3D CT modeling demonstrates the anatomic feasibility of S1AI screw trajectory for spinopelvic fixation in neuromuscular scoliosis.

PURPOSE: In patients with neuromuscular scoliosis undergoing posterior spinal fusion, the S2 alar iliac (S2AI) screw trajectory is a safe and effective method of lumbopelvic fixation but can lead to implant prominence. Here we use 3D CT modeling to demonstrate the anatomic feasibility of the S1 alar iliac screw (S1AI) compared to the S2AI trajectory in patients with neuromuscular scoliosis. METHODS: This retrospective study used CT scans of 14 patients with spinal deformity to create 3D spinal reconstructions and model the insertional anatomy, max length, screw diameter, and potential for implant prominence between 28 S2AI and 28 S1AI screw trajectories. RESULTS: Patients had a mean age of 14.42 (range 8-21), coronal cobb angle of 85° (range 54-141), and pelvic obliquity of 28° (range 4-51). The maximum length and diameter of both screw trajectories were similar. S1AI screws were, on average, 6.3 ± 5 mm less prominent than S2AI screws relative to the iliac crests. S2AI screws were feasible in all patients, while in two patients, posterior elements of the lumbar spine would interfere with S1AI screw insertion. CONCLUSION: In this cohort of patients with neuromuscular scoliosis, we demonstrate that the S1AI trajectory offers comparable screw length and diameter to an S2AI screw with less implant prominence. An S1AI screw, however, may not be feasible in some patients due to interference from the posterior elements of the lumbar spine.

A New Look at Vertebral Body Tethering (VBT): Through the Modified Clavien-Dindo-Sink (mCDS) Classification.

INTRODUCTION: Anterior vertebral body tethering (AVBT) is increasingly popular as an option for surgical treatment of idiopathic scoliosis (IS). While the technology remains new, it is important for families and patients to be able to compare it to the current standard of care, posterior spinal fusion (PSF). The purpose of this study is to describe the complication rate of AVBT in IS using the mCDS and to compare it to the recently reported complication rate of PSF in IS. METHODS: A multicenter pediatric spine deformity database was queried for all idiopathic scoliosis patients who underwent vertebral body tethering. There were 171 patients with a minimum 9-month follow-up included in this study. Complications were retrospectively graded by 2 attending pediatric spine surgeons using the mCDS classification system. RESULTS: Data from 171 patients with idiopathic scoliosis was available for analysis, with 156/171 (91%) of patients being female and an average age of 12.2 years old at surgery. There were 156 thoracic tethers (1 with an LIV below L2), 5 lumbar tethers, 9 staged double tethers, and only 1 patient with same-day double tether. Fifty-five (55) (32%) patients experienced a total of 69 complications. The most common complication type for VBT by mCDS was Grade IIIb, encompassing 29/69 (42%) of complications. The second most frequent complication grade was Grade I at 23/69 (33%). Thirty-four (34) out of 69 (49%) of the VBT complications reported required either procedural/surgical intervention or admission to the ICU. CONCLUSIONS: This is the first study to directly compare the complication profile of VBT to PSF using the mCDS. Forty-nine percent (49%) of the VBT complications reported were at least Grade III, while only 7% of complications in the control PSF cohort from the literature were Grade III or higher. The mCDS complication classification brings light to the early learning experience of a new technique compared to the widely accepted standard of PSF for IS. LEVEL OF EVIDENCE: III - Retrospective comparative study.

Cannabidiol Use Patterns and Efficacy for Children Who Have Cerebral Palsy.

Cannabidiol (CBD)-containing supplements are used by children with cerebral palsy (CP), but the prevalence and efficacy of their use have not been studied. We sought to describe CBD use patterns and perceived efficacy in the pediatric population with CP, evaluating any association between CBD use and health-related quality of life. Patients with CP were prospectively enrolled, and caregivers were offered the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) Questionnaire and a survey assessing CBD use. Of 119 participants, 20 (16.8%) endorsed CBD use (CBD+) and 99 (83.2%) denied it (CBD-). Participants in the CBD+ group had worse functional status (85% Gross Motor Function Classification System level IV-V for CBD+ vs 37.4% for CBD-, P<.001) and lower health-related quality of life (mean CPCHILD score of 49.3 for CBD+ vs 62.2 for CBD-, P=.001). Spasticity was the rationale most cited for CBD use (29%), followed by pain and anxiety (both 22.6%). CBD was perceived to be most effective for improving emotional health, spasticity, and pain. Fifty percent of the patients in the CBD+ group underwent surgery in the previous 2 years and most endorsed a general benefit in the postoperative setting. The most common side effects noted were fatigue and increased appetite (both 12%). Most participants endorsed no side effects (60%). CBD may serve as a useful adjunct for some children with CP, especially those with worse disease severity. Caregivers perceive CBD as offering some benefits, particularly in the domains of emotional health, spasticity, and pain. We found no evidence of severe adverse events in our small cohort. [Orthopedics. 2024;47(1):52-56.].

Does spinal deformity affect adolescents' quality of life before we tell them it should?

PURPOSE: The Scoliosis Research Society 22r Questionnaire(SRS-22r) is the standard for assessing health-related quality of life(HRQoL) in patients with adolescent idiopathic scoliosis. Here we investigate whether patients' perceptions of their HRQoL are influenced by knowledge of scoliosis and counseling by an orthopedic surgeon. METHODS: Patients ages 10-18 years referred for their first visit with an orthopaedic surgeon for scoliosis were enrolled from 9/30/19 to 10/22/20. Patients completed the SRS-22r pre- and post-visit. A Wilcoxon signed-rank test was used to analyze the SRS-22r scores. RESULTS: 52 patients participated in the study at a mean age of 14.3 years (95% CI 13.8-14.8 years) with an average major curve magnitude of 23.2 degrees (95% CI 19.4-27.0 degrees). SRS-22r scores were not correlated to curve magnitude pre- or post-visit. The SRS-22r Satisfaction with care domain exhibited a small increase from pre- to post-visit (pre: 3.3, post: 3.6). All other SRS-22r domains and total scores did not exhibit clinically significant differences. CONCLUSION: Among new adolescent referrals for scoliosis, it is unlikely that counseling by a surgeon influences perceptions of HRQoL as measured by the SRS-22r. LEVEL OF EVIDENCE: III.

Temporary Flexible Rods for Correction of Severe Pediatric Spinal Deformity.

Surgical correction of large, rigid scoliotic and kyphotic curves carries an increased risk of perioperative complications, such as neurological injury and excessive blood loss, compared with correction of less severe curves. Titanium temporary flexible rods (TFRs), designed for pediatric long bone fracture fixation, may be helpful as adjuncts to achieve gradual, stepwise intraoperative correction of severe pediatric spinal deformities. A retrospective review was conducted of spinal fusion cases for pediatric scoliosis or kyphosis at our institution that used TFRs as a correction technique from 2007 to 2019. Patients underwent posterior spinal fusion with predominantly pedicle screw instrumentation. Intraoperatively, a non-contoured titanium elastic nail was temporarily positioned in the screws unilaterally to achieve partial correction while the contralateral side was instrumented. Then, the TFR was removed and replaced with a permanent rod. Thirty-four patients with severe spinal deformities underwent posterior spinal fusion. Seventeen had scoliosis (mean major Cobb angle, 89.3°) and 17 had kyphosis (mean T5-T12 kyphosis, 73.8°). Idiopathic deformity was the most common etiology; neuromuscular, syndromic, and postsurgical causes contributed to the remainder of cases. All patients had Ponte osteotomies. Four patients (11.8%) had neuromonitoring alerts, 1 of which was related to insertion of the TFR; all were reversible. For patients with scoliosis, the mean postoperative Cobb angle measured 40.2° (53.6% correction). For patients with kyphosis, the mean postoperative T5-T12 angle measured 43.3° (30.4° of correction). TFRs appear to be helpful adjuncts for correction of severe pediatric spinal deformities, facilitating gradual intraoperative correction in a single-stage operation. Neuromonitoring alerts are common but reversible. [Orthopedics. 2023;46(4):234-241.].

The Influence of Race, Income, and Sex on Treatment and Complications of Common Pediatric Orthopedic Fractures.

Despite best intentions, health care disparities exist and can consequently impact patient care. Few studies have examined the impact of disparities in pediatric orthopedic populations. The current study aimed to determine if the treatment type or complication rates of supracondylar, both-bone forearm, or femur fractures are associated with race, ethnicity, sex, or socioeconomic status. The New York Healthcare Cost and Utilization Project's database was used to identify all pediatric patients treated for supracondylar humerus fractures, both-bone forearm fractures, and femoral shaft fractures in 2016. Risk-adjusted relationships with race, ethnicity, sex, hospital location, and median income by zip code were assessed with multivariable logistic regression. Patients who were non-White, resided in the zip codes with the lowest median income (<$42,999 annually), and were treated in metropolitan areas were more likely to receive nonoperative treatments for supracondylar humerus fractures. Female patients with a femoral shaft fracture were less likely to be treated with open reduction and internal fixation vs intramedullary fixation. Finally, complications were not associated with patient race, sex, or socioeconomic statuses. These findings bring attention to health care disparities in the treatment of common pediatric orthopedic fractures. Further studies investigating the underlying etiology behind these disparities are warranted. [Orthopedics. 2023;46(3):e156-e160.].

Opioid Represcriptions After ACL Reconstruction in Adolescents Are Associated With Subsequent Opioid Use Disorder.

INTRODUCTION: Postoperative opioid prescriptions may confer a risk for subsequent opioid use disorders (OUDs). For many children, postoperative analgesia is often the first opioid exposure. The rates of anterior cruciate ligament (ACL) reconstruction in pediatric populations are rising. Here, we use an administrative claims database to describe opioid prescription patterns after ACL reconstruction and their effect on subsequent risk of OUD. METHODS: Using International Classification of Diseases (ICD)-9, ICD-10, and CPT codes, we identified patients, with ages 10 to 18, undergoing primary ACL reconstruction between 2014 and 2016 with minimum 1 year follow-up in the Optum Clinformatics Data Mart, which is a nationally representative administrative claims database. Demographic variables and prescription patterns (in morphine milligram equivalents [MMEs]) were analyzed using univariate tests and multivariable logistic regression to determine any potential association with the appearance of anew an ICD-9 or ICD-10 code for OUD within 1 year of the initial procedure. RESULTS: A total of 4459 cases were included and 29 (0.7%) of these patients were diagnosed with an OUD within 1 year of surgery. Upon univariate analysis, opioid represcriptions within 6 weeks were significantly more common among patients with OUD; 27.6% vs. 9.7% of patients that did not develop a new diagnosis of OUD ( P =0.005). Multivariable logistic regression indicated an independent significant relationship between total MMEs initially prescribed and the odds of a subsequent OUD diagnosis: for each additional 100 MMEs prescribed in total, the odds of OUD increased by 13% ( P =0.002). Patients with a represcription within 6 weeks of surgery had an average increase in the odds of OUD by 161% ( P =0.027). CONCLUSIONS: In this cohort of patient ages 10 to 18 undergoing primary isolated ACL reconstruction, we found substantial variability in opiate prescribing patterns and higher initial opioid prescription volume, as well as opioid represcription within 6 weeks were predictive of the subsequent development of OUD. LEVEL OF EVIDENCE: Level III.

The effect of intraoperative lidocaine administration in a disrupted erector spinae fascial plane on intercostal transcranial motor evoked potentials.

STUDY OBJECTIVE: Erector spinae plane (ESP) blocks have been recently described for postoperative pain management following spine surgery but their effects on intraoperative neuromonitoring are unknown. DESIGN: Retrospective cohort study. SETTING: Pediatric patients at a tertiary care center. PATIENTS: 26 pediatric patients who received bilateral surgically-placed ESP catheters for single-stage posterior spine fusion (PSF) from August 2020 to June 2021. INTERVENTIONS: Patients in this study did not receive any special interventions as part of this observational retrospective study. MEASUREMENTS: This retrospective study investigated the effects of local anesthesia administration through bilateral surgically-placed ESP catheters on intraoperative intercostal transcranial motor evoked potentials (tcMEPs) in the setting of a disrupted erector spinae fascial plane in pediatric patients undergoing single-stage posterior spine fusion. MAIN RESULTS: Of the 26 patients that received bilateral surgically-placed ESP catheters for pediatric posterior spine fusion surgery, none exhibited any changes in intercostal tcMEPs attributable to intraoperative lidocaine administration through the ESP catheters. CONCLUSIONS: The administration of a local anesthetic into a disrupted erector spinae fascial plane does not appear to interfere with intraoperative neuromonitoring of posterior spine fusion surgeries.

Curve Characteristics and Surgical Outcomes in Scoliosis Associated With Childhood Sternotomy or Thoracotomy.

BACKGROUND: The purpose of this study is to describe curve characteristics and postoperative outcomes in patients undergoing spinal fusion (SF) to treat thoracogenic scoliosis related to sternotomy and/or thoracotomy as a growing child. METHODS: A retrospective review of electronic medical records of all patients with Post-Chest Incision scoliosis treated with SF was performed at 2 tertiary care pediatric institutions over a 19-year period. Curve characteristics, inpatient, and outpatient postoperative outcomes are reported. RESULTS: Thirty-nine patients (62% female) were identified. Eighteen had sternotomy alone, 14 had thoracotomy alone, and 7 had both. Mean age at the time of first chest wall surgery was 2.5 years (range: 1.0 d to 14.2 y). Eighty-five percent of patients had a main thoracic curve (mean major curve angle 72 degrees, range: 40 to 116 degrees) and 15% had a main lumbar curve (mean major curve angle 76 degrees, range: 59 to 83 degrees). Mean thoracic kyphosis was 40 degrees (range: 4 to 84 degrees). Mean age at the time of SF was 14 years (range: 8.2 to 19.9 y). Thirty-six patients had posterior fusions and 3 had combined anterior/posterior. Mean coronal curve correction measured at the first postoperative encounter was 53% (range: 9% to 78%). There were 5 (13%) neuromonitoring alerts and 2 (5%) patients with transient neurological deficits. Mean length of hospital stay was 9±13 days. At an average follow-up time of 3.1±2.4 years, 17 complications (10 medical and 7 surgical) were noted in 9 patients for an overall complication rate of 23%. There was 1 spinal reoperation in the cohort. 2/17 (12%) complications were Clavien-Dindo-Sink class III and 5/17 (29%) were class IV. CONCLUSION: Kyphotic thoracic curves predominate in patients with Post-Chest Incision scoliosis undergoing SF. Although good coronal and sagittal plane deformity can be expected after a fusion procedure, postoperative complications are not uncommon in medically complex patients, often necessitating longer postoperative stays. LEVEL OF EVIDENCE: Level III.

Complication risks and costs associated with Ponte osteotomies in surgical treatment of adolescent idiopathic scoliosis: insights from a national database.

PURPOSE: Risks of Ponte osteotomies (POs) used for posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) are challenging to assess because of the rarity of complications. Using a national administrative claims database, we evaluated trends, costs and complications associated with PO used in PSF for AIS patients. METHODS: Using ICD-9/CPT codes, we identified patients (ages 10-18) with AIS who underwent PSF (± PO) between 2007 and 2015 in the IBM® MarketScan® Commercial Databases. Costs and trends of POs were evaluated. Odds of neurological complications and readmissions within 90 days and reoperations within 90 days and 2 years were assessed. RESULTS: We identified 8881 AIS patients who had undergone PSF, of which 8193 had 90-day follow-up and 4248 had 2-year follow-up. Overall, 28.8% had PO. Annual rate of POs increased from 17.3 to 35.2% from 2007 to 2015 (p < 0.001). Risk-adjusted multivariable logistic regression demonstrated no relationship between POs and neurologic complications (p = 0.543). POs were associated with higher odds for readmission (1.52 [1.21-1.91]; p < 0.001) and reoperation (2.03 [1.13-3.59]; p = 0.015) within 90 days, but there were no differences in the odds of reoperation within 2 years (p = 0.836). Median hospital costs were $15,854 (17.4%) higher for patients with POs (p < 0.001) and multivariable modeling demonstrated POs to be an independent predictor of increased costs (p < 0.001). CONCLUSION: Annual rate of POs increased steadily from 2007 to 2015. POs were not associated with increased odds of neurological complications but had higher costs and higher rates of readmissions and reoperations within 90 days. By 2 years, differences in reoperation rate were not significant. LEVEL OF EVIDENCE: III.

Indications for and Risks Associated With Implant Removal After Pediatric Trauma.

A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.

Does Navigation Make Spinal Fusion for Adolescent Idiopathic Scoliosis Safer? Insights From a National Database.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To evaluate the effect of computer-assisted navigation (NAV) on rates of complications and reoperations after spinal fusion (SF) for adolescent idiopathic scoliosis (AIS) using a nationally representative claims database. SUMMARY OF BACKGROUND DATA: Significant controversy surrounds the reported benefits of NAV in SF for AIS. Previous studies have demonstrated decreased rates of pedicle screw breaches with NAV compared to free-hand methods but no impact on complication rates. Thus, the clinical utility of NAV remains uncertain. METHODS: Analyses were performed using the IBM MarketScan databases. Patients aged 10 to 18 undergoing SF for AIS were grouped by use of NAV. Patients with nonidiopathic scoliosis were excluded. Univariate and risk-adjusted multivariate analyses were performed. Primary outcomes were neurological complications, any medical complications, and reoperations. Secondary outcomes included adjusted total reimbursements and length of stay. RESULTS: A total of 12,046 patients undergoing SF for AIS were identified, and 8640 had 90-day follow-up. NAV was used in 467 patients (5.4%), increasing from 2007 to 2015. After risk adjustment, the odds for any complication within 90 days were lower with NAV (OR = 0.61, P = 0.025), but neurological complications were unrelated to NAV (P = 0.742). NAV was not associated with reoperation within 90 days (P = 0.757) or 2 years (P = 0.095). We observed a $25,038 increase in adjusted total reimbursements (P < 0.001) and a 0.32-day decrease in length of stay (P = 0.022) with use of NAV. CONCLUSION: In this national sample, NAV was associated with a lower rate of total complications but no change in rates of neurological complications or reoperations. In addition, NAV was associated with a large increase in total payments, despite a modest decrease in hospital stay. Considering the increasing popularity of NAV, this study provides important context regarding the utility of NAV for AIS.Level of Evidence: 3.

The Impact of Subspecialty Fellows on Orthopaedic Resident Surgical Experience: A Multicenter Study of 51,111 Cases.

INTRODUCTION: Meaningful participation in surgery is important for orthopaedic resident education. This study aimed to quantify the effect of fellows on resident surgical experience. We hypothesized that as fellowship programs expanded, resident caseload would decrease, whereas "double-scrubbed" cases would increase. METHODS: This multicenter retrospective study included 9 years of surgical caselog data from two orthopaedic residency programs. Six subspecialty services on which fellow number varied over time were included (trauma, spine, foot and ankle, adult reconstruction, and hand). Case volume and personnel composition per case were extracted. Statistical analysis was performed with two-sample equal variance Student t-tests. RESULTS: A total of 51,111 cases were assessed. Surgical volume increased across all sites/services over time. Fellow numbers did not affect average resident caseload. However, in years with more fellows, an 11% decrease in one-on-one resident-attending cases (P = 0.002) and a 17% increase in resident-fellow-attending "double-scrubbed" cases was observed (P < 0.001). DISCUSSION: Increasing orthopaedic fellows did not affect resident case volume but resulted in fewer one-on-one cases with the attending and more "double-scrubbed" cases with a fellow. The implications of these findings to resident education require further study, but orthopaedic educators should be aware of these findings to try to maximize educational opportunities. LEVEL OF EVIDENCE: Level III.

Remodeling of Sagittal Plane Malunion After Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Pediatric supracondylar humeral fractures (SCHFs) can heal in hyperextension malunion after casting or surgical treatment. Here the authors present quantitative evidence concerning the ability of children to remodel sagittal plane malunion. Their null hypothesis was that like varus and valgus malunion, children have little capacity to remodel sagittal plane malunion after SCHFs. METHODS: The authors performed a prospective longitudinal radiographic study of 41 children, aged 22 to 126 months, who were registered during the study interval. They calculated the percent displacement of the center of the capitellum behind the anterior humeral line (AHL) as the distance of the midpoint of the capitellum from the AHL, divided by the diameter of the capitellum, multiplied by 100. Longitudinal measurements were made using the embedded software on our institution's digital radiographic system. The primary outcome focus was the percent displacement of the center of the capitellum relative to AHL on the initial and on the latest radiograph. RESULTS: The average initial displacement (hyperextension) of the capitellum behind the AHL for all patients was 61% (range, 23% to 134%). At an average follow-up of 21 months, 24 children (60%) had remodeled 100% the sagittal plane malunion, 12 children (30%) had remodeled such that the AHL passed through the central third of the capitellum, and 5 children (10%) had minimal or no remodeling. CONCLUSIONS: The authors rejected their null hypothesis. Children do have the capacity to remodel radiographically measurable sagittal plane malunion of SCHFs. Children younger than 5 years of age can remodel 100% displacement of the center of the capitellum, whereas those over 8 years of age have minimal remodeling capacity.

Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights From a National Sample.

OBJECTIVES: To describe the incidence of and risk factors for vascular injury associated with P-SCD. METHODS: We used data from the HCUP-NIS from 2015 to 2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics, and injury severity score in this cohort. RESULTS: Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD, <2% of patients had a vascular injury, all of whom had an injury severity score ≥15, independent of the vascular injury itself. Among patients with an isolated P-SCD injury (55), overall length of stay was 1.8 days and total charges averaged $29,724.45. There was no mortality among patients with isolated P-SCD. CONCLUSIONS: Here, we report no vascular injuries in the largest known series of P-SCD. Among all patients with SCD, vascular injury was rare, occurring only in severely polytraumatized patients. The recommendation for routine involvement of cardiothoracic surgeons in all cases of P-SCD should be re-examined. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Debridement, antibiotic pearls, and retention of the implant (DAPRI): A modified technique for implant retention in total knee arthroplasty PJI treatment.

We describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining an infected total knee arthroplasty. This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration using calcium sulfate beads. The combination of three different surgical techniques (methylene blue staining, argon beam electrical stimulation, and chlorhexidine gluconate brushing) might enhance the identification, disruption, and finally removal of the bacterial biofilm, which is the main responsible of antibiotics and antibodies resistance. The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous periprosthetic joint infection.

Treatment in a Nonpediatric Hospital Is a Risk Factor for Open Reduction of Pediatric Supracondylar Humerus Fractures: A Population-Based Study.

OBJECTIVES: To describe the distribution of open versus closed treatment and its relationship with the location of care in pediatric specialty versus general hospitals. METHODS: Patient data were extracted from the Healthcare Cost and Utilization Project's Kid's Inpatient Database for the years 2000-2012. ICD9-CM diagnosis and procedure codes were used to identify open versus closed treatment of closed supracondylar humerus fractures in children younger than 12 years. A multilevel logistic regression model to control for confounders and identify drivers of open treatment was used. RESULTS: An estimated 40,706 inpatient surgical fixation procedures met our inclusion criteria. Overall rate of open treatment was 13.65%. Fractures were less likely to be treated open at pediatric hospitals versus general hospitals 7.61% versus 16.13% (P < 0.0001). Over the study period, rates of open treatment have fallen at nonpediatric hospitals from 20.21% in 2000 to 17.42% in 2012 (P < 0.001) but have remained stable at pediatric hospitals: 7.8% in 2000 and 8.62% in 2012 (P = 0.4369). Mean hospital length of stay was higher for patients who had open treatment 1.63 versus 1.20 days (P < 0.0001), and mean hospital charges were higher for patients who had open treatment $21,465 versus $15,026 (P < 0.0001). After controlling for time trends as well as demographic and hospital characteristics with a logistic regression model, treatment at a nonpediatric hospital was the single most significant predictor of open treatment for an isolated closed supracondylar humerus fractures with an odds ratio of 1.96 (95% confidence interval 1.56-2.46; P < 0.001). CONCLUSIONS: In this comprehensive population-based study of risk factors for open treatment of supracondylar humerus fractures in the United States, we identified differences in practice patterns by hospital type. Pediatric supracondylar fractures of the elbow have almost twice the odds of open treatment at nonpediatric hospitals. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Severity Adjusted Risk of Long-term Adverse Sequelae Among Children With Osteomyelitis.

BACKGROUND: The purpose of this investigation was to evaluate the risk for long-term, adverse outcomes among children with osteomyelitis. METHODS: Children with osteomyelitis were prospectively enrolled from 2012 to 2014. Care was accomplished by a multidisciplinary team according to an institutional algorithm. Data were collected to define the severity of illness during the initial hospitalization and assess short, intermediate and long-term outcomes. Clinical examination, radiographic assessment and functional outcome survey administration were performed at a minimum of 2 year follow-up. A comparison cohort analysis was performed according to initial severity of illness score of mild (0-2), moderate (3-6) and severe (7-10). RESULTS: Of 195 children enrolled, 139 (71.3%) returned for follow-up at an average of 2.4 years (range, 2.0-5.0 years). Children with severe illness were less likely to have normal radiographs (severe, 4.0%; moderate, 38.2%; mild, 53.2%, P < 0.0001), and more likely to have osteonecrosis, chondrolysis, or deformity (severe, 32.0%; moderate, 5.9%; mild, 1.3%, P < 0.0001). Functional outcome measures did not significantly differ between severity categories. By regression analysis severity of illness score, plus age less than 3 years and Methicillin-resistant Staphylococcus aureus predicted severe sequelae with an area under the curve of 0.8617 and an increasing odds ratio of 1.34 per point of increase in severity score. CONCLUSION: Long-term severe adverse outcomes among children with osteomyelitis occurred in 11 of 139 (7.9%) children and were predicted by initial severity of illness. Other risks that diminished the likelihood of complete resolution or increased the risk of severe sequelae included Methicillin-resistant Staphylcoccus aureus etiology and young age. The majority of children with osteomyelitis do not require long-term follow-up beyond the initial treatment period.