6%.In total, 46% of patients failed observation and underwent surgical treatment. Only 14% of stage IV trigger thumbs resolved when observed, compared with 53% of stage II and 25% of stage III trigger thumbs. Stage IV thumbs were 4.6 times more likely to fail conservative treatment and go on to surgery than stage II or III thumbs (odds ratio, 4.6; P=0.006).Thirty-two percent of patients underwent surgery without an observation period. Older children with bilateral stage 3 thumbs were the most likely to go straight to the odds ratio instead of being observed (P=0.002, r=0.17).Of the total amount of patients who underwent surgery (116), there were 4 complications for a rate of 3.4% with a recurrence rate of 1.7%. CONCLUSIONS: On the basis of the data in this study, the authors would recommend that stage IV thumbs undergo surgery without an observational period. Second, stage II and stage III thumbs can be safely observed for at least 1 year before surgery. Finally, our study concurs with the literature that surgery can be successful with low rates of complications and recurrence. LEVEL OF EVIDENCE: Level IV.

Proximal Femoral Deformity Following Threaded Prophylactic Fixation for Slipped Capital Femoral Epiphysis: Risk Stratification Using the Modified Oxford Score.

BACKGROUND: This study assesses the effect of skeletal maturity on the development of iatrogenic proximal femoral deformity following threaded prophylactic screw fixation in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). METHODS: Children who underwent threaded screw prophylaxis of the uninvolved hip (Group P) and those who were observed with no prophylaxis (Group N) on presentation with unilateral SCFE were compared. Skeletal maturity was assessed with the Modified Oxford Score (MOS). Proximal femoral morphology was characterized by femoral neck length, femoral neck width, neck shaft angle, and trochanteric femoral head overlap percentage (TFHOP). Femoral head deformity at final follow-up was characterized as spherical (Type 1), mildly aspherical (Type 2), or ovoid (Type 3). Analysis of variance and t test were used to compare the groups. RESULTS: Thirty-eight patients in Group P and 17 patients in Group N met inclusion criteria. The average follow-up was 2.6 years. Group P was younger than Group N by an average of 9.6 months (P=0.04), but the MOS for skeletal maturity was not different between groups (P=0.15). Group P had significantly diminished neck length (P=0.008) and significantly increased relative trochanteric overgrowth as evidenced by increased trochanteric femoral head overlap percentage (P<0.001), but there was no difference between groups in neck shaft angle and neck width. No patient in Group N developed femoral head deformity (all Type 1). In Group P, 14 patients (37%) developed Types 2 and 3 deformity. In patients with MOS 16 in Group P, 60% (3/5) developed Type 2 deformity and 40% (2/5) developed Type 3 deformity. In patients with MOS 17 in Group P, 45% (5/11) had Type 2 deformity. CONCLUSIONS: Skeletally immature patients with an MOS of 16 and 17 are at high risk for developing the triad of relative trochanteric overgrowth, coxa breva, and femoral head asphericity with prophylactic threaded screw fixation for SCFE. When prophylactic surgery is indicated, consideration should be given to growth friendly fixation strategies to avoid iatrogenic proximal femoral deformity. LEVELS OF EVIDENCE: Level III-therapeutic retrospective comparative study.

Is It Growth or Natural History? Increasing Spinal Deformity After Sanders Stage 7 in Females With AIS.

BACKGROUND: Accurate prognosis and treatment decisions in adolescent idiopathic scoliosis (AIS) demand a reliable radiographic marker of growth cessation. Specifically, Sanders Stage 7 (SS7) is a useful marker of spine growth cessation in females and is proposed as a bracing endpoint. The purpose of this study was to determine the amount of curve progression noted in female individuals with AIS after achieving SS7. We hypothesize that a subset of patients continues to progress at a greater rate than the natural history at SS7. METHODS: This retrospective review included female patients with AIS treated at a single institution from May 2008 to 2018. Patients required a hand radiograph demonstrating SS7 and concurrent spine radiograph measuring <50 degrees, plus 2-year follow-up spine radiograph. Curve types were categorized by the modified Lenke Classification. Risser grade, menarche, height, weight, and bracing data were collected. Progression was defined as an increase of the main curve ≥5 degrees. Comparison between groups was analyzed using independent t tests and χ or Fisher exact tests as appropriate. Binary logistic regressions were used to construct a model predictive of progressing beyond 50 degrees or undergoing surgery. RESULTS: A total of 89 patients met inclusion criteria, average main curve magnitude 33 degrees (SD 9) at SS7 and 38 degrees (SD 11) at 2-year follow-up. Forty-five (51%) patients progressed ≥5 degrees and 17 (19%) progressed at least 10 degrees. Seventy patients had curves <40 degrees at SS7 and 22 (31%) progressed to >40 degrees at 2 years. Eleven (12%) patients progressed to >50 degrees or had surgery at 2-year follow-up. Receiver operating characteristic curve analysis identified a threshold of 39.5 degrees curvature at SS7 associated with progression to >50 degrees or surgery (area under the curve=0.94, P<0.001, sensitivity=100%, specificity=87%). Patients with initial curves >40 degrees did have additional height gained (2.1 cm; SD 1.5), but this was not different than those <40 degrees, P>0.05. In addition, no other variables had statistically significant association with those that progressed (P>0.05). CONCLUSIONS: A curve >40 degrees at SS7 is at high risk for progressing to a curve measuring >50 degrees or requiring surgery. Those with curves below this threshold still have potential to make clinically significant progression after skeletal maturity. Follow-up of patients beyond SS7 is essential for curves measuring >40 degrees. Reaching SS7 with a curve <50 degrees may not be the endpoint for curve progression, even if predictive of the end of spinal growth. LEVEL OF EVIDENCE: Level III-retrospective research study.

Brace Yourselves: Outcomes of Ponseti Casting and Foot Abduction Orthosis Bracing in Idiopathic Congenital Talipes Equinovarus.

BACKGROUND: Foot abduction orthoses (FAO) are believed to decrease recurrence following treatment of congenital talipes equinovarus (CTEV) as described by Ponseti. The purpose of this project is to examine the outcomes of FAO bracing following treatment by the Ponseti method in a cohort of idiopathic CTEV patients. METHODS: After IRB approval, a cohort of patients aged 3 to 46 days with idiopathic CTEV was identified in a previous prospective study of brace compliance by family report and sensor. Dimeglio score and family demographic information were collected. Initial treatment was by the Ponseti method, with or without Achilles tenotomy. Following correction, patients had three months of full-time FAO bracing during which parents kept a log of compliance. Patients were followed until recurrence (need for further treatment) or age 5. RESULTS: In total, 42 patients with 64 affected feet met the above criteria and were included in the final analysis. Twenty-six feet (40%) went on to develop recurrence requiring further treatment, including casting, bracing, or surgery. Because of poor tolerance of the original FAO, 20 feet were transitioned to an alternative FAO, and 14 of these (70%) went on to recur (P<0.01). The casting duration (P=0.02) had a statistically significant relationship to recurrence. Patients who were casted for 9 weeks or more had a higher rate of recurrence (57.1% vs. 27.8%; P=0.02). Age at treatment start, Dimeglio score, demographic factors, and compliance during full-time bracing, whether by report or sensor, did not show a significant relationship with recurrence. CONCLUSIONS: The study showed a statistically significant relationship between the difficulty of CTEV correction and the risk of recurrent deformity requiring treatment. This relationship could be used to provide prognostic information for patients' families. Caregiver-reported compliance was not significantly related to recurrence. LEVEL OF EVIDENCE: Level III-Prognostic Retrospective Cohort Study.

Idiopathic Genu Valgum and Its Association With Obesity in Children and Adolescents.

BACKGROUND: Obesity as a cause of lower extremity deformity in children has been well established. This deformity is most often seen as tibia vara, however, at our institution we have observed more obese children and adolescents over age 7 years with excessive or progressive idiopathic genu valgum. Our hypothesis is that children with idiopathic genu valgum have high rates of obesity which impact the severity of their disease. METHODS: Retrospective review of existing data was performed on 66 consecutive children/112 limbs over age 7 years with idiopathic genu valgum, seen from 2010 to 2013. Children with known metabolic or skeletal disease were excluded. Genu valgum was defined as mechanical axis in zone II or III and mechanical tibiofemoral angle ≥4 degrees on standing anteroposterior radiograph of the lower extremities. Body mass index (BMI) was calculated and classified by Center for Disease Control percentiles. Skeletal maturation was rated by closure of pelvic and peri-genu physes. Severity of genu valgum was also assessed by femoral and tibial mechanical axes and the mechanical axis deviation. RESULTS: Mean patient age was 12.2±2.2 years. 47% of patients had BMI≥30 and 71% were categorized as obese (>95th percentile). No sex differences were identified. Skeletal maturation explained 25% of the variance in the mechanical axis deviation and 22% of the mechanical tibiofemoral angle. BMI predicted 9.8% of the tibial valgus. Because of its skewed distribution, BMI percentile was a less useful parameter for assessment. CONCLUSIONS: The 71% obesity rate found in our children with idiopathic genu valgum is significantly higher than the normal population. Higher BMI is associated with more tibial valgum but skeletal maturation was the main predictor of overall valgus severity. This suggests that obesity may play a role in the etiology of idiopathic genu valgum which progresses with skeletal maturation, thereby increasing the risk of osteoarthritis in adulthood. LEVEL OF EVIDENCE: Level III.

Pediatric Forearm Fractures Are Effectively Immobilized With a Sugar-Tong Splint Following Closed Reduction.

INTRODUCTION: Following closed reduction and initial casting of pediatric forearm fractures, loss of reduction (LOR) occurs in ∼5% to 75% of fractures. Sugar-tong splinting has been shown to maintain acceptable reduction in pediatric distal radius fractures while potentially avoiding issues associated with circumferential casting. We hypothesized that the sugar-tong splint would be an acceptable method for initial immobilization to prevent LOR in distal, mid-shaft, and proximal pediatric forearm fractures. METHODS: This is an IRB-approved, retrospective study. Inclusion criteria included pediatric patients age 4 to 16 years old, open growth plates, with a displaced forearm fracture (radius, ulna, or both bone) that underwent closed reduction. The clinical protocol involved closed reduction and application of a sugar-tong splint by an orthopaedic resident under conscious sedation in the emergency room. Clinical follow-up occurred at 1, 2, 4, and 6-week intervals with a long-arm cast overwrap applied at the initial clinic visit. Primary outcome was radiographic LOR which was defined as a change of >10 degrees of angulation on anterior posterior/lateral projections from initial postreduction radiograph or previous follow-up radiograph. The secondary outcome was the need for further intervention. RESULTS: Sixty-four (38%) patients demonstrated radiographic LOR with 90% of LORs occurring in the first 2 weeks. LOR was significantly more common in distal radius fractures [48/110 (44%)] than with either proximal [2/14 (14%), P=0.04] or mid-shaft radius fractures [7/41 (17%), P=0.004]. There was no difference in LOR by location for ulna fractures [proximal=2/13 (15%), middle=4/38 (11%), distal=20/77 (26%), P>0.08]. There was no difference in radial LOR in patients with isolated radius fractures compared with both bone forearm fracture (17/40 vs. 40/125, P=0.22), or ulnar LOR between isolated ulna and both bone forearm fracture (0/3 vs. 26/125, P>0.99). CONCLUSION: The sugar-tong splint is effective at maintaining reduction of pediatric forearm fractures similar to published rates for casting. While effective at all levels of the forearm, the sugar-tong splint performed best in proximal and mid-shaft forearm fractures. LEVEL OF EVIDENCE: Level IV.

Hamstring lengthening in females with cerebral palsy have greater effect than in males.

Children with spastic diplegia cerebral palsy often demonstrate crouched gait patterns, and typically undergo hamstring lengthenings. The objective of this retrospective study was to determine if the surgical response to medial and lateral hamstring lengthenings is different between males and females. Preoperative and postoperative kinematic data of 109 (71 males and 38 females) patients with cerebral palsy were evaluated. Females demonstrated larger decreases in popliteal angle, larger decreases in mid-stance knee flexion, and higher incidences of knee hyperextension postoperatively. Results indicate that females have larger responses to hamstring lengthenings than males.

Increased acute postoperative wound problems following spinal fusion in overweight patients with adolescent idiopathic scoliosis.

This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.

Effect of Amputation Level on Quality of Life and Subjective Function in Children.

BACKGROUND: Our aim was to discern whether children with amputations have differences in subjective function based on amputation level. We hypothesized that children with more proximal amputations would report poorer function and quality of life. METHODS: An IRB-approved, retrospective chart review of patients aged 0 to 21 years old with lower extremity amputations was performed. Demographic information, type of amputation, type of prosthesis, and the Pediatric Outcomes Data Collection Instrument (PODCI) was collected from parents and children (above 10 y old). Patients were divided into 4 groups based on the level of amputation (ankle; transtibial; knee; transfemoral), and PODCI scores were compared between groups. PODCI subscores were also compared between unilateral versus bilateral amputations, high-demand versus low-demand prostheses, and congenital versus acquired amputations. RESULTS: We identified 96 patients for analysis (39 ankle, 21 transtibial, 27 knee, and 9 transfemoral amputations). The sports/physical functioning subscale of the PODCI showed the only statistically significant difference between amputation level and outcome with ankle-level amputations reporting higher scores than knee-level amputations (parent: 78.3±16.4 vs. 60.0±25.3, P=0.006; child: 87.4±15.3 vs. 65.4±31.5, P=0.03). Although not significantly different from either the ankle, knee, or transfemoral groups, patients with transtibial amputations reported intermediate scores (parent: 68.5±27.5; child: 78.9±25.5). There were no significant differences among amputation level for PODCI transfers, pain/comfort, global function, or happiness subscales. In subgroup analysis, same-level congenital amputees had similar scores to acquired amputees (P>0.05). When compared with unilateral knee amputations patients, patients with bilateral knee amputations had significantly worse transfer (62.4 vs. 88.3; P=0.02), sports/physical functioning (34.2 vs. 66.2; P=0.01), and global domains (58.4 vs. 80.5; P=0.02). CONCLUSIONS: Subjective sports and physical functioning of pediatric amputees were significantly worse after knee amputation when compared with ankle-level amputations. Although not statistically significant at all levels, our data suggest a graded decline in sports/physical functioning with higher level amputations. Amputation level did not affect pain, happiness, or basic mobility. LEVEL OF EVIDENCE: Level III.

Lower Extremity Fractures in Children: How to Avoid Pitfalls and Manage Complications.

One in three children in the United States will sustain a fracture before the age of 16 years, and nearly one of every four pediatric visits is for a lower extremity musculoskeletal complaint. Clinicians should be familiar with the epidemiology, management, and complications of pediatric pelvis, hip, femur, tibia, and ankle fractures.

Foot size asymmetry following Ponseti treatment versus comprehensive surgical releases for unilateral clubfeet.

Using age and height matched cohorts with unilateral idiopathic clubfeet (n=40 each), we retrospectively reviewed pedobarographic studies to determine the impact of treatment, Ponseti versus comprehensive surgical releases (CSR), on the foot length, width, and contact area. The foot pressures were determined by self-selected walking across a force plate. Ponseti treatment results in more symmetrical foot lengths, widths, and total contact areas with an improvement of 1.3 shoe sizes difference compared with treatment with CSR. This suggests that there is improved growth in the clubfoot in those treated with Ponseti management compared with those treated with CSR.

Magnetic Resonance Imaging in Infantile Idiopathic Scoliosis: Is Universal Screening Necessary?

STUDY DESIGN: Retrospective chart review. OBJECTIVE: Determine if there is a subset of presumed infantile idiopathic scoliosis (IIS) patients who have a low incidence of neural axis abnormalities (NAAs) such that screening magnetic resonance imaging (MRI) may be delayed. SUMMARY OF BACKGROUND DATA: Individuals with presumed IIS have an increased incidence of NAA. Because of the increased incidence, screening MRI is recommended for all patients. We follow these guidelines at our institution. However, MRI screening in this age group is not without cost or risk. METHODS: This is a retrospective study of 53 presumed IIS (onset ≤3 years) patients who had screening MRIs. Demographic and radiographic characteristics were collected. A binary regression using continuous and categorical variables was used to determine if a model could be created to accurately predict MRI necessity. A receiver operating characteristic (ROC) analysis was performed to determine if a threshold Cobb angle exists that is associated with an increased likelihood of NAA. RESULTS: Of the 53 patients, 13 had NAA findings, resulting in a 24.5% incidence of NAAs. Significantly fewer abnormal MRIs were found in patients with Cobb angles <29.5° than those with Cobb angles >29.5° (13/33 [39%] vs. 0/20 [0%], p = .0008). Patients with Cobb angles >29.5° were 27 times more likely to have NAAs than those with angles <29.5° (odds ratio = 27.0 [95% CI = 1.5-486.0], p = .03). No other parameters have a predictive value for NAA (p > .05). CONCLUSION: This is the first study in IIS patients to identify a radiographic parameter that helps select out a subgroup for MRI screening. Additionally, we report an incidence of 24.5% NAAs in these patients, which is higher than previously reported.