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

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

Temporary Flexible Rods for Correction of Severe Pediatric Spinal Deformity.

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

Mindset correlates with health-related quality of life assessment in patients with adolescent idiopathic scoliosis.

PURPOSE: Mindset theory describes two different belief systems regarding ability: "fixed", in which a particular personal characteristic is seen as unchangeable, and "growth", in which the characteristic is viewed as malleable and subject to improvement. The purpose of this study is to evaluate how that mindset toward one's health correlates with health-related quality of life assessments (HRQoL) in patients with adolescent idiopathic scoliosis (AIS). METHODS: Patients undergoing brace treatment for AIS were prospectively recruited for this study and completed both an SRS-30 and Health Mindset Scale questionnaire. Inclusion criteria for patients are based on Scoliosis Research Society standardized criteria for bracing studies: diagnosis of AIS, a prescribed TLSO brace for full-time wear, skeletal immaturity at brace initiation (Risser 0-2), Cobb angles 25-50 degrees, no prior treatment, and, if female, no more than 1 year post-menarchal at the time of brace initiation. Statistical analysis was performed utilizing Mann-Whitney U tests for skewed data and two-sample t tests for normally distributed data. Multivariable models were also used to evaluate the relationships of SRS-30 subscores with health mindset, adjusting for age, gender, and pre-treatment curve magnitudes. RESULTS: Among the 110 enrolled patients, a stronger growth mindset was associated with significantly higher SRS-30 scores overall (p = 0.001), as well as in the appearance (p = 0.003), and mental (p = 0.001) subscores. CONCLUSION: We demonstrate that health mindset affects an AIS patients' HRQoL. Prior studies have demonstrated that mindset is malleable and can be altered. Further studies are required to determine whether changing health mindset from a fixed to a growth mindset can also improve HRQoL in patients with scoliosis.

Day of the Week of Surgery Affects Time to Discharge for Patients With Adolescent Idiopathic Scoliosis.

Unnecessary delays in discharge are extraordinarily common in the current US health care system. These delays are even more protracted for patients undergoing orthopedic procedures. A traditional hospital staffing model is heavily weighted toward increased resources on weekdays and minimal coverage on the weekend. This study examined the effect of this traditional staffing model on time to discharge for patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Patients undergoing surgery later in the week had a significantly longer hospital stay compared with patients undergoing surgery early in the week (5.5 days vs 4.9 days, respectively; P=.003). This discrepancy resulted in a mean cost increase of $7749.50 for patients undergoing surgery later in the week. A subsequent quality, safety, value initiative (QSVI) was undertaken to balance physical therapy resources alone. Following the QSVI, patients undergoing surgery later in the week had a decreased mean length of stay of 3.78 days (P=.002). Patients undergoing fusion early in the week also had a decreased mean length of stay of 3.66 days (P<.001). There was no longer a significant difference in length of stay between the "early" and the "late" groups (P=.84). This study demonstrates that simply having surgery later in the week in a hospital with a traditional staffing model adversely affects the timing of discharge, resulting in a significantly longer and more costly hospital course. By increasing physical therapy availability on the weekend, the length of stay and the cost of hospitalization decrease precipitously for these patients. [Orthopedics. 2020; 43(1);8-12.].

Team Approach: Complex Regional Pain Syndrome in Children and Adolescents.

Children and adolescents with chronic pain are best managed by an interdisciplinary team. In cases of complex regional pain syndrome (CRPS), the interdisciplinary team consists of a pain management specialist, such as an anesthesiologist or physiatrist, a physical therapist, an occupational therapist, a pain psychologist, and an orthopaedist. It may also include other professions, such as a gastroenterologist, psychiatrist, nurse practitioner, nutritionist, endocrinologist, acupuncturist, or social worker. Key factors include rapid recognition of CRPS and the initiation of appropriate treatment, both for the pain syndrome as well as for the orthopaedic injury. Intensive therapies have been shown to be effective in treating CRPS in children. Children often are more responsive to noninvasive treatments than adults.

Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes?

OBJECTIVE: To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours. DESIGN: Retrospective. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included. INTERVENTION: Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays). MAIN OUTCOME MEASURES: Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records. RESULTS: There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59. CONCLUSIONS: There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Local versus distal transplantation of human neural stem cells following chronic spinal cord injury.

BACKGROUND CONTEXT: Previous studies have demonstrated functional recovery of rats with spinal cord contusions after transplantation of neural stem cells adjacent to the site of acute injury. PURPOSE: The purpose of the study was to determine if the local or distal injection of neural stem cells can cause functional difference in recovery after chronic spinal cord injury. STUDY DESIGN/SETTING: Twenty-four adult female Long-Evans hooded rats were randomized into four groups, with six animals in each group: two experimental and two control groups. Functional assessment was measured after injury and then weekly for 6 weeks using the Basso, Beattie, and Bresnahan locomotor rating score. Data were analyzed using two-sample t test and linear mixed-effects model analysis. METHODS: Posterior exposure and laminectomy at the T10 level was used. Moderate spinal cord contusion was induced by the Multicenter Animal Spinal Cord Injury Study Impactor with 10-g weight dropped from a height of 25 mm. Experimental subjects received either a subdural injection of human neural stem cells (hNSCs) locally at the injury site or intrathecal injection of hNSCs through a separate distal laminotomy 4 weeks after injury. Controls received control media injection either locally or distally. RESULTS: A statistically significant functional improvement in subjects that received hNSCs injected distally to the site of injury was observed when compared with the control (p=.042). The difference between subjects that received hNSCs locally and the control did not reach statistical significance (p=.085). CONCLUSIONS: The transplantation of hNSCs into the contused spinal cord of a rat led to significant functional recovery of the spinal cord when injected distally but not locally to the site of chronic spinal cord injury.