Unplanned return to the operating room (UPROR) occurs in 40% of MCGR patients at an average of 2 years after initial implantation.

PURPOSE: This study calculated the rates of Unplanned Return to the Operating Room (UPROR) in early-onset scoliosis patients who had no previous spine surgery and underwent Magnetically Controlled Growing Rod (MCGR) implantation. METHODS: We reviewed surgical, radiographic, and UPROR outcomes for EOS patients treated with the MCGR implant < 12 years + 11 months of age, had complete preop/postop major curve measurements, and had complete MCGR details. RESULTS: 376 patients underwent MCGR implantation at a mean age of 7.7 years (1.8-12.9). Diagnoses included 106 (28%) idiopathic, 84 (22%) syndromic, 153 (41%) neuromuscular, and 33 (9%) congenital. The mean preop-cobb was 76.7° (9-145°), and an immediate postop correction was 41% (0-84%). We found that 38% (142/376) of patients experienced an UPROR prior to the maximal actuator length being achieved. UPROR occurred at mean 2 years (3 days-5 years) after initial implantation. Of the 142 patients who experienced UPROR there were 148 complications that lead to an UPROR. The most common reason for UPROR was anchor (55/148: 37%) or MCGR implant related (33/148: 22%). Wound related (22/148:15%), Neuro related 4/148: 3%), and other (34/148: 23%) accounted for the remaining UPROR occurrences. CONCLUSION: In conclusion, the MCGR UPROR rate was 142/376 (38%) after an average of 2 years post implantation. At 2-year follow-up, only 20% of MCGR patients had experienced an UPROR. However, between 2 and 5 years, the development of an UPROR increased precipitously with only 39% of MCGR patients remaining UPROR free at 5 years post MCGR implantation. The most common reason for UPROR was related to anchor or MCGR implant-related complications. This information can be utilized to set realistic expectations about the need and timing of future surgical procedures with patients and their families.

The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial.

BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Segmental spinal dysgenesis: insights from three consecutive cases and a review of the literature.

OBJECTIVE: Segmental spinal dysgenesis (SSD) is a rare congenital spinal abnormality affecting the thoracic and lumbar region of the spine, as well as the spinal cord of neonates and infants. The purpose of the study was to analyze our institution's surgical case series to provide insights into our best practices to contribute to SSD management principles, while conducting a comprehensive literature review. METHODS: Following institutional review board approval, a retrospective review of SSD surgical cases was examined to observe clinical findings, radiographic findings, management, surgical intervention, and outcomes. Keywords in the comprehensive literature review included SSD, congenital spinal dysgenesis, congenital spinal stenosis, spinal aplasia, and surgery. RESULTS: Three cases underwent successful surgical management with either improvement or maintenance of neurological baseline. Patients were diagnosed at an average age of 2.7 months, while surgical intervention averaged at 40.3 months with fecal incontinence, neurogenic bladders, spinal cord compression, clubfoot, and concerns for worsening spinal deformity as surgical indicators. The average time for follow-up was 33.7 months and no complications were reported. CONCLUSIONS: Operative management for SSD is a clinically complex decision that requires multidisciplinary input and care. Patients should be observed at neurological baseline and receive intervention at the appropriate time to allow sufficient growth for functioning without permitting drastic disease progression. Consideration of patient size and spinal instrumentation are significant towards surgical success.

Building consensus for the medical management of children with moderate and severe acute spinal cord injury: a modified Delphi study.

OBJECTIVE: The focus of this modified Delphi study was to investigate and build consensus regarding the medical management of children with moderate and severe acute spinal cord injury (SCI) during their initial inpatient hospitalization. This impetus for the study was based on the AANS/CNS guidelines for pediatric SCI published in 2013, which indicated that there was no consensus provided in the literature describing the medical management of pediatric patients with SCIs. METHODS: An international, multidisciplinary group of 19 physicians, including pediatric neurosurgeons, orthopedic surgeons, and intensivists, were asked to participate. The authors chose to include both complete and incomplete injuries with traumatic as well as iatrogenic etiologies (e.g., spinal deformity surgery, spinal traction, intradural spinal surgery, etc.) due to the overall low incidence of pediatric SCI, potentially similar pathophysiology, and scarce literature exploring whether different etiologies of SCI should be managed differently. An initial survey of current practices was administered, and based on the responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final meeting was held virtually to generate final consensus statements. RESULTS: Following the final Delphi round, 35 statements reached consensus after modification and consolidation of previous statements. Statements were categorized into the following eight sections: inpatient care unit, spinal immobilization, pharmacological management, cardiopulmonary management, venous thromboembolism prophylaxis, genitourinary management, gastrointestinal/nutritional management, and pressure ulcer prophylaxis. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines. CONCLUSIONS: General management strategies were similar for both iatrogenic (e.g., spinal deformity, traction, etc.) and traumatic SCIs. Steroids were recommended only for injury after intradural surgery, not after acute traumatic or iatrogenic extradural surgery. Consensus was reached that mean arterial pressure ranges are preferred for blood pressure targets following SCI, with goals between 80 and 90 mm Hg for children at least 6 years of age. Further multicenter study of steroid use following acute neuromonitoring changes was recommended.

A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency.

PURPOSE: Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes. METHODS: 367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests. RESULTS: Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed. CONCLUSION: Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.

Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study.

OBJECTIVE: Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery. METHODS: A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS: Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6-12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1-2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level. CONCLUSIONS: In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

Impact of surgical treatment on parent-reported health related quality of life measures in early-onset scoliosis: stable but no improvement at 2 years.

PURPOSE: The etiology of early-onset scoliosis (EOS) has been shown to significantly influence baseline parent-reported health-related quality of life (HRQoL) measures as assessed by the Early Onset Scoliosis Questionnaire (EOSQ). We sought to assess the influence of distraction-based surgery and scoliosis etiology on EOSQ 2 years following surgical intervention remains unclear. METHODS: A retrospective review of a multi-center prospective EOS database was performed. Children untreated with distraction-based, growth friendly instrumentation for EOS with completed baseline and 2-year post-surgical EOSQ were included. Children were subdivided by curve etiology individually and in combined cohorts (congenital/idiopathic [C/I], neuromuscular/syndromic [NMS]). EOSQ domains and compositive HRQoL score at presentation and 2-year follow-up were compared across C-EOS etiologies. Minimal clinically important difference (MCID) was defined as ≥ 20% change in domain score and compared across etiologies. RESULTS: 150 children with EOS met inclusion criteria (mean 7.09 ± 2.6 years, 58.9% female). There were no differences in EOSQ domains between Congenital vs. Idiopathic nor NM vs. Syndromic etiologies at any timepoint. Combined C/I children demonstrated significantly higher EOSQ scores than combined NMS at initial and 2-years post-treatment. Etiology remained the only independent predictor of 2-year EOSQ composite HRQoL score. Overall, the vast majority of children demonstrated stable HRQoL composite scores, with a trend toward more positive MCID in NMS etiologies. CONCLUSION: EOS etiology remains the most significant influence on EOSQ scores 2 years following surgical intervention. However, the majority of patients, regardless of etiology, maintain stable HRQoL scores suggesting that surgery may only serve to stabilize HRQoL at 2 years.

Case Volume Benchmarks During Residency and Fellowship Training for Pediatric Orthopedic Surgeons.

Higher case volumes correlate with improved clinical outcomes across surgical specialties. This study establishes case volume benchmarks after completion of pediatric orthopedic fellowship training. Case logs for orthopedic surgery residents and pediatric orthopedic fellows at accredited programs were analyzed (2017-2018 to 2020-2021). Case volumes for pediatric orthopedic surgery were compared using parametric tests. Case logs from 3,000 orthopedic surgery residents and 149 pediatric orthopedic fellows were analyzed. There was an increase in total pediatric cases among orthopedic surgery residents over the study period (273 ± 68 to 285 ± 76, 1.1% annual increase, P<0.001). On average, pediatric orthopedic fellows reported 276 cases: Spine deformity (55 cases, 20%), foot and ankle deformity (45 cases, 16%), hip reconstruction (34 cases, 12%), limb deformity (32 cases, 12%), trauma lower limb (24 cases, 9%), treatment of supracondylar humerus fracture (23 cases, 8%), trauma upper limb (19 cases, 7%), clubfoot (18 cases, 7%), soft tissue procedures (13 cases, 5%), open treatment of femoral shaft fractures (6 cases, 2%), and treatment of infection (7 cases, 3%). Pediatric orthopedic fellows effectively doubled their pediatric case volume from fellowship training. The distribution of pediatric orthopedic fellow case volume percentiles was: 10th - 191 cases; 30th - 237 cases; 50th - 275 cases; 70th - 318 cases; 90th - 382 cases. Case volume benchmarks can help inform orthopedic trainees, faculty, and patients about the impact of pediatric orthopedic fellowship training. More research is needed to elucidate optimal training environments for future pediatric orthopedic surgeons.

How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis.

STUDY DESIGN: Retrospective, multicenter comparative. OBJECTIVES: Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates. METHODS: EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6). EXCLUSION CRITERIA: < 2 years follow-up from fusion or inadequate radiographs. RESULTS: A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04). CONCLUSIONS: Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate. LEVEL OF EVIDENCE: III.

The role of traditional growing rods in the era of magnetically controlled growing rods for the treatment of early-onset scoliosis.

PURPOSE: To describe the clinical and radiographic profile of early-onset scoliosis (EOS) patients treated with traditional growing rods (TGR) during the magnetically-controlled growing rod (MCGR) era. METHODS: A US multicenter EOS database was reviewed to identify (1) patients who underwent TGR after MCGR surgery was introduced at their institution, (2) patients who underwent MCGR during the same time period. Of 19 centers, 8 met criteria with all EOS etiologies represented. Clinical notes were reviewed to determine the indication for TGR. Patient demographics and pre-operative radiographs were compared between groups. RESULTS: A total of 25 TGR and 127 MCGR patients were identified. The TGR patients were grouped by indication into the sagittal plane profile (n = 11), trunk height (n = 6), co-morbidities/need for MRI (n = 4), and other (ex: behavioral issues, remaining growth). Four patients had a combination of sagittal profile and short stature with sagittal profile listed as primary factor. The TGR short trunk group had a mean T1-S1 length of 192 mm vs 273 mm for the MCGR group (p = 0.0002). The TGR sagittal profile group, had a mean maximal kyphosis of 61° vs 55° for the MCGR group (p = 0.09). CONCLUSION: TGR continues to have a role in the MCGR era. In this study, the most commonly reported indications for TGR were sagittal plane profile and trunk height. These results suggest that TGR is indicated in patients of short stature with stiff hyperkyphotic curves. As further experience is gained with MCGR, the indications for TGR will likely be refined.

Posterior Tibial Slope is Increased in Patients With Tibial Tubercle Fractures and Osgood-Schlatter Disease.

BACKGROUND: Osgood-Schlatter disease (OSD) and tibial tubercle fractures are pathologies that affect the tibial tubercle apophysis in preadolescents and adolescents. Anatomic alignment of the proximal tibia may explain why some children develop OSD or sustain tibial tubercle fractures and some do not. Recent data has shown an association between posterior tibial slope angle (PTSA) and both OSD and proximal tibia physeal fractures. In this study, we compare radiographic parameters between patients with non-OSD knee pain, knees with OSD, and knees with tibial tubercle fracture to elucidate a difference between these groups. METHODS: Patients treated for OSD, tibial tubercle fractures, and knee pain, from 2012 to 2018, were retrospectively reviewed. Radiographic parameters for each study group included PTSA, anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, patellar articular height, and the distance from the inferior aspect of the patellar articular surface. Caton-Deschamps index was then calculated. Demographic data was collected including age, sex, and body mass index. Demographic and radiographic data was compared using analysis of variance tests, χ2 tests, 2-sample t tests, and multiple linear regression. RESULTS: Two hundred fifty-one knees in 229 patients met inclusion criteria for the study. In all, 76% were male and the average age of the overall cohort was 14 years old. In patients with tibial tubercle fractures, the majority of fractures were Ogden type 3b (65%). After controlling for demographic variability, average PTSA in the fracture cohort was significantly greater than that in the control cohort (ß=3.49, P<0.001). The OSD cohort had a significantly greater posterior slope (ß=3.14) than the control cohort (P<0.001). There was no statistically significant difference between the fracture and OSD cohorts. There was also no difference in Caton-Deschamps index between the 2 study groups when compared with the control group. CONCLUSION: This study demonstrates that patients with tibial tubercle fractures and patients with OSD have an increased PTSA when compared with the control group. This information adds to the body of evidence that increased tibial slope places the proximal tibial physis under abnormal stress which may contribute to the development of pathologic conditions of proximal tibia such as OSD and tibial tubercle fractures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Scoliosis Screening.

The national recommendations for school screening programs for scoliosis in the United States have undergone a shift in perspective over the past two decades. In 2004, the United States Preventive Services Task Force recommended against screening programs but changed its recommendation to be inconclusive in 2018. Early diagnosis of scoliosis can allow for close monitoring of the deformity and early initiation of bracing treatment when appropriate, with the goal of preventing costly and invasive surgical intervention. Several different diagnostic tools are available, including Adam's forward bending test alone, Adam's forward bending test with scoliometry, the humpometer, and Moiré topography, each with varying degrees of sensitivity and specificity. Controversy prevails over the cost efficacy of screening programs and possible unnecessary exposure of adolescents to radiation for confirmatory radiographs after a positive screening test. However, the recent definitive evidence of bracing treatment efficacy in slowing the progression of scoliotic curves and preventing the need for surgery indicates that school screening programs may still have a role in allowing early diagnosis.

Effect of Etiology, Radiographic Severity, and Comorbidities on Baseline Parent-Reported Health Measures for Children with Early-Onset Scoliosis.

BACKGROUND: The Classification of Early-Onset Scoliosis (C-EOS) allows providers to differentiate patients, for clinical and research purposes, on the basis of the etiology of their disease as well as radiographic parameters. The Early Onset Scoliosis Questionnaire (EOSQ) is the first disease-specific, parent-reported HRQOL (health-related quality-of-life) outcome measure for this condition. We sought to determine the influence of the C-EOS etiology designation, radiographic parameters, and medical comorbidities on EOSQ scores to differentiate quality of life in this heterogeneous patient population. We hypothesized that baseline EOSQ scores for patients with EOS would be strongly affected by the C-EOS etiology designation. METHODS: The analysis included prospectively enrolled patients with EOSQ scores recorded in a multicenter EOS database prior to intervention for the EOS. EOSQ scores were compared across C-EOS etiologies, severity of disease based on radiographic measurements, and patient comorbidities prior to scoliosis intervention. RESULTS: Six hundred and ten patients with EOS were available for analysis; 119 had congenital, 201 had idiopathic, 156 had neuromuscular, and 134 had syndromic EOS. In multivariate analysis, neuromuscular and syndromic etiologies were associated with lower scores than congenital and idiopathic etiologies in many EOSQ domains including general health, transfer, daily living, fatigue/energy level, and emotion. Patients with neuromuscular EOS had the lowest EOSQ scores in general. Congenital and idiopathic EOS did not differ from each other in any EOSQ domain. Coronal Cobb and kyphosis angles had significant inverse but generally weak correlations with EOSQ domains. Individual medical comorbidities had a minor effect on certain domains while American Society of Anesthesiologists (ASA) class and total number of comorbidities had inverse correlations with most domains. CONCLUSIONS: The underlying etiology of EOS appears to have a significant influence on the parent-reported HRQOL outcomes of the disease. Specifically, syndromic and neuromuscular C-EOS diagnoses are associated with lower EOSQ scores before treatment compared with congenital and idiopathic diagnoses. Radiographic measurements of severity have a relatively small influence on EOSQ scores. These baseline differences in C-EOS-designated etiology should be accounted for in studies comparing outcomes of treatment for this heterogeneous patient population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS: A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS: Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS: Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE: Level III.

A novel surgical navigation technology for placement of implants in slipped capital femoral epiphysis.

BACKGROUND: Fixation with a single screw is the recommended treatment for slipped capital femoral epiphysis (SCFE). Achieving optimal implant positioning can be difficult owing to the complex geometry of the proximal femur in SCFE. We assessed a novel navigation technology incorporating an inertial measurement unit to facilitate implant placement in an SCFE model. METHODS: Guidewires were placed into 30 SCFE models, using a navigation system that displayed the surgeon's projected implant trajectory simultaneously in multiple planes. The accuracy and the precision of the system were assessed as was the time to perform the procedure. RESULTS: Implants were placed an average of 5.3 mm from the femoral head center, with a system precision of 0.94 mm. The actual trajectory of the implant deviated from the planned trajectory by an average of 4.9° ± 2.2°. The total average procedure time was 97 seconds. CONCLUSION: The use of computer-based navigation in a SCFE model demonstrated good accuracy and precision in terms of both implant trajectory and placement in the center of the femoral head.

Common Elements in Surgical Site Infection Care Bundles for Adolescent Idiopathic Scoliosis at North American Pediatric Institutions: A Survey of POSNA QSVI Challenge Participants.

BACKGROUND: Surgical site infection (SSI) following posterior spinal fusion for idiopathic scoliosis is a difficult complication, with little information published regarding the best preventative comprehensive care plan. The Spine Subgroup of the Quality, Safety, Value Initiative (QSVI) committee of the Pediatric Orthopaedic Society of North America undertook a survey to generate an overview of bundle elements in comprehensive SSI care bundles across institutions in North America. The purpose of this study was to develop a toolkit of SSI care bundle elements that could be used in developing future SSI care bundles. METHODS: A survey email was sent to pediatric orthopaedic surgeons requesting a copy of the SSI prevention care bundle used in their practice. Surgeons were included if they had participated in the 2016 POSNA QSVI challenge, indicated they performed pediatric spine surgery, and had a spine SSI bundle. These bundles were evaluated by the QSVI committee and divided into preoperative, intraoperative, and postoperative elements with the frequency of use of each element recorded. A follow-up qualitative questionnaire was sent assessing the implementation and development of these SSI bundles. RESULTS: In total, 16 care bundles from 15 different institutions were included for review. The response rate for this survey was 44% of individuals (50/113 QSVI challenge participants) and 43% (15/35) of unique institutions. The most common elements included: use of preoperative antibiotics, use of preoperative chlorhexidine wipes, use of wound irrigation intraoperatively, and a standardized prescription for the length of postoperative antibiotic. Each of these elements was included in ≥75% of the SSI bundles evaluated. CONCLUSIONS: SSI care bundles are increasingly being used by pediatric institutions to lower the risk of SSI following pediatric spinal surgery. This study provides an overview of various care elements used in established SSI care bundles across multiple institutions in North America. It is hoped this data will provide institutions interested in developing their own SSI care bundle with useful information for beginning this process. LEVEL OF EVIDENCE: Level V-Decision Analysis.

Cost-Effectiveness of Magnetically Controlled Growing Rods: Who Really Benefits?

STUDY DESIGN: Retrospective case analysis. OBJECTIVES: Evaluate the cost difference between magnetically controlled growing rod (MCGR) and traditional growing rod (TGR) surgeries at initial implantation and determine the recipient of cost savings. SUMMARY OF BACKGROUND DATA: Treatment of early-onset scoliosis is challenging and costly, with growing rods (GRs) becoming a standard treatment. Although both effectively control deformity, TGR requires repeat surgical lengthening and MCGR does not. Previous cost analyses have suggested that MCGR results in lower overall cost after 3 years because of the elimination of repeat surgeries; however, the benefactor of these savings is unclear. METHODS: All patients who underwent initial GR implantation from May 2011 to January 2016 at a tertiary care children's hospital were included (37 cases: 16 MCGR and 21 TGR; 4 TGR to MCGR conversions). Financial information was analyzed including insurance provider, and amount billed to and reimbursed from payer. Charges at the time of implantation were divided into categories (surgery time, room/board, anesthesia, implant cost, lab, radiology, therapy, medications, neuromonitoring, operating room materials, and recovery room). Variables were compared using t-tests to determine differences overall and per category. RESULTS: The average overall charge for MCGR implantation was 1.5 times greater than TGR implementation (p = .04). Average charges were statistically similar across all categories, except implant costs, which were significantly higher for MCGR (MCGR: $31,621 vs. TGR: $8,966, p < .0001). The average percentage reimbursement of total charges were similar between surgeries (MCGR 43% vs. TGR 46%, p = .26). CONCLUSIONS: MCGR implantation has a significantly higher charge than TGR, secondary to the higher expense of MCGR implants. Despite this, total institutional reimbursement is similar between the two procedures. Although MCGRs have been shown to be "cost effective" after 3 years, our findings suggest health care institutions bear the cost of this new technology while payers gain the long-term financial benefit. LEVEL OF EVIDENCE: Level III, economic analysis.

Factors Associated With Nonaccidental Trauma Evaluation Among Patients Below 36 Months Old Presenting With Femur Fractures at a Level-1 Pediatric Trauma Center.

BACKGROUND: In 2009, the American Academy of Orthopedic Surgeons published clinical practice guidelines (CPGs) on the treatment of pediatric diaphyseal femur fractures, which recommended a nonaccidental trauma (NAT) evaluation for all patients below 36 months of age. A recent study of these guidelines found <50% clinical compliance with this treatment recommendation. We aimed to identify areas for improvement in compliance with this guideline. METHODS: A retrospective review was performed of all patients presenting to a single pediatric tertiary care hospital with a diaphyseal femur fracture from January 2007 to June 2013 who were below 36 months old. Medical records were reviewed for documentation of a NAT evaluation, patient characteristics, presence of other fractures or injuries, and hospital of presentation. Radiographs were reviewed for fracture pattern. Statistical analysis was performed to assess for differences overall and before and after CPG publication. RESULTS: During the study period, 281 children below 36 months presented with femur fractures; 41% were evaluated for NAT. Overall, the following factors were significantly associated with receipt of a NAT evaluation: younger age (P<0.001), transfer from an outside facility (P=0.027), and identification of another fracture (P=0.004). Before publication of the CPG, nonwhite patients were much more likely to undergo NAT evaluation compared with white patients (43% vs. 19%; P=0.014). After publication of the CPGs, this differential disappeared (43% vs. 47%; P=0.685). Fracture pattern and patient sex did not influence receipt of NAT evaluation. CONCLUSIONS: We found poor utilization of NAT evaluation for patients below 36 months old presenting with femur fracture. Despite CPG publication, only modest improvements in this evaluation occurred over the study period, with less than half of all patients being evaluated. Younger children, patients transferred from other institutions, and patients presenting with concomitant fractures were more likely to undergo NAT evaluation. Compliance with the CPG may be improved by focusing on older children, patients who initially present to tertiary care centers, and those with an isolated femur fracture. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion.

BACKGROUND: Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. OBJECTIVE: The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. METHODS: Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. RESULTS: For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0 mL/kg preperioperative surgical home vs 22.8 mL/kg postperioperative surgical home; mean difference = -0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4 mL/kg ± 20.4 mL/kg preperioperative surgical home vs 28.0 mL/kg ± 13.7 mL/kg postperioperative surgical home; log mean difference = 0.37 [95% CI 0.21-0.53], P < 0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference = -0.47 [95% CI -0.70 to -0.23]; P < 0.001), received a significantly higher total anti-fibrinolytic dose (mean difference = -3939 [95% CI -5364 to -2495]; P < 0.001), and were exposed to shorter surgical times (mean difference = 0.72 [95% CI 0.36-1.09]; P < 0.001). CONCLUSIONS: Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.