Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND: Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. METHODS: Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. RESULTS: Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. CONCLUSION: COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. LEVEL OF EVIDENCE: Level III-prognostic study.

Telehealth Potential in Pediatric Orthopaedics and Sports Medicine Care is Comparable to In-Person Care But Disparities Remain.

BACKGROUND: Understanding the challenges and potential of telehealth visits (THVs) in a large population can inform future practice and policy discussion for pediatric orthopaedic and sports medicine (OSM) care. We comprehensively assess telehealth challenges and potential in a large pediatric OSM population based on access, visit completion, patient satisfaction, and technological challenges. METHODS: Demographics, address, insurance, visit information, patient feedback, experience with video visits, and technical challenges of all 2019 to 2020 visits at our hospital were assessed (3,278,006 visits). We evaluated the differences in rate of telehealth utilization, rate of patient adherence, disparities in care access and patient satisfaction, and technological issues. RESULTS: Compared with in-person prepandemic visits, THVs had lower ratios of non-White patients (by 5.8%; P <0.001), Hispanic patients (by 2.8%; P <0.001) and patients with public insurance (by 1.8%; P <0.001), and a higher mean distance between the patient's residence and clinic (by 18.8 miles; P <0.001). There were minimal differences in median household income (average $2297 less in THV; P <0.001) and social vulnerability index (average 0.01 points lower in THV; P <0.001) between groups. THVs had comparable patient satisfaction to in-person visits. Non-White patients, Hispanics, and those with public insurance had lower ratings for both in-person visits and THVs and had more technical difficulties during their THV. CONCLUSIONS: Telehealth is a viable method of care for a range of pediatric OSM conditions, providing a similar quality of care as in-person visits with a greater geographic reach. However, in its current format, reduced disparities were not observed in pediatric OSM THVs. LEVEL OF EVIDENCE: Level III.

Preoperative Considerations for Teenagers Undergoing Orthopaedic Surgery: VTE Prevention, Mental Health Assessment, Vaping, and Drug Addiction.

INTRODUCTION: Adolescents undergoing pediatric orthopaedic surgery typically experience an uncomplicated postoperative course. However, adolescence represents a unique transition period from pediatric to adult physiology. As a result, the astute pediatric orthopaedic surgeon will be aware of unique medical and social scenarios which are relevant to adolescents during the perioperative course including the risk of venous thromboembolism (VTE), prevalence of mental health conditions, and rising use of electronic cigarettes or "vaping" to consume nicotine and cannibas. DISCUSSION: Adolescents are at a greater risk of VTE after pediatric orthopaedic surgery. In particular, adolescent females with a family history of blood clotting disorders and those with a change in mobility after surgery should be considered for prophylaxis. The prevalence of adolescent mental health conditions including anxiety, depression, and behavioral issues is increasing in the United States. Higher levels of preoperative anxiety and the presence of mental health pathology are associated with slower recovery, higher levels of postoperative pain, and the increased likelihood for chronic pain. Several quick screening instruments are available to assess adolescents for preoperative anxiety risk, including the Visual Analogue Scale for Anxiety or the Amsterdam Perioperative Anxiety Information Scale. Unfortunately, electronic cigarettes have become increasingly popular for the consumption of nicotine and cannabis among adolescents. Preoperative use of combustive cigarettes (nicotine/cannabis) represents perioperative risks for induction/anesthesia, postoperative pain, and analgesia requirements and issues with delayed wound and fracture healing. CONCLUSIONS: VTE, underlying mental health conditions, and usage of nicotine and cannabis are clear detriments to the recovery and healing of adolescent patients following orthopaedic surgery. Therefore, standardized screening for adolescents before orthopaedic surgery is indicated to identify perioperative risk factors which have negative impacts on functional outcomes.

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

BACKGROUND: Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. METHODS: All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. RESULTS: In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. CONCLUSIONS: Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. LEVEL OF EVIDENCE: Level III.

Femoral Neck Stress Fractures in Children Younger Than 10 Years of Age.

BACKGROUND: Femoral neck stress fractures are rare in healthy children, with only 9 cases previously reported. The present article reviews our institutional experience with femoral neck stress fractures in children younger than 10 years of age, to highlight the unique features of this condition. METHODS: We undertook a retrospective review of clinical records of patients who had been treated at our institution for an idiopathic femoral neck stress fracture between 2000 and 2014. To focus on children rather than adolescents, the World Health Organization's definition of adolescent as a person between 10 and 19 years of age was used; we thereby limited our analysis to patients younger than 10 years of age. RESULTS: The study included 6 patients (3 males, 3 females) treated for an idiopathic femoral neck stress fracture, with a mean age at diagnosis of 7.7 years (range, 5.2 to 8.9 y). All patients presented with a limp, which worsened with activity and had persisted for a mean of 5 weeks (range, 2 to 9 wk). None of the patients had experienced an increase in activity level or sporting volume before symptom onset. On examination, 3 patients experienced pain with terminal hip flexion and 3 patients demonstrated pain-free hip range of motion. Plain radiography demonstrated inferior femoral neck cortical disruption, suggesting a compression-type stress fracture mechanism. The diagnosis was confirmed by cross-sectional imaging in all cases. All patients were initially treated with 6 to 8 weeks of non-weight-bearing followed by 4 to 6 weeks of partial weight-bearing, leading to complete healing in 4 patients. Two patients demonstrated incomplete healing and were managed with spica casting for an additional 6 weeks. CONCLUSIONS: Our case series illustrates the unique features of this rare condition in children, with a history and examination profile distinct from those of adolescents and adults. Compliance with weight-bearing restrictions is difficult in this population and hip spica casting may be required to permit complete healing. LEVEL OF EVIDENCE: Level IV-case series.

Surgical Reconstruction of Metatarsal Type Preaxial Polydactyly Using an Amalgamating Osteotomy.

BACKGROUND: Polydactyly of the foot is a relatively common condition. Approximately 15% of cases are preaxial, with one third of these cases involving duplication of the metatarsal [metatarsal type preaxial polydactyly (MTPP)].Surgical reconstruction of polydactyly is indicated to improve shoe tolerance. Reconstruction of MTPP has traditionally involved resection of the hypoplastic lateral ray in addition to soft tissue reconstruction to correct hallux varus. Poor postoperative results have frequently been reported, primarily due to residual hallux varus. We present a novel surgical technique for the treatment of children with MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy that permits retention of the stable medial metatarsotarsal joint while avoiding the complication of residual hallux varus. METHODS: This was a retrospective case series describing the surgical technique of an amalgamating osteotomy in the treatment of patients with MTPP and a cosmetic lateral hallux. The surgical technique involves corresponding metatarsal osteotomies of the medial and lateral halluces, with amalgamation of the metatarsals and ablation of the residual medial hallux, without the need for extensive soft tissue reconstruction. Clinical and radiologic outcomes were evaluated at a minimum of 2 years postoperatively in 2 patients who underwent this technique. RESULTS: Two children, 1 female and 1 male, underwent an amalgamating osteotomy at the age of 31 and 18 months, respectively. At latest follow-up, 7.3 and 2.8 years after osteotomy, respectively, both patients displayed an excellent functional result according to the Phelps and Grogan clinical outcome scale. Plain radiographs in both cases demonstrated a well-aligned first ray with no growth abnormality and no hallux varus. CONCLUSIONS: We have presented a novel surgical technique for the reconstruction of MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy without extensive soft tissue reconstruction. This simple technique maintains the stable medial metatarsotarsal joint, permits ongoing longitudinal metatarsal growth, and avoids the complication of hallux varus. LEVEL OF EVIDENCE: Level IV-case series.

Quality, Safety, Value: From Theory to Practice Management What Should We Measure?

Over the past 35 years the health care community and in particular orthopaedic surgery, has undergone a transformation from retrospective case-series-based expert opinion to randomized prospective clinical trials. During this transition, orthopaedic surgeons have become very skilled in the measurement of physician-derived outcomes (radiographic angles, complications, recurrences, and mortality); however, these are not patient-centered outcomes and they are of little importance to our patients' satisfaction. Moving forward outcome measurement needs to be restructured to focus more on patient-reported outcomes. This paper outlines why outcome measurement is important, reviews outcome strategies that have been used historically, introduces a new outcome measurement tool and identifies strategies for future implementation and measurement of health care quality and value within pediatric orthopaedics.

Adolescent Idiopathic Scoliosis Minimum Data Set: Towards Standardization of Data Elements in History and Physical Examination.

INTRODUCTION: Nonoperative care represents a cornerstone of adolescent idiopathic scoliosis (AIS) management, although no consensus exists for a minimal data set. We aimed to determine a consensus in critical data points to obtain during clinical AIS visits. METHODS: A REDCap-based survey was distributed to Pediatric Orthopedic Society of America (POSNA), Pediatric Spine Study Group (PSSG), and International Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT). Respondents ranked the importance of data points in history, physical examination, and bracing during AIS visits.  Results: One hundred eighty-one responses were received (26% response rate), of which 86% were physicians and 14% were allied health professionals. About 80% of respondents worked at pediatric hospitals or pediatric spaces within adult hospitals, and 82% were academic, with the majority (57%) seeing 150+ unique AIS patients annually. Most respondents recommended six-month follow-up for patients under observation (60%) and bracing (54%). Most respondents (75%) considered family history and pain important (69%), with the majority (69%) asking about pain at every visit. Across all time points, Adam's forward bend test, shoulder level, sagittal contour, trunk shift, and curve stiffness were all considered critically important (>60%). At the first visit, scapular prominence, leg lengths, motor and neurological examination, gait, and iliac crest height were also viewed as critical. At the preoperative visit, motor strength and scapular prominence should also be documented. About 39% of respondents use heat sensors to monitor bracing compliance, and average brace wear since the prior visit was considered the most important (85%) compliance data point. CONCLUSIONS: This study establishes recommendations for a 19-item minimum data set for clinical AIS evaluation, including history, physical exam, and bracing, to allow for future multicenter registry-based studies.

Occipital condyle fracture in the pediatric population: A management algorithm and systematic review.

Purpose: This study aims to develop an accessible stepwise management algorithm for pediatric presentations of occipital condyle fractures (OCFs) based on a systematic review of the published literature regarding diagnostic evaluation, treatment, and outcomes. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric OCFs. Data extraction of clinical presentation, management strategies, imaging, and treatment outcome was performed. Results: A total of 15 studies reporting on 38 patients aged 18 years and younger presenting with OCFs were identified. Loss of consciousness (LOC), depressed level of consciousness, neck pain, decreased neck range of motion (ROM), and cranial nerve injury were the most common presenting symptoms. Diagnostic imaging included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and functional radiographs to assess cervical stability. Treatment options varied and included soft collar, hard collar, and halo vest. All studies resulted in a complete healing of the OCF, with resolution of associated pain. Conclusion: The proposed treatment algorithm suggests a framework for the management of pediatric OCFs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a stepwise approach should be utilized in the management of isolated pediatric OCFs.

Utility of postoperative laboratory testing after posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: With advancements to blood management strategies, risk of perioperative transfusion following surgical treatment of adolescent idiopathic scoliosis (AIS) has diminished. We hypothesize that routine laboratory testing on postoperative-day 1 (POD1) and beyond is unnecessary. The purpose of this study is to determine necessity of POD1 labs, particularly hematocrit and hemoglobin levels, following surgical management of AIS. METHODS: We performed a retrospective cohort study of consecutive AIS patients aged 11-19 who underwent posterior spinal fusion (PSF) at a single institution. Univariable logistic regression was utilized to determine factors associated with hematocrit ≤ 22% on POD1 or a postoperative transfusion. Firth's penalized logistic regression was used for any separation in data. Youden's index was utilized to determine the optimal point on the ROC curve that maximizes both sensitivity and specificity. RESULTS: 527 patients qualified for this study. Among the eight total patients with POD1 hematocrit ≤ 22, none underwent transfusion. These patients had lower last intraoperative hematocrit levels compared to patients with POD1 hematocrit > 22% (24.1% vs 31.5%, p < 0.001), and these groups showed no difference in preoperative hematocrit levels (38.2% vs 39.8%, p = 0.11). Four patients underwent postoperative transfusion. Both preoperative hematocrit levels (34.0% vs 39.9%, p = 0.001) and last intraoperative hematocrit levels (25.1% vs 31.4%, p = 0.002) were lower compared to patients without transfusion. Intraoperative hematocrit < 26.2%, operative time of more than 35.8 min per level fused, or cell salvage > 241 cc were significant risk factors for postoperative transfusion. CONCLUSION: Transfusion after PSF for AIS is exceedingly rare. POD1 labs should be considered when last intraoperative hematocrit < 26%, operative time per level fused > 35 min, or cell salvage amount > 241 cc. Otherwise, unless symptomatic, patients do not benefit from postoperative laboratory screening.

More Than a Flesh Wound: Trisomy 21 Patients Undergoing Posterior Spinal Fusion for Scoliosis Have High Odds of Wound Complications.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Patients with trisomy 21 (T21) often have soft tissue differences that lead to greater risk of postoperative wound complications. Our aim was to use a matched cohort of adolescent idiopathic scoliosis (AIS) patients with >2 year outcomes to determine odds of specific wound complications when comparing T21 and AIS patients. METHODS: 14 T21 and 544 AIS patients were available for matching. Propensity score matching was conducted using logistic regression models and yielded a 1:5 match of 14 T21 patients and 70 AIS patients. Bivariate analyses were conducted across both patient groups. The proportion of wound complications was estimated along with a 95% confidence interval. Multivariable logistic regression analysis was utilized to determine if there was a significant association between T21 patients and wound outcomes. RESULTS: 64% of T21 patients experienced a wound complication (9/14; 95% CI = 35.63-86.02) while only 3% of the AIS patients experienced a wound complication (2/70; 95% CI = .50-10.86). Patients with T21 had 56.6 times the odds of having a wound complication compared to matched AIS patients (OR = 56.57; 95% CI = 8.12-394.35; P < .001), controlling for age at surgery, BMI percentile, and propensity score. T21 patients had 10.4 times the odds of reoperation compared to AIS patients (OR = 10.36; 95% CI = 1.62-66.02; P = .01). CONCLUSION: T21 patients have 10.4× the odds of reoperation and 56.6× the odds of overall wound complication when compared to AIS patients in a 1:5 matched cohort with appropriate controls. This is important for surgical planning, surgeon awareness, and communication with families preoperatively.

The Troubling Rise of Scurvy: A Review and National Analysis of Incidence, Associated Risk Factors, and Clinical Manifestations.

INTRODUCTION: In the era of modern medicine, scurvy has been thought of as a rare disease of ancient times because of improved emphasis on diet and nutrition; however, isolated case reports are plentiful. This investigation presents a comprehensive review of scurvy, including an analysis on its rising incidence, with specific focus on its orthopaedic manifestations and commonly associated diagnoses. METHODS: This comprehensive review includes a retrospective analysis of 19,413,465 pediatric patients in the National Inpatient Sample database from 2016 through 2020. Patients with scurvy were identified by the ICD-10 code, and an estimated incidence of scurvy in the inpatient pediatric population was calculated. Concurrent diagnoses, musculoskeletal reports, and demographic variables were collected from patient records. Comparisons were made using analysis of variance or chi-square with Kendall tau, where appropriate. RESULTS: The incidence of scurvy increased over the study period, from 8.2 per 100,000 in 2016 to 26.7 per 100,000 in 2020. Patients with scurvy were more likely to be younger (P < 0.001), male (P = 0.010), in the lowest income quartile (P = 0.013), and obese (P < 0.001). A majority (64.2%) had a concomitant diagnosis of autism spectrum disorder. Common presenting musculoskeletal reports included difficulty walking, knee pain, and lower limb deformity. Burden of disease of scurvy was markedly greater than that of the average inpatient population, with these patients experiencing greater total charges and longer hospital stays. CONCLUSION: Clinicians should be aware of the increasing incidence of scurvy in modern medicine. In cases of vague musculoskeletal reports without clear etiology, a diagnosis of scurvy should be considered, particularly if risk factors are present. TRIAL REGISTRATION NUMBER: NA.

Evaluation and Management of Pediatric Humeral Shaft Fractures.

Diaphyseal humerus fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity, and size. Treatment strategies include closed reduction with various immobilization techniques, flexible nails, uniplanar or multiplanar external fixation, or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, and the multiplanar motion of the shoulder joint can accommodate for greater variations in alignment than many other long bone fractures. Complications such as radial nerve palsy are possible with both open and closed injuries, and mal/nonunions, although rare, can occur. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

Vascular Injury After Scoliosis Correction in Ehlers-Danlos Syndrome: Proceed With Caution.

Ehlers-Danlos syndrome (EDS) is a rare inherited connective tissue disorder characterized by collagen synthesis disruption, resulting in joint hyperlaxity, skin and vascular fragility, and bleeding diathesis. Patients with EDS are susceptible to spinal deformities, with scoliosis accounting for up to 23.4% of musculoskeletal abnormalities. Conservative management is often trialed initially; however, severe scoliosis can lead to significant sagittal imbalance and cardiopulmonary compromise. Surgical intervention for scoliosis correction in patients with EDS presents unique challenges because of tissue fragility and an increased risk of vascular and wound complications. This case report discusses a 20-year-old man with type II EDS and scoliosis, who experienced retroperitoneal compartment syndrome, significant left lower extremity weakness, and loss of sensation after scoliosis correction surgery. The report also provides an overview of the existing literature on scoliosis surgery outcomes in patients with EDS, highlighting the need for heightened vigilance and cautious surgical approaches.

Spinal osteoid osteoma in the pediatric population: A management algorithm and systematic review.

Purpose: The purpose of this study is to develop an accessible step-wise management algorithm for the management of pediatric spinal osteoid osteomas (OOs) based on a systematic review of the published literature regarding the diagnostic evaluation, treatment, and outcomes following surgical resection. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric spinal OOs. Data extraction of clinical presentation, management strategies and imaging, and treatment outcomes were performed. Results: Ten studies reporting on 85 patients under the age of 18 years presenting with OOs were identified. Back pain was the most common presenting symptom, and scoliosis was described in 8 out of 10 studies, and radicular pain in 7 out of 10 studies. Diagnostic, intraoperative, and postoperative assessment included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), bone scans, and frozen section. Treatment options varied, including conservative management, open surgical resection with or without intraoperative imaging, and percutaneous image-guided treatment. All included studies described partial or complete resolution of pain in the immediate postoperative period. Conclusions: The proposed algorithm provides a suggested framework for management of pediatric spinal OOs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a step-wise approach should be utilized in the management of pediatric spinal OOs.

Disparities in cannabis use and documentation in electronic health records among children and young adults.

The legalizations of medical and recreational cannabis have generated a great deal of interest in studying the health impacts of cannabis products. Despite increases in cannabis use, its documentation during clinical visits is not yet mainstream. This lack of information hampers efforts to study cannabis's effects on health outcomes. A clear and in-depth understanding of current trends in cannabis use documentation is necessary to develop proper guidelines to screen and document cannabis use. Here we have developed and used a natural language processing pipeline to evaluate the trends and disparities in cannabis documentation. The pipeline includes a screening step to identify clinical notes with cannabis use documentation which is then fed into a BERT-based classifier to confirm positive use. This pipeline is applied to more than 23 million notes from a large cohort of 370,087 patients seen in a high-volume multi-site pediatric and young adult clinic over a period of 21 years. Our findings show a very low but growing rate of cannabis use documentation (<2%) in electronic health records with significant demographic and socioeconomic disparities in both documentation and positive use, which requires further attention.

Socioeconomic Status Affects Postoperative Time to Union in Pediatric Patients with a Surgically Treated Fracture.

Fractures account for 10% to 25% of all pediatric injuries, and surgical treatment is common. In such cases, postoperative healing can be affected by a number of factors, including those related to socioeconomic status (SES). The purpose of this study was to investigate the relationship between time to fracture union and SES, which was measured with use of the median household income (MHI) and Child Opportunity Index (COI). Methods: A retrospective review was conducted of pediatric patients with a long-bone fracture that had been surgically treated at a Level-I pediatric trauma center between January 2010 and June 2020. Demographic and relevant medical data were collected. Patients were sorted into union and nonunion groups. The ZIP code of each patient was collected and the MHI and COI of that ZIP code were identified. Income brackets were created in increments of $10,000 ranging from $20,000 to $100,000, with an additional category of >$100,000, and patients were sorted into these groups according to MHI. Comparisons among the income groups and among the union status groups were conducted for each of the collected variables. A multiple regression analysis was utilized to determine the independent effect of each variable on time to union. Results: A total of 395 patients were included in the final sample, of whom 51% identified as Hispanic. Patients in the union group had a higher mean COI and MHI. Nonunion occurred in only 8 patients. Patients who achieved fracture union in ≤4 months had a significantly higher mean COI and MHI. When controlling for other demographic variables, the time to union increased by a mean of 9.6 days for every $10,000 decrease in MHI and increased by a mean of 6.8 days for every 10-unit decrease in the COI. Conclusions: The present study is the first, to our knowledge, to investigate the relationship between SES and time to fracture union in pediatric patients. When controlling for other demographic factors, we found a significant relationship between SES and time to union in pediatric patients with a surgically treated fracture. Further investigations of the relationship between SES and time to union in pediatric patients are needed to determine potential mechanisms for this relationship. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of paediatric Lisfranc injuries: A systematic review and introduction of a novel treatment algorithm.

Background: Pediatric Lisfranc injuries (PLI) are rare injuries that have few studies published about their occurrence and treatment in pediatric population. Due to this lack of information, the diagnostic criteria and surgical or non-surgical methods for treatment have not been clearly established within the pediatric orthopedic literature. The objective of this study was to review the published literature related to treatment options and develop a concise stepwise treatment algorithm for pediatric patients presenting with Lisfranc injuries. Methods: A systematic literature review was conducted using PubMed to find studies discussing the treatment of PLI with reported long-term outcomes. Data collection accounted for the mechanism of injury, diagnostic imaging modality used, injury type, fracture classification using the Myerson system, treatment method used, and postoperative complications. Results: An initial PubMed search revealed 290 articles, but only 10 studies fulfilled the criteria for in-depth review. A total of 114 patients were included in this review from the selected case reports and case series studies. Primary treatment methods were as follows: 44% (50/114) with open reduction internal fixation (ORIF) using Kirschner wires (K-wires) and/or screws, 3% (3/114) with closed reduction percutaneous fixation (CRPF), 4% (4/114) with suture-button constructs, 20% (23/114) with cast immobilization, and 29% (33/114) were described as not requiring reduction. Conclusion: There were two main limitations to this study. First, there are few published studies with longitudinal outcomes of PLI treatment. Second, some case series did not disclose which procedure a patient with post-treatment complications underwent. Therefore, an overall statistical analysis of success and failure rates with associated complications of each procedure could not be conducted. In conclusion, we found that a stepwise approach to evaluating conservative and surgical treatment options based on the presentation of the PLI should be utilized to optimize long-term outcomes.

Double Sublaminal Band Passage Technique for Spinal Deformity Correction.

Sublaminar band fixation is a reliable way to anchor spinal rods to the vertebral column. This technique is especially useful when the anatomy precludes safe pedicle screw placement. Sublaminar bands allow for deformity correction and stabilization of the spine. One of the disadvantages of using the sublaminar band technique is the risk for neurologic injury during the passage of the band between the dura and lamina. In this article, we describe a new technique for passing sublaminar bands, i.e., the double sublaminar band passage technique. This technique decreases the number of passes against the dura, thereby decreasing the opportunity for neural injury. In addition, we present an illustrative case of an 11-year-old female with neuromuscular scoliosis who underwent a posterior spinal instrumented fusion with a hybrid screw and sublaminar band construct.

Marijuana Use Results in Increased Time to Union in Surgically Treated Pediatric Fracture Patients.

OBJECTIVE: To identify the impact of marijuana use on fracture healing in surgically treated pediatric patients. DESIGN: Retrospective review. SETTING: Level 1 trauma center, single-center study. PATIENTS/PARTICIPANTS: Surgically treated pediatric patients 10-18 years with extremity fractures from 2010 to 2020. Conservatively treated patients and patients with nonunions were excluded from the study. Three hundred thirty-nine patients were included in the study, 21 of which were confirmed marijuana users by toxicology screening. INTERVENTION: Surgical treatment of extremity fractures by any type of fixation. MAIN OUTCOME MEASUREMENTS: Time to union was the primary outcome and was defined as radiographic evidence of bridging callus on all sides of the fracture and absence of the previous fracture line. Analysis of covariance, logistic regression analysis, and Fisher exact tests were used to establish the relationship between all collected variables and time to radiographic union. RESULTS: The average time to union for marijuana users (159.1 ± 69.5 days, 95% confidence interval) was significantly longer than for nonusers (80.3 ± 7.8 days), P < 0.001. The odds of having a time to union of greater than 4 months and greater than 6 months were 4.17 (P = 0.00192) and 6.19 (P = 0.000159), respectively, for marijuana users compared with nonusers. CONCLUSION: Marijuana users demonstrated longer time to union in surgically treated pediatric fracture patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.