Incidence of Tether Breakage in Anterior Vertebral Body Tethering.

BACKGROUND: Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively. METHODS: All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts. RESULTS: In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002). CONCLUSIONS: The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively. LEVEL OF EVIDENCE: Level IV.

Building Self-Confidence and Other Skills: What Surgeons Can Learn From Other Professions.

Self-confidence is one of the attributes often assigned to surgeons, but surgeons do not always feel self-confident in the operating room. A lack of confidence may lead to poor performance for both the surgeon and the surgical team. The ideal qualities of a self-confident surgeon, barriers to achieving confidence and strategies for becoming a more confident surgeon and leader in the operating room are outlined in this chapter.

Surveying the POSNA Landscape: What Can We Learn From Society Survey Studies?

BACKGROUND: A growing trend of survey-based research has been seen in the field of pediatric orthopaedics. The purpose of this study was to describe patterns of surveys of Pediatric Orthopaedic Society of North America (POSNA) membership and evaluate for associations between study characteristics and response rates in order to inform future research efforts. We hypothesized that studies with fewer survey questions and study group or committee involvement would demonstrate higher response rates. METHODS: A systematic review of the literature was performed to identify all peer-reviewed survey publications targeting POSNA members published up to December 2017. Included studies were reviewed to identify author and publication characteristics, survey development and methodology, survey distribution procedures, and response rates. Statistical analyses were performed to describe publication patterns and evaluate for associations between study characteristics and response rates. RESULTS: Thirty-four studies published from 1991 to 2017 were identified as meeting inclusion criteria, with a substantial increase noted over the last 3 years. Studies included 4.6 (SD 1.9) authors and 14.7% had affiliations with study groups or committees. Survey development methodology was detailed in only 1 study. Surveys included a median of 19.5 questions (3 to 108) and were primarily electronically distributed. The mean survey response rate was 42% with a downward trend noted over the studied time period. None of the studied author, publication, and design characteristics were associated with increased response rates. CONCLUSIONS: Survey-based studies of the POSNA membership have become increasingly popular study designs in recent years. Response rates are lower than reports in other physician cohorts, and appear to be declining, possibly representative of respondent fatigue. No associations were identified between response rates and the modifiable study characteristics evaluated (number of authors, committee or subgroup affiliation, number of questions, and mode of distribution). Efforts should be made to identify tactics to sustain participation as these studies become more widely utilized within our field. Optimizing study design and implementation features while valuing physician time and effort spent on survey completion is important to avoid member survey fatigue. LEVEL OF EVIDENCE: Level V-systematic review of Level V research.

Congenital Scoliosis: A Case-Based Approach.

Congenital scoliosis is lateral curvature of the spine caused by vertebral anomalies. Congenital scoliosis is associated with congenital anomalies of other organ systems. Traditionally, treatment options for patients with congenital scoliosis focused on posterior spinal fusion. Current surgical treatment options for young children include growing rods, vertical expandable prosthetic titanium ribs, and, most recently, magnetic rods. Hemivertebrae resection is an important early treatment option for patients who have a hemivertebra. Intraoperative navigation may be an important tool that can be used to improve the accuracy of pedicle screw placement in patients who have abnormal pedicles.

Adolescent Idiopathic Scoliosis: Update on Bracing, Surgical Techniques, and Patient Safety.

The primary goal in the management of adolescent idiopathic scoliosis is to prevent the progression of spinal deformity either with the use of a brace or with surgery. The goals of surgery, if indicated, are to correct the spinal deformity safely and to preserve overall spinal balance and as many motion segments as possible, which maximizes the long-term health of a patient's spine. Recently, tremendous advances have been made in the surgical techniques that are used to correct adolescent idiopathic scoliosis, and improved tools have allowed surgeons to perform spinal deformity surgery as safely and with as few complications as possible. Surgeons should be aware of recent evidence that demonstrates the efficacy of bracing in patients who have adolescent idiopathic scoliosis. In addition, surgeons should understand recent advances in spinal deformity surgery with regard to fusion level selection, implant placement, three-dimensional deformity correction, and techniques that are used to minimize perioperative complications.

Pediatric Injuries at an Annual Motocross Competition: Rates and Severity.

PURPOSE: Pediatric motocross injuries occur frequently and with significant associated morbidity; however, data are limited regarding injury occurring during competition. North Central Florida hosts an annual motocross competition with numerous pediatric competitors. We sought to evaluate the rate and severity of injuries sustained at this event over a multiyear period. Our primary hypothesis was that motocross injury rates and severity in competition exceed that of other competitive sports in this age group. METHODS: A retrospective review was performed to identify pediatric patients (17 and younger) presenting to a single Level 1 Trauma Center as a result of injury sustained at an annual motocross competition from 2009 to 2012. Demographic, diagnostic, and treatment data were collected including injuries, procedural interventions, and length of hospital stay. Rate, type, and severity of injury were evaluated and compared with established norms of other competitive sports in a similar age group. RESULTS: Over a 4-year period, 51 pediatric motocross competitors sustained 75 injuries. Injured riders were 14.2±2.51 years (range, 8 to 17 y) old and 92% (47/51) male. Forty (78%) patients sustained at least 1 orthopaedic injury and 17 (33%) patients suffered polytrauma. The majority of injuries occurred in the upper extremity (36%). Twenty-four (47%) patients required procedural intervention, 15 of which were operative. Thirty-nine (76%) patients necessitated surgical specialty care. Average injury severity score was 6.5 (1 to 75) and 1 death occurred. The injury rate for pediatric motocross riders in this study was 19.9 injuries per 1000 competitors. CONCLUSIONS: High rates of injury occur among pediatric patients in competitive motocross, exceeding those seen in other competitive sports in a comparable age group. Significant morbidity and at least 1 fatality were demonstrated in the group studied. The majority of patients suffer at least 1 orthopaedic injury and nearly all patients require pediatric surgical specialist care. Polytrauma is common. Motocross participants and parents should be aware of these risks of competition and event organizers should arrange events near facilities with appropriate pediatric surgical specialty services. LEVEL OF EVIDENCE: Level IV-case series.

Dosing Cefazolin for Surgical Site Infection Prophylaxis in Adolescent Idiopathic Scoliosis Surgery: Intermittent Bolus or Continuous Infusion?-A Pilot Study.

Background: Cefazolin may minimize the risk of surgical site infection (SSI) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Cefazolin dosing recommendations vary and there is limited evidence for achieved tissue concentrations. Methods: We performed a randomized, controlled, prospective pharmacokinetic pilot study of 12 patients given cefazolin by either intermittent bolus (30 mg/kg every 3 h) or continuous infusion (30 mg/kg bolus followed by 10/mg/kg per hour) during PSF for AIS. Results: Patients were well matched for demographic and perioperative variables. While total drug exposure, measured as area-under-the-curve (AUC), was similar in plasma for bolus and infusion dosing, infusion dosing achieved greater cefazolin exposure in subcutaneous and muscle tissue. Using the pharmacodynamic metric of time spent above minimal inhibitory concentration (MIC), both bolus and infusion dosing performed well. However, when targeting a bactericidal concentration of 32 µg/mL, patients in the bolus group spent a median of 1/5 and 1/3 of the typical 6 h operative time below target in subcutaneous and muscle tissue, respectively. Conclusions: We conclude that intraoperative determination of cefazolin tissue concentrations is feasible and both bolus and infusion dosing of cefazolin achieve concentrations in excess of typical MICs. Infusion dosing appears to more consistently achieve bactericidal concentrations in subcutaneous and muscle tissues.

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.

Development of Consensus-Based Best Practice Guidelines for the Peri- and Post-operative Care of Pediatric Patients with Spinal Deformity and Programmable Implanted Devices.

STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.

Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update.

PURPOSE: Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago. METHODS: 11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described. RESULTS: Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves. CONCLUSION: Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population. LEVEL OF EVIDENCE: Level V.

Early onset scoliosis: modern treatment and results.

BACKGROUND: Early onset scoliosis (EOS) is a potentially fatal, challenging group of diseases the management of which has markedly changed in the last decade. The purpose of this review is to provide the reader with a brief description of each of these new therapeutic modalities, their indications for use, and early clinical results. METHODS: A systematic review of peer-reviewed publications and abstracts related to the treatment of EOS in the last decade was carried out and synthesized into a review of modern treatment methods. RESULTS: Recent advances in techniques and understanding of preserving the thoracic space have improved the morbidity and mortality of children with progressive EOS. Derotational casting may be used in younger patients with curves between 25 and 60 degrees. The vertical expandable prosthetic titanium rib is best suited for patients with thoracic insufficiency syndrome. Single or dual growing rods may be used alone or in combination with vertical expandable prosthetic titanium rib to treat patients with progressive EOS who are not candidates for casting. Shilla technique is an alternative to growing rods that avoids the morbidity of repeated lengthenings but is not as well proven as the techniques described above. Other methods such as automatic growing rods and growth modulation techniques are still investigational, and their role needs to be defined after further study. CONCLUSIONS: Recent advances have improved the treatment of children with EOS. Treatment continues to be challenging with complication rates higher than treatment of idiopathic scoliosis. LEVEL OF EVIDENCE: Level V.

Semirigid Fiberglass Casting for the Early Management of Clubfoot: A Single-Center Experience.

Background Semirigid fiberglass (SRF) is an alternative material to plaster of Paris (POP) for idiopathic clubfoot casting in the Ponseti method. The purpose of this study was to evaluate early clinical outcomes in a series of idiopathic clubfoot patients treated with SRF at a single institution and to compare these findings to historical norms with POP casting present in the literature. Methods A series of idiopathic clubfoot patients managed exclusively with SRF in the Ponseti method was identified. Treatment efficacy was evaluated by number of casts, change in Pirani score, frequency of treatment-related complications, and frequency of surgery other than tenotomy. A comprehensive literature review was used for comparative historical norms. Results The study included 34 feet in 26 patients. Pirani score was 4.7±1.3 at presentation and 1.9±1.4 at the end of casting, representing a score change of 2.8±1.3 with SRF. Initial correction was obtained with 6.9±1.4 casts. Treatment-related complications occurred in six treated feet (17.6%) including 13 cast slippages in five feet and one cast-related thigh abrasion. A total of 25 (73.5%) feet underwent tenotomy. Two feet required an additional surgical procedure. Conclusion Clubfoot patients treated with SRF demonstrated acceptable deformity correction following Ponseti-style casting. The quantitative clinical outcomes evaluated appeared similar to norms using POP present in the literature. The findings of this study support SRF as a viable alternative to plaster casting for clubfoot correction utilizing the Ponseti method. As such, further investigation for rigorous comparative assessment is warranted.

Anterior Vertebral Body Tethering Compared with Posterior Spinal Fusion for Major Thoracic Curves: A Retrospective Comparison by the Harms Study Group.

BACKGROUND: Anterior vertebral body tethering (AVBT) is an alternative to posterior spinal fusion (PSF) for the surgical treatment of scoliosis. The present study utilized a large, multicenter database and propensity matching to compare outcomes of AVBT to PSF in patients with idiopathic scoliosis. METHODS: Patients with thoracic idiopathic scoliosis who underwent AVBT with a minimum 2-year follow-up retrospectively underwent 2 methods of propensity-guided matching to PSF patients from an idiopathic scoliosis registry. Radiographic, clinical, and Scoliosis Research Society 22-Item Questionnaire (SRS-22) data were compared preoperatively and at the ≥2-year follow-up. RESULTS: A total of 237 AVBT patients were matched with 237 PSF patients. In the AVBT group, the mean age was 12.1 ± 1.6 years, the mean follow-up was 2.2 ± 0.5 years, 84% of patients were female, and 79% of patients had a Risser sign of 0 or 1, compared with 13.4 ± 1.4 years, 2.3 ± 0.5 years, 84% female, and 43% Risser 0 or 1 in the PSF group. The AVBT group was younger (p < 0.001), had a smaller mean thoracic curve preoperatively (48 ± 9°; range, 30° to 74°; compared with 53 ± 8°; range, 40° to 78° in the PSF group; p < 0.001), and had less initial correction (41% ± 16% correction to 28° ± 9° compared with 70% ± 11% correction to 16° ± 6° in the PSF group; p < 0.001). Thoracic deformity at the time of the latest follow-up was 27° ± 12° (range, 1° to 61°) for AVBT compared with 20° ± 7° (range, 3° to 42°) for PSF (p < 0.001). A total of 76% of AVBT patients had a thoracic curve of <35° at the latest follow-up compared with 97.4% of PSF patients (p < 0.001). A residual curve of >50° was present in 7 AVBT patients (3%), 3 of whom underwent subsequent PSF, and in 0 PSF patients (0%). Forty-six subsequent procedures were performed in 38 AVBT patients (16%), including 17 conversions to PSF and 16 revisions for excessive correction, compared with 4 revision procedures in 3 PSF patients (1.3%; p < 0.01). AVBT patients had lower median preoperative SRS-22 mental-health component scores (p < 0.01) and less improvement in the pain and self-image scores between preoperatively and the ≥2-year follow-up (p < 0.05). In the more strictly matched analysis (n = 108 each), 10% of patients in the AVBT group and 2% of patients in the PSF group required a subsequent surgical procedure. CONCLUSIONS: At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent AVBT had a residual curve of <35° compared with 97.4% of patients who underwent PSF. A total of 16% of cases in the AVBT group required a subsequent surgical procedure compared with 1.3% in the PSF group. An additional 4 cases (1.3%) in the AVBT group had a residual curve of >50° that may require revision or conversion to PSF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inter- and intra-rater reliability and accuracy of Sanders Skeletal Maturity Staging System when used by surgeons performing vertebral body tethering.

PURPOSE: Pediatric orthopedic surgeons must accurately assess the skeletal stage of adolescent idiopathic scoliosis (AIS) patients for selection and timing of optimal treatment. Successful treatment using vertebral growth modulation is highly dependent on skeletal growth remaining. We sought to evaluate the current-state use of the Sanders Skeletal Maturity System (SSMS) in regard to precision and accuracy. We hypothesized that pediatric orthopedic surgeons currently use SSMS with moderate precision and accuracy. METHODS: Eight practicing pediatric orthopedic surgeons who perform vertebral body tethering surgery without specific training in SSMS were asked to assign the SSMS stage for 34 de-identified hand radiographs from AIS patients. Precision was evaluated as inter-rater reliability, using both Krippendorff's α and Weighted Cohen's kappa statistics, and as intra-rater reliability, using only Weighted Cohen's kappa statistics. Surgeon accuracy was evaluated using Weighted Cohen's kappa statistics with comparison of surveyed surgeons' responses to the gold standard rating. RESULTS: Inter-rater reliability across the surveyed surgeons indicated moderate to substantial agreement using both statistical methods (α = 0.766, κ = 0.627) with the majority of discord occurring when assigning SSMS stages 2 through 4. The surveyed surgeons displayed substantial accuracy when compared to the gold standard (κ = 0.627) with the majority of inaccuracy involving the identification of stage 3B. When re-surveyed, the surgeons showed substantial intra-rater reliability (κ = 0.71) with increased inconsistencies when deciding between SSMS stage 3A and stage 3B. CONCLUSION: The current-state use of SSMS across pediatric orthopedic surgeons for evaluation of AIS patients displays adequate but imperfect precision and accuracy with difficulties delineating SSMS stages 2 through 4, which correlate with adolescent growth periods germane to scoliosis growth modulation surgery. Centralized assessment of hand-bone age may help ensure standardized reporting for non-fusion scoliosis research.

Transcranial Motor Evoked Potential Monitoring in a Patient With a Deep Brain Stimulator: A Case Report.

SUMMARY: A major complication of surgical scoliosis correction is permanent injury of the spinal cord. Intraoperative neuromonitoring continually evaluates spinal cord function through monitoring sensory and corticospinal motor tracts. There is no literature or manufacturer recommendation on whether transcranial motor evoked potential (tcMEP) monitoring can be performed safely in the presence of a deep brain stimulator (DBS) system. A 17-year-old adolescent boy with severe neuromuscular scoliosis presented for a posterior spinal fusion. The patient suffered from generalized dystonia treated with a DBS terminating in the left and right globus pallidus internus. The competing goals of monitoring motor function during the spinal fusion and preserving the integrity of the DBS system were discussed preoperatively. The DBS system was deactivated for the duration of surgery, and tcMEPs were used sparingly at the lowest suitable stimulation voltage. Intraoperative management focused on facilitating neurophysiologic monitoring through a total intravenous anesthetic of propofol, methadone, and remifentanil. The tcMEPS remained unchanged throughout the operation and the patient emerged able to move his lower extremities to command. Postoperatively, the DBS system was turned back on and showed retained settings, normal functioning, and unchanged impedance of the DBS leads. Neither the patient nor his parents reported any subjective changes in the symptoms of dystonia. The authors conclude that monitoring tcMEPs in the presence of a DBS implant may be done safely, when the clinical circumstances suggest that the added information gained from tcMEPs outweighs the theoretical risk to the DBS system and the course of the medical condition treated by the DBS.

Approaches for the very young child with spinal deformity: what's new and what works.

Treating very young children with spinal deformities is challenging and complex, and it entails risks. The consequences of surgical treatment can be profound, with lifelong implications. The recent focus on "fusionless" surgery and spinal column lengthening strategies, such as growing rod instrumentation and the use of a Vertical Expandable Prosthetic Titanium Rib, illustrate the current understanding of the importance of spinal growth and lung development in infants and young children.

What They Want - Caregiver and Patient Immobilization Preferences for Pediatric Buckle Fractures of the Wrist.

Background: Recent literature supports minimalist approaches such as splinting for pediatric buckle fractures of the wrist. Uptake of this practice, however, has lagged behind the evidence. Barriers to implementation of this strategy necessitate further investigation, and caregiver and patient preferences represent an obstacle that has not been previously evaluated. This study sought to examine caregiver and patient treatment preferences and factors influencing care decisions for buckle fractures of the wrist. We hypothesized that the majority of caregivers and patients prefer cast immobilization for buckle fractures of the wrist. Methods: A 22-item caregiver survey was created to assess demographics, treatment preferences and influential factors. The survey was completed by a convenience sample of caregivers presenting with patients of any diagnosis to our pediatric orthopaedic clinic. Results: 297 surveys were collected predominantly from mothers (81.2%) caring for 2.4 (SD 1.3) children. Forty-one percent had previously cared for a child with a fracture. Caregivers accompanied patients who were 9.0+/-5.0-years-old, 34% of whom were actively being treated for an orthopaedic injury. Caregiver immobilization preferences for buckle fractures of the wrist were: no preference (43.1%), cast (32.3%) and splint (24.6%). The doctor's recommendation was the most influential factor on this decision while the child's gender was the least of the factors assessed. Those who rated treatment durability and child's activity level higher were associated with a preference for casting, while those who rated comfort higher were associated with a preference for splinting. Discussion: This study is the first to characterize caregiver preferences regarding immobilization devices in the realm of buckle fractures of the wrist. Findings identified that preferences are mixed, with the interest in casting being less than anticipated. Factors influencing caregiver preference include the doctor's recommendation, durability, the patient's activity level, and comfort. Findings can help guide treatment discussions for providers seeking to implement splint-based immobilization strategies.Level of Evidence: III.

Buckling Down on Torus Fractures - Assessing Treatment Preferences and Perceived Management Barriers at a Single Institution.

Background: Pediatric buckle fractures of the wrist can be safely managed in 'minimalist' fashion with splinting and limited follow-up; however, traditional means of treatment remain prevalent. The purpose of this study was to 1) evaluate preferences for buckle fracture management among providers at a single institution and 2) identify factors influencing clinical decision-making and barriers to implementation of minimalist practices. Methods: A 13 question survey was developed split into three sections: 1) Demographics, 2) Preferred management, and 3) Influential factors. The survey was distributed to 32 providers within our hospital system involved in buckle fracture management via email over a 1 year period. Descriptive statistics of responses were performed to address study aims. Results: The survey participation rate was 72%. Respondents had 12.2+/-12.5 (Range: 1-41) years of experience. Casting of buckle fractures was preferred by 56.5% of providers. Most (77%) were aware of literature supporting minimalist strategies. Family preferences (59.1%) and compliance concerns (54.5%) were cited as the biggest barriers to implementing these practices. Colleague recommendations and patient and caregiver preferences had the strongest influence on providers' practice. Following completion, 88.2% of providers stated they would change or consider changing their practices. Discussion: Despite awareness of the evidence base, a casting preference still exists. While other aspects of the minimalist approach were popular, prior work suggests this does not necessarily translate into practice. Commonly cited barriers include family preferences and compliance concerns; however, awareness of these issues may enable change. Level of Evidence: III.

Methadone and a Clinical Pathway in Adolescent Idiopathic Scoliosis Surgery: A Historically Controlled Study.

STUDY DESIGN: Historically controlled clinical trial. OBJECTIVES: Patients presenting for correction of adolescent idiopathic scoliosis (AIS) by posterior spinal fusion may benefit from structured clinical pathways. We studied the effects of implementing a published clinical pathway for the perioperative care of patients with AIS that required intraoperative use of methadone at our institution. METHODS: We performed a historically controlled clinical trial of patients undergoing posterior spinal fusion for AIS by comparing a retrospectively collected control group of 25 patients with a prospective experimental group of 14 patients receiving methadone, gabapentin, propofol, and remifentanil as part of a new clinical pathway. RESULTS: Use of the pathway decreased average pain scores evaluated by the Numeric Rating Scale in the 24 hours following surgery (4.8 [4-6] to 3.4 [2-4], P = .03 [-2.6 to -0.2; t = -2.3]) and postoperative opioid consumption by 76% (41 [29-51] mg to 10 [4-17] mg, P < .001 [-45 to -15; Welch's t = 4.9]) during the same period. Improved analgesia and reduced reliance on opioids facilitated other postoperative elements of the clinical pathway and shortened the average hospital length of stay by 1 day (4 [3-6] days to 3 [3-5] days, P = .001 [-2 to -1; U = 67, Z = -3.3]). CONCLUSIONS: Multimodal analgesia and a clinical pathway add value in the perioperative care of patients undergoing posterior spinal fusion for AIS by improving analgesia and shortening hospitalization. The prospective arm of the trial was registered at clinicaltrials.gov under NCT02481570.

MRI utilization and rates of abnormal pretreatment MRI findings in early-onset scoliosis: review of a global cohort.

STUDY DESIGN: Retrospective review OBJECTIVES: To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with early-onset scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS. METHODS: We reviewed data from patients enrolled from 1993-2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings. RESULTS: MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings. CONCLUSION: In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type. LEVEL OF EVIDENCE: Prognostic, Level III.