Orthopaedic Surgery Subspecialty Podcast Effectively Disseminates Peer-reviewed Articles Relative to Traditional Online Publishing.

BACKGROUND: Podcasts have become increasingly utilized in medical education over the past decade, especially in orthopaedic surgery. Compared with more traditional learning tools, podcasts are easily accessible, free, and capable of use while multitasking. Despite these apparent benefits, the effectiveness of podcasts as a dissemination tool for emerging peer-reviewed literature is not well understood. The Peds Ortho Podcast is the official podcast of Pediatric Orthopedic Society of North America that highlights recently published peer-reviewed articles through author interviews and executive summaries of featured articles. The purpose of this study was to compare the distribution of the Peds Ortho Podcast to traditional media by comparing electronic access statistics between the podcast episodes and the journal articles they summarize. METHODS: Podcast episodes were reviewed to catalog the abstracts and articles discussed therein. Because podcasts and articles utilize different electronic metrics to track distribution, we established a common metric of an "access," which we defined as an "intent to consume the media." For articles, we defined an "access" as the largest value of a publisher's online metrics, be it abstract views, full text views, or article downloads. For podcast episodes, we defined an "access" as any play >0 seconds. Access data were analyzed using independent samples t test and analyses of variance. RESULTS: Eighty episodes of the Peds Ortho Podcast have featured 333 published, peer-reviewed articles to date, with 303 included in the final analysis with available article metrics. There were significantly more mean electronic accesses per podcast episode than featured articles (1236 vs. 482, P <0.001). Podcast consumption greatly varies in the first 30 days following episode release; however, recent episodes have a substantial proportion of accesses soon after publication. CONCLUSIONS: Given that podcast electronic access is greater than traditional media, podcasts appear to be a valuable tool for health care providers and trainees. Podcasts serve a complementary role to traditional media by quickly disseminating main points and raising awareness of emerging research.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends.

BACKGROUND: Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time. MATERIALS AND METHODS: This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication. RESULTS: A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) ( P =0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered ( P >0.05). CONCLUSIONS: Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy. LEVEL OF EVIDENCE: Level III-retrospective.

Complications With Surgical Treatment of Pediatric Supracondylar Humerus Fractures: Does Surgeon Training Matter?

INTRODUCTION: National trends reveal increased transfers to referral hospitals for surgical management of pediatric supracondylar humerus (SCH) fractures. This is partly because of the belief that pediatric orthopaedic surgeons (POs) deliver improved outcomes compared with nonpediatric orthopaedic surgeons (NPOs). We compared early outcomes of surgically treated SCH fractures between POs and NPOs at a single center where both groups manage these fractures. METHODS: Patients ages 3 to 10 undergoing surgery for SCH fractures from 2014 to 2020 were included. Patient demographics and perioperative details were recorded. Radiographs at surgery and short-term follow-up assessed reduction. Primary outcomes were major loss of reduction (MLOR) and iatrogenic nerve injury (INI). Complications were compared between PO-treated and NPO-treated cohorts. RESULTS: Three hundred and eleven fractures were reviewed. POs managed 132 cases, and NPOs managed 179 cases. Rate of MLOR was 1.5% among POs and 2.2% among NPOs (P=1). Rate of INI was 0% among POs and 3.4% among NPOs (P=0.041). All nerve palsies resolved postoperatively by mean 13.1 weeks. Rates of reoperation, infection, readmission, and open reduction were not significantly different. Operative times were decreased among POs (38.1 vs. 44.6 min; P=0.030). Pin constructs were graded as higher quality in the PO group, with a higher mean pin spread ratio (P=0.029), lower rate of "C" constructs (only 1 "column" engaged; P=0.010) and less frequent crossed-pin technique (P<0.001). Multivariate analysis revealed minimal positive associations only for operative time with MLOR (odds ratio=1.021; P=0.005) and INI (odds ratio=1.048; P=0.009). CONCLUSIONS: Postsurgical outcomes between POs and NPOs were similar. Rates of MLOR were not different between groups, despite differences in pin constructs. The NPO group experienced a marginally higher rate of INI, though all injuries resolved. Pediatric subspecialty training is not a prerequisite for successfully treating SCH fractures, and overall value of orthopaedic care may be improved by decreasing transfers for these common injuries. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried.

BACKGROUND: Nonaccidental trauma (NAT) is a rising source of morbidity and mortality in the pediatric population. Fractures are often the first cause for presentation to health care providers in the case of NAT but can be misidentified as accidental. Given that elbow fractures are the most common accidental injuries among pediatric patients, they are not traditionally associated with NAT. This study aims to determine the prevalence of NAT among elbow fractures and identify common features in nonaccidental elbow fractures. METHODS: Current Procedural Terminology (CPT) codes were used to retrospectively identify all pediatric (0 to 17) elbow fractures at a single, tertiary children's hospital between 2007 and 2017. Among these, all fractures for which an institutional child abuse evaluation team was consulted were identified. The medical record was then used to determine which of these fractures were due to NAT. Standard injury radiographs of all victims of NAT as well as all patients under 1 year of age were blinded and radiographically evaluated for fracture type by a pediatric orthopaedic surgeon. RESULTS: The prevalence of nonaccidental elbow fractures across the 10-year study period was 0.4% (N=18). However, the prevalence of nonaccidental elbow fractures in those patients below 1 year of age was markedly higher at 30.3% (10/33). Among all elbow fractures in patients below 1 year of age, supracondylar humerus fractures were the most common fracture type (19/33, 57.6%), yet transphyseal fractures (6/33, 18.1%) were most commonly the result of NAT (5/6, 83.3%). In children over 1 year of age, fracture type was not an indicator of NAT. CONCLUSIONS: The vast majority of pediatric elbow fractures (99.6%) are accidental. However, certain factors, namely age below 1 year and transphyseal fractures increase the likelihood that these fractures may be a result of NAT. LEVEL OF EVIDENCE: Level IV: retrospective case series.

When Is a Growth-friendly Strategy Warranted? A Matched Comparison of Growing Rods Versus Primary Posterior Spinal Fusion in Juveniles With Early-onset Scoliosis.

BACKGROUND: In 7 to 11-year-old juveniles with severe early-onset scoliosis (EOS) the optimal surgical option remains uncertain. This study compares growing rods (GRs) followed by definitive posterior spinal fusion (PSF) versus primary PSF in this population. We hypothesized that the thoracic height afforded by GRs would be offset by increased rigidity, more complications, and more operations. METHODS: This retrospective comparative study included EOS patients aged 7.0 to 11.9 years at index surgery treated with GR→PSF or primary PSF during 2013 to 2020. Primary outcomes were thoracic height gain (ΔT1-12H), major curve, complications, and total operations. Primary PSFs were matched with replacement 1-to-n to GR→PSFs by age at index, etiology, and major curve. RESULTS: Twenty-eight GR→PSFs met criteria: 19 magnetically controlled GRs and 9 traditional GRs. Three magnetically controlled GRs were definitively explanted without PSF due to complications. The remaining 25 GR→PSFs were matched to 17 primary PSFs with 100% etiology match, mean Δ major curve 1 degree, and mean Δ age at index 0.5 years (PSFs older). Median ΔT1-12H pre-GR to post-PSF was 4.7 cm with median deformity correction of 37%. Median ΔT1-12H among primary PSFs was 1.9 cm with median deformity correction of 62%. GR→PSFs had mean 1.8 complications and 3.4 operations. Primary PSFs had mean 0.5 complications and 1.3 operations. Matched analysis showed adjusted mean differences of 2.3 cm greater ΔT1-12H among GR→PSFs than their matched primary PSFs, with 25% less overall coronal deformity correction, 1.2 additional complications, and 2.2 additional operations per patient. CONCLUSIONS: In juveniles aged 7 to 11 with EOS, on average GRs afford 2 cm of thoracic height over primary PSF at the cost of poorer deformity correction and additional complications and operations. Primary PSF affords an average of 2 cm of thoracic height gain; if an additional 2 cm will be impactful then GRs should be considered. However, in most juveniles the height gained may not warrant the iatrogenic stiffness, complications, and additional operations. Surgeons and families should weigh these benefits and harms when choosing a treatment plan. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Impaired Annulus Fibrosus Development and Vertebral Fusion Cause Severe Scoliosis in Mice with Deficiency of c-Jun NH2-Terminal Kinases 1 and 2.

Mitogen-activated protein kinases, including c-Jun NH2-terminal kinase (JNK), play an important role in the development and function of a large variety of tissues. The skeletal phenotype of JNK1 and JNK2 double-knockout (dKO) mice (JNK1fl/flCol2-Cre/JNK2-/-) and control genotypes were analyzed at different embryonic and postnatal stages. JNK1/2 dKO mice displayed a severe scoliotic phenotype beginning during development that was grossly apparent around weaning age. Alcian blue staining at embryonic day 17.5 showed abnormal fusion of the posterior spinal elements. In adult mice, fusion of vertebral bodies and of spinous and transverse processes was noted by micro-computed tomography, Alcian blue/Alizarin red staining, and histology. The long bones developed normally, and histologic sections of growth plate and articular cartilage revealed no significant abnormalities. Histologic sections of the vertebral column at embryonic days 15.5 and 17.5 revealed an abnormal organization of the annulus fibrosus in the dKOs, with chondrocyte-like cells and fusion of dorsal processes. Spinal sections in 10-week-old dKO mice showed replacement of intervertebral disk structures (annulus fibrosus and nucleus pulposus) by cartilage and bone tissues, with cells staining for markers of hypertrophic chondrocytes, including collagen X and runt-related transcription factor 2. These findings demonstrate a requirement for both JNK1 and JNK2 in the normal development of the axial skeleton. Loss of JNK signaling results in abnormal endochondral bone formation and subsequent severe scoliosis.

Comparison of Staged Versus Same-day Bilateral Hip Surgery in Nonambulatory Children With Cerebral Palsy.

BACKGROUND: Bilateral hip reconstructions with osteotomies are commonly required in patients with severe cerebral palsy (CP) and dysplasia. These procedures can be performed by staging each hip surgery, separated by weeks to months, or by addressing both hips in a single-event surgery. The optimal timing of such surgery is yet to be determined. The purpose of this study was to retrospectively compare major complications between the staged and single-event approaches. METHODS: Medical records of patients who underwent bilateral hip osteotomies, with at least one side including a pelvic osteotomy, were retrospectively reviewed. Subjects were identified who had a diagnosis of nonambulatory CP (defined by Gross Motor and Functional Classification System level IV or V), and at least 1 year of clinical follow-up. All hips were treated by 1 of 7 surgeons: 2 surgeons who always performing single-event surgery and 5 who always perform staged surgeries. Complications were stratified by the Modified Clavien-Dindo Classification (grades 1 to 5). The primary outcome was major complications (grade ≥3), while minor complications, readmissions, reoperations, and resource utilization outcomes were investigated secondarily. RESULTS: Sixty-five patients met our inclusion criteria: 35 received single-event surgery and 30 received staged surgery. The staged group had a higher rate of major complications per patient (0.30 vs. 0; P=0.013). Unplanned readmissions and reoperations were likewise increased in the staged group. Minor complication rates were high in both groups, with no differences observed between staged and single-event approaches (3.27 per patient vs. 2.91; P=0.952). There were no complications causing permanent disability or death. The total length of stay (6.2 vs. 4.0 d; P<0.001) and mean nonsurgical operating room time (65.7 vs. 45.6 min; P<0.001) were increased in the staged group versus the single-event group. CONCLUSIONS: The staged approach to bilateral hip reconstructions in the nonambulatory CP population was associated with a higher rate of major complications compared with a single-event approach. Minor complications were similar for both approaches. Both approaches can have an acceptable safety profile with no observed grade 4 or 5 complications. LEVEL OF EVIDENCE: Level III.

Subspecialty Training Among Graduates of Pediatric Orthopaedic Fellowships: An 11-Year Analysis of the Database of American Board of Orthopaedic Surgery.

BACKGROUND: The field of pediatric orthopaedic surgery is evolving with a reported increase in the number of pediatric orthopaedic fellows being trained as well as an increase in the number of fellows completing additional fellowship training in another subspecialty. The purpose of this study was to examine the historic trends of trainees seeking multiple fellowships within pediatric orthopaedics over an 11-year period using the database of the American Board of Orthopaedic Surgery (ABOS). METHODS: We queried the ABOS database for fellowship choice of applicants for the ABOS part II oral examination with the self-declared subspecialty of pediatric orthopaedics during the years of 2005 to 2015. Descriptive analysis was performed to determine the percentage of applicants who completed >1 fellowship, and the type of subspecialty fellowship completed. χ analysis was used to compare the proportion of multiple fellowship trainees between years. RESULTS: From 2005 to 2015, 310 applicants for ABOS part II pediatric subspecialty examination had completed a fellowship in pediatric orthopaedic surgery, with that number increasing from 14 to 43/y over that span. Forty-five trainees (15%) completed 48 additional fellowships over that decade, with 2 recent trainees completing multiple additional fellowships. The most common additional fellowships were sports (n=22, 46%), hand (n=8, 17%), and spine (n=7, 15%). The rate of additional fellowship training increased over 5-fold from 5% in the first 3 years of the study to 28% in the last 2 years of the study (P=0.001). CONCLUSIONS: The proportion of trainees completing additional subspecialty fellowships in addition to pediatric orthopaedics has risen over the past decade. The precise cause and effect of such change is uncertain and likely multifactorial. Reexamination of our classic training paradigms may be warranted in light of these trends. LEVEL OF EVIDENCE: Level III.

Free flap reconstruction of the knee: an outcome study of 34 cases.

BACKGROUND: Open wounds around the knee joint can often be managed with local flaps; however, free tissue transfer may be required when local tissue options are unavailable or inadequate. Free tissue transfer around the knee can be challenging due to unique anatomic features of the joint. The outcomes of such procedures remain largely unreported. METHODS: We retrospectively analyzed 33 patients who underwent 34 free tissue transfer reconstructions to the knee from 1993 to 2010. Twenty-four flaps were composed of soft tissue only and 10 flaps included a bony component. Patient demographics, details of the defect, operative characteristics, and clinical outcomes were reviewed. Outcomes included rates of flap failure, flap reexploration, and limb salvage. RESULTS: Thirty-three (97%) of 34 flaps survived. One flap failed secondary to arterial thrombosis. In total, 6/34 flaps (18%) required reexploration (2 arterial thromboses and 4 venous thromboses). A wide variety of donor and recipient vessels were used. Vessel selection did not affect vascular reexploration. Overall, 88% of lower extremities were salvaged. Four of 10 (40%) patients receiving bone free flap reconstruction experienced delayed union and 2 (20%) of these required amputation for eventual nonunion. CONCLUSIONS: Free flap reconstruction of the knee has a high flap survival and limb preservation rate in threatened extremities. Flap survival rates in the knee are similar to reported rates elsewhere in the lower extremity. Despite flap survival, infected nonunions that occur after bone free flap reconstruction result in a high limb amputation rate.

Information exchange on adolescent scoliosis discussion forums among patients and caregivers: a thematic analysis.

PURPOSE: Online health-related support groups have increasingly become a regular resource for patients and caregivers; however, the content of these forums is largely unknown to medical teams. The purposes of this study were to (1) review posts from scoliosis discussion forums to establish common themes related to the care experience of patients with scoliosis and (2) understand how common themes vary among pediatric and adult patients, as well as caregivers. METHODS: Posts were collected from two public scoliosis forums. Analysis was performed using grounded theory-a methodology that relies on the repeated analyses of qualitative data to identify recurring concepts, which are then coded and grouped into categories and ultimately central themes that seek to synthesize the relationships between categories. Information posts were reviewed by a board-certified orthopedic surgeon who performs scoliosis surgery for factual basis or misinformation. RESULTS: Analysis of 911 posts revealed five central themes. The two most common themes among patients ≥ 18 and caregivers involve seeking out emotional support and information about surgical treatment. Patients < 18 frequently sought out emotional support but were also largely interested in information about bracing. The most prevalent theme among all contributors involved seeking out emotional support. There was very little medical misinformation found within posts. CONCLUSION: Scoliosis forums serve as an informal outlet where patients and families can offer emotional support and share experiences. Physicians should provide direct emotional support to patients and offer these forums as a resource, without significant concerns about propagating medical misinformation.

Flexibility-tilt agreement best predicts shoulder balance following posterior spine fusion for adolescent idiopathic scoliosis.

PURPOSE: We propose a novel concept, called flexibility-tilt agreement (FTA), which could be applied intra-operatively to improve shoulder balance following posterior spine fusion for Adolescent Idiopathic Scoliosis (AIS). We retrospectively applied this concept to a cohort with thoracic-only curves, seeking to: (1) evaluate the impact of FTA and other peri-operative variables on post-operative shoulder balance, and (2) evaluate deformity characteristics associated with achieving FTA. METHODS: A single-institution registry was queried for patients undergoing PSF from 2000 to 2017 with main thoracic and double thoracic curves with at least 2-year follow-up. Flexibility was defined as the Cobb angle of the unfused proximal thoracic curve (cephalad to chosen UIV) on pre-operative bender. Tilt refers to post-operative UIV tilt angle. FTA means these values cancel (Flexibility + Tilt = 0 ± 5°). Logistic regression was performed to determine the association between peri-operative variables and shoulder balance. RESULTS: One hundred and sixty-one patients were included, mean age 13.6 years old, and 47-month mean follow-up. FTA was achieved in 74 (46%) patients and was associated with post-operative (OR = 4.59) and final (OR = 6.98) medial shoulder balance with a threshold of 6° (AUC = 0.77, p = 0.038). FTA was the best predictor of shoulder balance of all tested variables. CONCLUSION: Patients that showed flexibility-tilt agreement, or FTA, had vastly increased odds of medial and lateral shoulder balance at a minimum of 2-year follow-up for all thoracic curves. Future studies can evaluate whether applying FTA to determine intra-operative corrective maneuvers prospectively leads to improvements in shoulder balance. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Growth modulation response in vertebral body tethering depends primarily on magnitude of concave vertebral body growth.

PURPOSE: There is variability in clinical outcomes with vertebral body tethering (VBT) partly due to a limited understanding of the growth modulation (GM) response. We used the largest sample of patients with 3D spine reconstructions to characterize the vertebra and disc morphologic changes that accompany growth modulation during the first two years following VBT. METHODS: A multicenter registry was used to identify idiopathic scoliosis patients who underwent VBT with 2 years of follow-up. Calibrated biplanar X-rays obtained at longitudinal timepoints underwent 3D reconstruction to obtain precision morphological measurements. GM was defined as change in instrumented coronal angulation from post-op to 2-years. RESULTS: Fifty patients (mean age: 12.5 ± 1.3yrs) were analyzed over a mean of 27.7 months. GM was positively correlated with concave vertebra height growth (r = 0.57, p < 0.001), 3D spine length growth (r = 0.36, p = 0.008), and decreased convex disc height (r = - 0.42, p = 0.002). High modulators (patients experiencing GM > 10°) experienced an additional 1.6 mm (229% increase) of mean concave vertebra growth during study period compared to the Poor Modulators (GM < - 10°) group, (2.3 vs. 0.7 mm, p = 0.039), while convex vertebra height growth was similar (1.3 vs. 1.4 mm, p = 0.91). CONCLUSION: When successful, VBT enables asymmetric vertebra body growth, leading to continued postoperative coronal angulation correction (GM). A strong GM response is correlated with concave vertebral body height growth and overall instrumented spine growth. A poor GM response is associated with an increase in convex disc height (suspected tether rupture). Future studies will investigate the patient and technique-specific factors that influence increased growth remodeling.

Analysis of three-dimensional spine growth for vertebral body tethering patients at 2 and 5 years post operatively.

PURPOSE: Scoliosis can be treated with vertebral body tethering (VBT) as a motion-sparing procedure. However, the knowledge of how growth is affected by a tether spanning multiple levels is unclear in the literature. Three-dimensional true spine length (3D-TSL) is a validated assessment technique that accounts for the shape of the spine in both the coronal and sagittal planes. This study aimed to assess if 3D-TSL increases over a five-year period after VBT implantation in thoracic curves for idiopathic scoliosis. METHODS: Prospectively collected radiographic data from an international pediatric spine registry was analyzed. Complete radiographic data over three visits (post-operative, 2 years, and 5 years) was available for 53 patients who underwent VBT. RESULTS: The mean age at instrumentation of this cohort was 12.2 (9-15) years. The average number of vertebrae instrumented was 7.3 (SD 0.7). Maximum Cobb angles were 50° pre-op, which improved to 26° post-op (p < 0.001) and was maintained at 5 years (30°; p = 0.543). Instrumented Cobb angle was 22° at 5 years (p < 0.001 vs 5-year maximum Cobb angle). An accentuation was seen in global kyphosis from 29° pre-operative to 41° at 5 years (p < 0.05). The global spine length (T1-S1 3D-TSL) started at 40.6 cm; measured 42.8 cm at 2 years; and 44.0 cm at the final visit (all p < 0.05). At 5 years, patients reached an average T1-S1 length that is comparable to a normal population at maturity. Immediate mean post-operative instrumented 3D-TSL (top of UIV-top of LIV) was 13.8 cm two-year length was 14.3 cm; and five-year length was 14.6 cm (all p < 0.05). The mean growth of 0.09 cm per instrumented level at 2 years was approximately 50% of normal thoracic growth. Patients who grew more than 0.5 cm at 2 years had a significantly lower BMI (17.0 vs 19.0, p < 0.05) and smaller pre-operative scoliosis (48° vs 53°, p < 0.05). Other subgroup analyses were not significant for age, skeletal maturity, Cobb angles or number of spanned vertebras as contributing factors. CONCLUSIONS: This series demonstrates that 3D-TSL increased significantly over the thoracic instrumented levels after VBT surgery for idiopathic scoliosis. This represented approximately 50% of expected normal thoracic growth over 2 years.

Diet-induced obesity significantly increases the severity of posttraumatic arthritis in mice.

OBJECTIVE: Obesity and joint injury are primary risk factors for osteoarthritis (OA) that involve potential alterations in the biomechanical and inflammatory environments of the joint. Posttraumatic arthritis is a frequent long-term complication of intraarticular fractures. Obesity has been linked to primary OA and may potentially contribute to the development of posttraumatic arthritis by a variety of mechanisms. The objectives of this study were to determine whether diet-induced obesity influences the severity of posttraumatic arthritis in mice and to examine the interrelationships between joint degeneration and serum levels of the inflammatory cytokines and adipokines that are involved in this response. METHODS: C57BL/6 mice were fed either normal chow (13% fat) or a high-fat diet (60% fat) starting at 4 weeks of age. At 16 weeks of age, half of the mice in each group were subjected to a closed intraarticular fracture of the left knee. At 8 weeks postfracture, knee OA was assessed by cartilage and synovium histology in addition to bone morphology. Serum cytokine concentrations were determined with multiplex assays. RESULTS: Fractured knee joints of mice receiving a high-fat diet showed significantly increased OA degeneration compared with nonfractured contralateral control knees, while fractured knee joints of mice receiving a low-fat diet did not demonstrate significant differences from nonfractured contralateral control knees. A high-fat diet increased serum concentrations of interleukin-12p70 (IL-12p70), IL-6, and keratinocyte-derived chemokine while decreasing adiponectin concentrations. Joint injury also increased IL-12p70 concentrations in mice receiving a high-fat diet. Systemic levels of adiponectin were inversely correlated with synovial inflammation in control limbs. CONCLUSION: Diet-induced obesity significantly increased the severity of OA following intraarticular fracture. Obesity and joint injury together can alter systemic levels of inflammatory cytokines such as IL-12p70.

Autologous blood use for free flap breast reconstruction: a comparative evaluation of a preoperative blood donation program.

BACKGROUND: New insights into potential adverse effects of banked blood and improved infectious surveillance have led to questions regarding the utility of preoperative autologous blood donation. METHODS: A retrospective chart review of 153 patients undergoing abdominal free flap breast reconstruction was performed with the goal of determining the effect of an autologous blood donation program on clinical outcomes. Demographic and premorbid conditions were evaluated along with outcome variables including complication and transfusion rates. RESULTS: As expected, the autologous blood donor group (n = 96) was more likely to receive a blood transfusion of any kind compared with the nondonors (98% vs. 18%, P < 0.0001). Surprisingly, the mean number of allogeneic transfusions was not decreased (0.26 vs. 0.84, P = 0.066). The mean number of complications between groups were comparable (0.53 vs. 0.57, P = 0.687). CONCLUSION: We found neither significant benefit nor adverse effect from the practice of autologous blood banking for free flap breast reconstruction. The practice should be considered safe but not routinely recommended for free flap breast surgery.

Reliability of radiographic assessment of growth modulation from anterior vertebral body tethering surgery in pediatric scoliosis.

PURPOSE: To assess the reliability of vertebral height and angular measurements for anterior vertebral body tethering (AVBT). METHODS: Eight observers measured PA radiographs of 15 idiopathic scoliosis patients treated with AVBT, pre-operative and 4-year follow-up. Vertebral wedging, disc wedging, convex vertebral body heights, and concave vertebral body heights of the 3 apical vertebrae were measured. For each observer, there were a total of 90 measurements for vertebral body height and 75 measurements for all wedging types At least 14 days elapsed between first and second round measurements. RESULTS: From the pre-operative to the 4-year follow-up time-point, the total wedging angle over the 3 peri-apical levels fell from 30 ± 7° to 16 ± 6° (p < 0.001) and the difference between the convex and concave vertebral heights decreased from 9 ± 4 to 6 ± 3 mm (p < 0.001). Interobserver agreement for pre-operative vertebral body heights was good [ICC = 0.80; 95% CI (0.74-0.85)]. At 4-year follow-up there was a moderate agreement [ICC = 0.67 (0.59-0.74)]. There was a poor interobserver agreement for pre-operative wedging angle measurements [ICC = 0.41 (0.32-0.52)] and 4-year follow-up [ICC = 0.45 (0.36-0.56)]. The Limits of Agreement with the Mean (LOAM) for pre-op heights was ± 2.4 mm, similar to the follow-up ± 2.6 mm. When raters are averaged in random groups of two the agreement limits decrease to ± 1.8 mm pre-op and ± 1.6 mm at follow-up. Similarly for wedging angles, LOAM values among the 8 observers of ± 4.6° pre-op and ± 4.2° dropped to ± 2.7° for both pre-op and follow-up when random groups of two raters were averaged together. Intraobserver agreement ranged from good to excellent per individual (ICC = 0.84-0.94) for pre-operative vertebral body heights, but this decreased at 4-year follow-up (ICC = 0.52-0.88). Intraobserver agreement was low overall for wedging (pre-operative ICC = 0.41-0.71; 4-year follow-up ICC = 0.41-0.76). CONCLUSION: Based on 8 individual observers, interobserver agreement ranged from good (pre-operative vertebral body heights) to moderate (4-year follow-up vertebral body heights) to poor (all wedging angles). To improve the reliability of the measurement of wedging angles, we recommend averaging the measurements of at least two observers.

Clinical and radiographic outcomes following correction of idiopathic scoliosis in adolescence vs young adulthood.

PURPOSE: The natural history of adolescent idiopathic scoliosis (AIS) has been well documented, but the impact of age at the time of surgical correction is relatively understudied. In this study, we matched patients undergoing surgical correction of adult idiopathic scoliosis (AdIS) with a cohort of AIS patients to compare: (1) coronal and sagittal radiographic correction, (2) operative variables, and (3) postoperative complications. METHODS: A single-institution scoliosis registry was queried for patients undergoing idiopathic scoliosis surgery from 2000-2017. INCLUSION CRITERIA: patients with idiopathic scoliosis, no previous spine surgery, and 2-year follow-up. AdIS patients were matched 1:2 with AIS patients based on Lenke classification and curve characteristics. Independent sample t-test and Chi-square test was used to analyze the data. RESULTS: 31 adults underwent surgical correction of idiopathic scoliosis and were matched with 62 adolescents. Mean age of adults was 26.2 ± 11.05, mean BMI was 25.6 ± 6.0, and 22 (71.0%) were female. Mean age of adolescents was 14.2 ± 1.8, mean BMI was 22.7 ± 5.7, and 41(66.7%) were female. AdIS had significantly less postoperative major Cobb correction (63.9% vs 71.3%, p = 0.006) and final major Cobb correction (60.6% vs 67.9%, p = 0.025). AdIS also had significantly greater postoperative T1PA (11.8 vs 5.8, p = 0.002). AdIS had longer operative times (p = 0.003), higher amounts of pRBCs transfused (p = 0.005), longer LOS (p = 0.016), more ICU requirement (p = 0.013), higher overall complications (p < 0.001), higher rate of pseudarthrosis (p = 0.026), and more neurologic complications (p = 0.013). CONCLUSION: Adult patients undergoing surgical correction of idiopathic scoliosis had significantly worse postoperative coronal and sagittal alignment when compared with adolescent patients. Adult patients also had higher rates of complications, longer operative times, and longer hospital stays. LEVEL OF EVIDENCE: III.

Principles of Amputation Surgery, Prosthetics, and Rehabilitation in Children.

Pediatric patients may benefit from extremity amputations with potential prosthetic fitting when addressing limb deficiencies, trauma, infection, limb ischemia, or other pathologies. The performance of a quality amputation is a fundamental skill to an orthopaedic surgeon, yet avoidance of pitfalls can be elusive in children. The need for surgical precision and sound decision-making is amplified in pediatric amputations, where the skeleton is dynamic and growing, anatomy can be miniscule and (in the case of congenital anomalies) variable. The principles that guide amputation level and technical approach are unique in children. Despite this, descriptions of these procedures as they should be applied to a growing or congenitally deficient skeleton are lacking. Furthermore, surgeons must also understand the unique prosthetic and psychosocial considerations for children. A collaborative approach between the surgeons, rehabilitation physicians, prosthetists, therapists, and families is essential to ensuring optimal results.

Elastic Stable Intramedullary Nailing of Pediatric Tibial Fractures.

BACKGROUND: Most pediatric tibial shaft fractures (75%)1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2. DESCRIPTION: After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied. ALTERNATIVES: Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3. RATIONALE: Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4. External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6. EXPECTED OUTCOMES: Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7. Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2. Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4. In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8. There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10. IMPORTANT TIPS: Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest.

Predicting epiphyseal stability of slipped capital femoral epiphysis with preoperative CT imaging.

BACKGROUND: We analyzed preoperative CT scans of hips with slipped capital femoral epiphysis (SCFE) for characteristics that could be predictive of intraoperative epiphyseal stability and developed a set of imaging criteria for stable and unstable SCFE. We then compared this grading system with the Loder classification. METHODS: We reviewed preoperative CT imaging to develop a SCFE stability classification system. Three orthopaedic surgeons used the classification system to grade stability on a series of SCFE hips. Kappa was used to evaluate intra- and interobserver reliability among the observers. A series of SCFE hips treated with open procedures in which intraoperative stability was determined under direct visualization was evaluated. Intraoperative stability was compared with stability ratings as determined by the CT classification system and the Loder classification system. RESULTS: Interobserver reliability among our three observers was κ = 0.823 (95% confidence interval (CI) 0.414 to 1.0; p < 0.001). Intraobserver reliability was κ = 0.901 (95% CI 0.492 to 1.31; p < 0.001). In all, 27 hips were used in the comparison of intraoperative stability with the Loder and CT classification systems. CT-predicted stability exhibited 78% concordance with intraoperative stability. The sensitivity and specificity of CT-predicted stability was 75% and 82%, respectively, versus Loder sensitivity of 69% and specificity of 91%. CONCLUSION: The CT evaluation method provided is easy to use and can help to improve the accuracy in determining preoperative epiphyseal stability, which may lead to improved treatment outcomes for this population. LEVEL OF EVIDENCE: III.