The Use of Biomarkers in the Early Diagnosis of Septic Arthritis and Osteomyelitis-A Pilot Study.

BACKGROUND: The diagnosis of septic arthritis (SA) and osteomyelitis (OM) has remained challenging in the pediatric population, often accompanied by delays and requiring invasive interventions. The purpose of this pilot study is to identify a novel panel of biomarkers and cytokines that can accurately differentiate SA and OM at initial presentation using serum alone. METHODS: Twenty patients below 18 years old whose working diagnosis included SA (n=10) and OM (n=10) were identified. Serum was collected at initial evaluation. Each sample underwent seven ELISA [C1-C2, COMP, CS-846, hyaluronan, procalcitonin, PIIANP, C-terminal telopeptide of type II collagen (CTX-II)] and 65-plex cytokine panels. Principal component and Lasso regression analysis were performed to identify a limited set of predictive biomarkers. RESULTS: Mean age was 4.7 and 9.5 years in SA and OM patients, respectively (P=0.029). 50% of SA patients presented within 24 hours of symptom onset, compared with 0% of OM patients (P=0.033). 30% of SA patients were discharged home with an incorrect diagnosis and re-presented to the emergency department days later. At time of presentation: temperature ≥38.5°C was present in 10% of SA and 40% of OM patients (P=0.12), mean erythrocyte sedimentation rate (mm/h) was 51.6 in SA and 44.9 in OM patients (P=0.63), mean C-reactive protein (mg/dL) was 55.8 in SA and 71.8 in OM patients (P=0.53), and mean white blood cells (K/mm3) was 12.5 in SA and 10.4 in OM patients (P=0.34). 90% of SA patients presented with ≤2 of the Kocher criteria. 100% of SA and 40% of OM patients underwent surgery. 70% of SA cultures were culture negative, 10% MSSA, 10% Kingella, and 10% Strep pyogenes. 40% of OM cultures were culture negative, 50% MSSA, and 10% MRSA. Four biomarkers [CTx-II, transforming growth factor alpha (TGF-α), monocyte chemoattractant protein 1 (MCP-1), B cell-attracting chemokine 1] were identified that were able to classify and differentiate 18 of the 20 SA and OM cases correctly, with 90% sensitivity and 80% specificity. CONCLUSIONS: This pilot study identifies a panel of biomarkers that can differentiate between SA and OM at initial presentation using serum alone. LEVEL OF EVIDENCE: Level II-diagnostic study.

Analysis of 280 Magnetically Controlled Growing Rod Lengthenings Comparing External Remote Control Readouts and Radiographic Measurements: Impact of Patient and Deformity Factors.

BACKGROUND: This study aimed to assess the accuracy of the external remote control (ERC) digital readout to the radiographic measurement of magnetically controlled growing rod (MCGR) actuators undergoing lengthenings/expansions and to analyze the impact of patient and spinal deformity factors on the accuracy of the ERC digital readout. METHODS: Single-surgeon database at 2 tertiary-care pediatric hospitals identified early-onset scoliosis patients with MCGR constructs. There were 14 males and 16 females with a minimum of 2 lengthenings included in the analysis. ERC readouts at each lengthening were recorded. RESULTS: Sixty-six MCGR actuators were assessed in 30 patients which underwent 280 lengthenings (mean of 5.7 lengthenings). At individual lengthening sessions the ERC and radiographic measurements were correlated (r = 0.69, P<0.001). The summed radiographic measurements averaged 15% less than the summed ERC readouts (SD = 19%). The difference between the sum of radiographic measurements and ERCs was positively correlated with subsequent lengthenings (r = 0.94, P = 0.015). The accuracy of the ERC did not improve with increased grouped sessions (r = -0.54, P = 0.388) with no difference between the group with 2 and the group with ≥5 lengthenings (P = 0.670). In patients with dual rods, the difference was correlated between rods (r = 0.66, P<0.001) and the distraction of each rod was not significantly different from the other (P = 0.124). Patient weight correlated with the difference between the radiographs and ERC readouts (r = 0.27, P = 0.032). In patients with multiple grouped lengthenings, increased weight was positively correlated with an increase in measurement difference (mean r = 0.972). CONCLUSIONS: Summed radiographic measurements during lengthening sessions averaged 15% less than the summed ERC readouts. The accuracy of radiographic measurements did not increase when sessions were grouped together (2 vs. ≥5). There was no difference in the ERC accuracy over lengthening sessions early versus late. Patient weight, but not body mass index, was positively correlated with the discrepancy between the ERC and radiographic measures. LEVEL OF EVIDENCE: Level III.

Pilot Study Analysis of Serum Cytokines to Differentiate Pediatric Septic Arthritis and Transient Synovitis.

BACKGROUND: In pediatric patients, the presentation of the nontraumatic acutely painful joint/limb poses a diagnostic dilemma due to the similarity of presentations of the most likely diagnoses [septic arthritis (SA), transient synovitis (TS), osteomyelitis]. Current tools employed to differentiate these diagnoses rely on nonspecific inflammatory markers, radiologic imaging, and arthrocentesis. Diagnostic algorithms utilizing these clinical, radiographic, and biochemical parameters have produced conflicting results. The purpose of this study was to identify a serum-based inflammatory signature which can differentiate SA from TS in pediatric patients. METHODS: Serum samples were collected from 22 pediatric patients presenting with joint/extremity pain whose working diagnosis included SA or TS. Each sample was analyzed for serum abundance of 72 distinct biomarkers and cytokines using enzyme linked immunosorbent assay based arrays. Linear discriminant analysis was performed to identify a combinatorial biomarker panel to predict a diagnosis of SA or TS. Efficacy of the biomarker panel was compared with definitive diagnoses as based on laboratory tests, arthrocentesis results, and clinical scenario. RESULTS: At the time of presentation: (1) mean erythrocyte sedimentation rate in the SA group was 56.6 mm/h and 12.4 mm/h in the TS group (P<0.001), (2) mean C-reactive protein was 55.9 mg/dL in the SA group and 13.7 mg/dL in the TS group (P=0.12), and (3) mean white blood cell was 10.9 k/mm3 in the SA group and 11.0 k/mm3 in the TS group (P=0.95). A combined panel of 72 biomarkers was examined using discriminant analysis to identify a limited set of predictors which could accurately predict whether a patient was diagnosed with SA or TS. A diagnostic algorithm consisting of transforming growth factor alpha, interleukin (IL)-7, IL-33, and IL-28A serum concentration correctly classified 20 of the 22 cases with a sensitivity and specificity of 90.9% (95% confidence interval: 73.9%-100.0%). CONCLUSION: This study identifies a novel serum-based 4-cytokine panel that accurately differentiates SA from TS in pediatric patients with joint/limb pain. LEVEL OF EVIDENCE: Level II-diagnostic study.

Characterizing Use of Growth-friendly Implants for Early-onset Scoliosis: A 10-Year Update.

BACKGROUND: Growth-friendly treatment of early-onset scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017. METHODS: We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05. RESULTS: From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years. CONCLUSIONS: From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change. LEVEL OF EVIDENCE: Level II.

Nasal Swab Screening for Staphylococcus aureus in Spinal Deformity Patients Treated With Growing Rods.

BACKGROUND: Surgical-site infections are one of the most concerning complications in patients treated with growing rods (GR). The purpose of this study was to evaluate the use of preoperative screening for Staphylococcus aureus (SA) for all growing spine procedures, and if this would permit alteration of prophylactic antibiotics to cover the identified resistances. METHODS: All patients were identified who had SA screening during the course of GR treatment. In otal, 34 patients [23 neuromuscular (NMS), 4 congenital, 4 idiopathic scoliosis (IS), and 3 syndromic] were identified who had 111 preoperative screenings [79 lengthenings, 23 insertions, 6 revisions, and 3 conversions to posterior spinal fusions (PSF)]. Mean age at GR insertion was 5.5 years (2 to 11 y). RESULTS: There were 11 methicillin-resistant Staphylococcus aureus (MRSA) "+" screenings in 6 patients (5 NMS, 1 IS): 3 in 3 patients before GR insertion and 8 in 3 patients (all 3 were negative at GR insertion screening) at subsequent surgeries. There were 23 methicillin-sensitive Staphylococcus aureus (MSSA) "+" screenings in 12 patients (7 NMS, 2 congenital, 2 IS, 1 syndromic): 2 in 2 patients before GR insertion and 21 in 10 patients at subsequent surgeries (18 lengthenings, 3 revisions). Overall, 13 patients (3 MRSA+10 MSSA) were initially negative but screened positive for the first time at a subsequent surgery (12 lengthenings, 1 GR to PSF). All patients (n=5) with positive screenings before GR insertion were in patients with NMS (3 MRSA, 2 MSSA). On the basis of sensitivities, 9 patients demonstrated SA resistance to cefazolin (8 MRSA and 1 MSSA) and 6 to clindamycin (5 MRSA and 1 MSSA). Hence, if cefazolin was routinely used for all patients 26.5% of patients (9/34) would have been inadequately covered at some point during their GR treatment; clindamycin, 17.7% (6/34). CONCLUSION: The use of SA nasal swab screening in GR patients identified 9 patients (26.5%) whose prophylactic antibiotics (cefazolin) could be altered to permit appropriate SA coverage. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Organ System Anomalies Associated With Congenital Scoliosis: A Retrospective Study of 305 Patients.

DESIGN: Retrospective analyses of congenital scoliosis patients at 2 tertiary care pediatric hospitals. OBJECTIVE: This study objectives were (1) to report the rates of anomalies of 10 organ systems in congenital scoliosis patients and (2) to determine whether the presence of a single organ system anomaly increases the rate of nonspinal organ system defects. SUMMARY OF BACKGROUND DATA: Intraspinal, cardiac, renal, and gastrointestinal anomalies have been reported to occur at higher rates in congenital scoliosis than the normal population. It is unknown whether the presence of 1 organ system defect increases the risk of nonspinal organ system anomalies. METHODS: All patients diagnosed, evaluated in the outpatient setting, with congenital scoliosis who were below 18 years of age at time of presentation with available cardiac echo, renal ultrasound, or magnetic resonance imaging were included in this study. RESULTS: There were 305 patients (161 females, 53%) whose mean age was 7+3 years. In total, 84% of patients were observed to have at least 1 organ defect. Overall, 22% of patients had 1 organ defect, 19% had 2, 18% had 3, and 18% had ≥4 organ defects. There was an average of 2.2 anomalies per patient (range=0 to 8). Intraspinal anomalies were documented in 43% of patients; syrinx occurred most frequently. Urogenital anomalies were documented in 39% of patients; solitary kidney was most prevalent. Cardiac anomalies were documented in 54% of patients; ventricular septal defect was most common. In 12% of patients, the triad of spinal, urogenital, and cardiac defects was observed. Multiple organ systems were found to have significant associations (P<0.05) in anomaly development. CONCLUSIONS: Cardiac anomalies were the most common defect (54%), and occurred at a rate >2 times higher than previously reported. The high rate of intraspinal, cardiac, and urogenital defects makes magnetic resonance imaging, echocardiography, and renal ultrasound a critical part of evaluation for all congenital scoliosis patients. LEVEL OF EVIDENCE: Level II.

Recurrent Patellar Instability: Implications of Preoperative Patellar Crepitation on the Status of the Patellofemoral Articular Cartilage.

BACKGROUND: The purpose of the study was to quantify the frequency, severity, and location of patellofemoral (PF) articular cartilage changes recurrent patellar instability treated surgically in patients with preoperative clinical patellar crepitation. METHODS: A single-surgeon database was queried for all knees with recurrent patellar instability between 3/2000 and 6/2012 (n=214). Only knees which underwent knee arthroscopy during the surgical treatment were included (n=148). PF articular cartilage condition was assessed arthroscopically. RESULTS: There were 148 knees in 130 patients (mean age, 16 y), which met inclusion criteria. There were 93 females and 37 males. Diagnoses were dislocations [122 (82.4%)] and subluxations (26). Preoperatively 28 knees (18.9%) had PF crepitation. Statistical analysis demonstrated preoperative PF crepitation was correlated with medial patellar facet lesions (P=0.0022) and were 3.6 times more likely to have medial patellar facet lesions. Crepitation was correlated with the higher outerbridge (OB) patellar grades (P<0.0001) and larger patellar lesion size (P=0.0021). At arthroscopy 89 knees (60.5%) had patellar articular cartilage damage with a mean OB grade of 1.3 (0 to 4) and mean size of 93.2 mm (0 to 750). The femoral articular cartilage was identified in 29 knees (19.7%) with a mean OB grade of 0.44 (0 to 4). CONCLUSIONS: PF articular damage was present in 63% of knees, which were surgically treated for patellar instability. The patella was involved in 61% (mean, 129 mm) and femoral trochlea in 20% (mean 166 mm) of knees. Knee with preoperative PF crepitation (20% of cohort) more commonly had medial patellar facet lesions with higher OB grades, and larger patellar lesion size than knees without preoperative crepitation. Because of the high frequency of patellar (83%) and femoral (36%) articular damage documented at the time of surgical reconstruction, visualization of the PF joint is recommended when knees have preoperative PF crepitation. LEVEL OF EVIDENCE: Level IV.

A Comparison of SHILLA GROWTH GUIDANCE SYSTEM and Growing Rods in the Treatment of Spinal Deformity in Children Less Than 10 Years of Age.

BACKGROUND: The purpose of this study was to compare the outcomes of the SHILLA GROWTH GUIDANCE SYSTEM and "intermittent distraction growing rod" (IDGR) in the treatment of children (less than 10 y of age) with progressive spinal deformity. This was a multicenter retrospective study of the SHILLA used as an alternative treatment to IDGR to support an HDE submission for Food and Drug Administration approval. METHODS: Inclusion criteria were progressive scoliosis in a patient less than 10 years of age at index procedure. The study population consisted of 19 SHILLA and 6 IDGR patients whose mean age was 6.1 and 5.8 years, respectively. Group demographics were similar between the 2 groups. RESULTS: The initial major curve magnitude was 70.3 degrees for SHILLA and 68.3 degrees for IDGR, which decreased postoperatively to 22.4 degrees (68.1% improvement) and 32.2 degrees (52.9% improvement). During the first 4 years the correction for SHILLA varied from 40.5% to 53.4% and for IDGR from 40.9% to 56.9%. At last follow-up, T1-S1 length was 32.9 cm for SHILLA (4.2 increase from preoperation) and 34.0 cm (5.0 cm increase from preoperation) for IDGR. Average growth per month from T1-S1: SHILLA 0.14 cm, IDGR 0.11 cm. Sagittal T2-T12 preoperatively was 36.3 degrees for SHILLA and 30.0 degrees for IDGR. There were 29 reoperations in 12 of the 19 SHILLA patients (63.2%) and 40 reoperations in all 6 of the IDGR patients (100%) related to the index procedure. CONCLUSIONS: The SHILLA GROWTH GUIDANCE SYSTEM compares favorably with traditional IDGR constructs in terms of correction of the major curve, spinal length and growth, and maintenance of sagittal alignment. The >4-fold decrease in additional surgeries makes the SHILLA an attractive alternative to minimize comorbidities associated with additional surgeries. LEVELS OF EVIDENCE: Level III.

Delayed Wound Dehiscence of Anterior Knee Incisions in Patients Aged 20 Years and Younger: A Comparison of Subcutaneous Skin Closure.

BACKGROUND: Delayed wound dehiscence (DWD) typically occurs 2 to 7 weeks postoperatively and is characterized by wound gapping and drainage at a surgical site which has initial normal wound healing. This wound problem clinically mimics deep surgical site infection and, after eventual skin healing, leaves a cosmetically unattractive widened, atrophic surgical scar. METHODS: A single-center, retrospective analysis was completed of 252 knees, over a 13-year period, in 194 patients (average age, 14.9 y) undergoing patellar realignment surgery. All knees in this study were treated through an anterior midline knee incision from mid-patella to the tibial tubercle. At wound closure either a 2-0 polyglactin 910 (Vicryl) group (V) or polydioxane (PDS) group (P) suture was used for subcutaneous reapproximation and then the skin was closed with a 4-0 subcuticular Poliglecaprone 25 and IRGACARE (Monocryl) suture. Wound complications were recorded and analyzed by subcutaneous suture type, severity, size of involvement, duration, and treatment type. RESULTS: Of the 252 knees, there were 132 knees in the V group and 120 in the P group. A total of 195 surgeries were primary surgeries and 57 knees were through previous surgical scars. Eleven patients had surgeries in which 1 knee was in each study group. Overall there were 6.1% (8/132) of the V group and 1.7% (2/120) of the P group with DWD (P=0.11); hence there was a trend toward more DWD with Vicryl than PDS, but this did not meet statistical significance. Mean time to resolution of wound dehiscence was 26 days for V group and 46 days for the P group. The length of incision was demonstrated to be a statistically significant independent risk factor for the development of DWD, irrespective of suture type. CONCLUSIONS: The frequency of DWD in anterior knee incisions in our study population was 6.1% in the polyglactin 910 (Vicryl) group and 1.7% in the polydioxane (PDS) group. Although this analysis did not achieve statistical significance, a 3.5 times decrease in DWD when PDS was used is considered by the authors to be clinically significant. The authors have definitively switched from Vicryl to PDS for the subcutaneous skin closure at the knee in patients aged 20 years and younger in the push to make wound complications a nonevent. LEVEL OF EVIDENCE: Level IV.

The Classification for Early-onset Scoliosis (C-EOS) Correlates With the Speed of Vertical Expandable Prosthetic Titanium Rib (VEPTR) Proximal Anchor Failure.

BACKGROUND: The Classification for Early-onset Scoliosis (C-EOS) was developed by a consortium of early-onset scoliosis (EOS) surgeons. This study aims to examine if the C-EOS classification correlates with the speed (failure/unit time) of proximal anchor failure in EOS surgery patients. METHODS: A total of 106 EOS patients were retrospectively queried from an EOS database. All patients were treated with vertical expandable prosthetic titanium rib and experienced proximal anchor failure. Patients were classified by the C-EOS, which includes a term for etiology [C: Congenital (54.2%), M: Neuromuscular (32.3%), S: Syndromic (8.3%), I: Idiopathic (5.2%)], major curve angle [1: ≤20 degrees (0%), 2: 21 to 50 degrees (15.6%), 3: 51 to 90 degrees (66.7%), 4: >90 degrees (17.7%)], and kyphosis ["-": ≤20 (13.5%), "N": 21 to 50 (42.7%), "+": >50 (43.8%)]. Outcome was measured by time and number of lengthenings to failure. RESULTS: Analyzing C-EOS classes with >3 subjects, survival analysis demonstrates that the C-EOS discriminates low, medium, and high speed of failure. The low speed of failure group consisted of congenital/51-90/hypokyphosis (C3-) class. The medium-speed group consisted of congenital/51-90/normal and hyperkyphosis (C3N, C3+), and neuromuscular/51-90/hyperkyphosis (M3+) classes. The high-speed group consisted of neuromuscular/51-90/normal kyphosis (M3N), and neuromuscular/>90/normal and hyperkyphosis (M4N, M4+) classes. Significant differences were found in time (P<0.05) and number of expansions (P<0.05) before failure between congenital and neuromuscular classes.As isolated variables, neuromuscular etiology experienced a significantly faster time to failure compared with patients with idiopathic (P<0.001) and congenital (P=0.026) etiology. Patients with a major curve angle >90 degrees demonstrated significantly faster speed of failure compared with patients with major curve angle 21 to 50 degrees (P=0.011). CONCLUSIONS: The ability of the C-EOS to discriminate the speeds of failure of the various classification subgroups supports its validity and demonstrates its potential use in guiding decision making. Further experience with the C-EOS may allow more tailored treatment, and perhaps better outcomes of patients with EOS. LEVEL OF EVIDENCE: Level III.

Pediatric Lawnmower Injuries.

OBJECTIVE: The aim of this study was to evaluate demographics, characteristics, and mechanisms of injuries caused by lawnmowers in children. METHODS: Chart review from 1990 to 2010 at a level I pediatric trauma center identified patients younger than 18 years with lawnmower injuries. Demographics and characteristics of the injuries were analyzed by descriptive statistical analysis. RESULTS: The study identified 88 subjects, with 80% males and 42% of the subjects younger than 5 years. When the lawnmower type was specified, riding lawnmowers caused the majority of injuries (72%). The most common mechanism of injury was related to slipping under lawnmower/being run over (51%). The most common injuries were lacerations (36%), fractures (27%), and amputations (22%); lower extremities were injured more frequently than other body areas (62%). The majority of patients (76%) required hospitalization with a mean length of stay (LOS) of 9.7 days and a mean number of procedures of 4. Complications included 6 infections, 1 tissue necrosis, and 1 death from hemorrhagic shock. Riding-lawnmower injuries were associated with younger children (P < 0.0001). Riding lawnmowers and younger age were associated with longer hospital LOS (P = 0.01, 0.006) and increased number of procedures (P = 0.03, 0.003, respectively). CONCLUSIONS: Lawnmower injuries are still prevalent in children despite national safety recommendations. Injuries seen with riding lawnmowers were associated with younger age, higher number of procedures, longer LOS, and more severe injuries.

Arthroscopic Lateral Retinacular Release in Adolescents With Medial Patellofemoral Ligament-centered Knee Pain.

BACKGROUND: The medial patellofemoral ligament (MPFL) has been implicated as a common pain generator in adolescents with anterior knee pain. The purpose of this study is to report the clinical outcomes of arthroscopic lateral retinacular release (ALRR) for refractory MPFL-centered pain and to identify risk factors for poor outcomes and surgical failures. METHODS: A single-surgeon database was queried to identify all patients undergoing ALRR. Inclusion criteria included minimum 12-month follow-up and ALRR performed for MPFL pain rather than for generalized anterior knee pain or patellar instability. All patients had persistent MPFL-centered pain despite participating in a nonsurgical protocol before surgery. Primary outcomes included International Knee Documentation Committee (IKDC) subjective score and need for further surgery, typically tibial tubercle osteotomy (TTO). RESULTS: Eighty-eight knees in 71 patients [66 female, 5 male; average age, 15.7 y (range, 8.4 to 20.2 y)] were included. Average follow-up was 59 months (range, 12 to 138 mo). Average preoperative IKDC score was 41.9 (range, 18.4 to 67.8), whereas average postoperative IKDC score was 77.8 (range, 11.5 to 98.9; P<0.01). Postoperative IKDC scores were worse in patients with a preoperative sulcus angle of <134 degrees than those with sulcus angle of ≥134 degrees (69.9±22.1 vs. 82.0±12.5, P=0.04). Lower preoperative IKDC score correlated negatively with improvement of IKDC score postoperatively (r=-0.40, P<0.05). Seventeen knees (19.3%) subsequently underwent TTO for persistent symptoms. Patients who ultimately required TTO were younger than patients who did not (14.8±1.5 vs. 15.9±2.1; P=0.04) and had lower mean preoperative Blackburne-Peel ratio (0.95±0.25 vs. 1.11±0.24; P=0.02). CONCLUSIONS: This study demonstrates that patients with refractory MPFL-centered knee pain had significant improvements in clinical outcomes after undergoing ALRR at mean 5 years' follow-up. Poor outcomes and surgical failures were associated with lower preoperative IKDC score, younger age, lower preoperative Blackburne-Peel ratio, and sulcus angle of <134 degrees. Outcomes were not recorded prospectively, but mean IKDC scores <60 months postoperatively were similar to those collected ≥60 months after surgery (80.4 vs. 78.3, P=0.15). LEVEL OF EVIDENCE: Level IV.

A Comparative Analysis of International Knee Documentation Committee Scores for Common Pediatric and Adolescent Knee Injuries.

BACKGROUND: Several different etiologies cause knee pain in the pediatric and adolescent population, including anterior knee/patellofemoral pain, patellar instability, anterior cruciate ligament (ACL) tears, meniscal tears, osteochondritis dissecans (OCD) lesions, and discoid meniscus. The purpose of the current study was to determine the relative morbidity of different causes of knee pain in children and adolescents using the International Knee Documentation Committee (IKDC) score. METHODS: We performed a retrospective review of prospectively collected data of a cohort of pediatric and adolescent patients with knee pain who presented to a single surgeon. Each patient completed an IKDC questionnaire at the time of diagnosis and patients were grouped by diagnosis for analysis. Statistical analysis was performed to compare the IKDC scores of the 7 diagnostic groups, and a P-value <0.05 was considered significant. RESULTS: The IKDC mean score for all 242 patients was 50.3±18.3. The mean IKDC score for patients with isolated meniscal tears was 41.2±16.0, combined ACL and meniscal injuries was 50.2±13.9, and isolated ACL tears was 48.1±14.1. The mean IKDC score for patients with symptomatic discoid meniscus was 46.3±13.2, anterior knee pain/patellofemoral pain was 49.0±17.4, patellar instability was 49.2±22.1, and OCD lesions was 62.2±19.5. CONCLUSIONS: The IKDC scores of most of the diagnostic groups were similar to the overall average score, with the notable exception of patients with OCD lesions exhibiting statistically significant less morbidity reflected by a higher IKDC score. Although symptoms in each individual clinical presentation may vary, knowledge of the relative morbidity of these diagnostic groups is valuable in counseling patients and their families regarding these common pediatric and adolescent sources of knee pain. LEVEL OF EVIDENCE: Level IV.

Radiographic Assessment of Shoulder Position in 619 Idiopathic Scoliosis Patients: Can T1 Tilt Be Used as an Intraoperative Proxy to Determine Postoperative Shoulder Balance?

BACKGROUND: The purpose of this study is to assess radiographic shoulder measures from the preoperative to the postoperative time period, specifically to determine whether T1 tilt could be used as an intraoperative proxy for shoulder balance determination. This study focused on radiographic shoulder measures of 619 adolescent idiopathic scoliosis patients who underwent spinal deformity surgery. METHODS: A prospective, multicenter database of adolescent idiopathic scoliosis was queried to identify all patients who had undergone spinal deformity surgery with >2 years of follow-up postoperatively. Radiographic analysis focused on measures of shoulder balance: T1 tilt, clavicle angle, and radiographic shoulder height. RESULTS: A total of 619 patients were included in this analysis. Mean age at surgery was 14.8 years with 83% female. Mean preoperative curve size was 58.0 degrees. Mean T1 tilt preoperatively was -0.10 degrees and postoperatively 2.42 degrees. Mean clavicle angle preoperatively was -1.39 degrees and postoperatively 0.79 degrees. Mean radiographic shoulder height preoperatively was -7.04 mm and postoperatively 1.63 mm. All 3 radiographic parameters demonstrated reasonable correlation preoperatively and postoperatively to each other. To assess the viability of T1 tilt as an intraoperative proxy for shoulder balance, standardized ratios between the variables were created. Analysis of these ratios demonstrated little or no relationship preoperatively to postoperatively, hence the relationship of T1 tilt to radiographic shoulder height does not remain constant. CONCLUSIONS: Analysis of the relationship of T1 tilt to radiographic shoulder height from preoperative to postoperative did not demonstrate consistency. Lenke 3 and 6 curve patterns demonstrated preoperative to postoperative correlation, both with nonstructural proximal thoracic curves; however, for the remaining curve patterns T1 tilt cannot be used as an intraoperative proxy for shoulder balance. LEVEL OF EVIDENCE: Level IV.

Treatment of femur fractures in young children: a multicenter comparison of flexible intramedullary nails to spica casting in young children aged 2 to 6 years.

BACKGROUND: Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting. METHODS: This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups. RESULTS: Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P<0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P<0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023). CONCLUSIONS: TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN. LEVEL OF EVIDENCE: Level III, this was a retrospective comparative study.

Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children.

BACKGROUND: There exist varying reports in the literature regarding the incidence of compartment syndrome (CS) after intramedullary (IM) fixation of pediatric forearm fractures. A retrospective review of the experience with this treatment modality at our institution was performed to elucidate the rate of postoperative CS and identify risk factors for developing this complication. METHODS: In this retrospective case series, we reviewed the charts of all patients treated operatively for isolated radius and ulnar shaft fractures from 2000 to 2009 at our institution and identified 113 patients who underwent IM fixation of both-bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, 7 grade II fractures, and 1 grade IIIA fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. RESULTS: CS occurred in 3 of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared with none of 74 closed fractures (P=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS postoperatively (168 vs. 77 min, P<0.001). CS occurred within the first 24 postoperative hours in all 3 cases. CONCLUSION: CS was an uncommon complication after IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS; however, 51.4% of these patients required a small open approach to aid reduction and nail passage. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft-tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft-tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.

Breaking the "law of diminishing returns" with novel, staged, unilateral magnetically controlled growing rods to guided growth surgery for severe, progressive infantile scoliosis.

PURPOSE: Infantile scoliosis presents a significant challenge due to high risk of pulmonary complications and morbidity. While dual growing rod constructs are often utilized, they are not always feasible in a young patient with a severe curve. In this study, we present a series of eight patients treated with a unilateral magnetically controlled growing rod (uMCGR) construct later converted to guided growth surgery (GGS). METHODS: A multicenter database was queried for patients with progressive infantile scoliosis treated with uMCGR before later conversion to GGS. A minimum of 2 year follow-up was required for inclusion. Curve magnitude, trunk growth, revisions, and complications were tracked at all time points. RESULTS: Eight patients were included in the study. Mean age at index surgery was 4.1 years, while conversion to GGS occurred at average 7.9 years and final follow-up was at 10.5 years of age. At index procedure, major curve averaged 77.1°, which improved to 45.4°. Major curve increased to 48.4° prior to conversion, then improved to 30.9°. Major curve averaged 36.8° at final follow-up, for a maintained curve correction of 52.3%. T1-12 height and T1-S1 height averaged 15.4 and 21.5 cm at index procedure and increased to 20.6 and 32.7 cm at final follow-up. Nine revisions were performed in 6 patients, and no patient showed evidence of premature fusion. CONCLUSIONS: Treatment of severe progression infantile scoliosis with this staged protocol provided excellent curve correction with continued trunk growth through treatment, without evidence of the "Law of Diminishing Returns".

Intraoperative anaphylaxis secondary to intraosseous gelatin administration.

BACKGROUND: FloSeal and SurgiFlo Hemostatic Matrices are commonly used in surgical procedures to promote coagulation and minimize blood loss. They are composed of bovine and porcine gelatin matrix, respectively, that can be injected into pedicles to stop osseous bleeding during pedicle screw insertion. METHODS: This report details 2 pediatric spinal deformity reconstructive surgery patients who experienced intraoperative cardiovascular events after the intraosseous administration of animal-derived gelatin. RESULTS: Case #1 is an 11-year-old female with adolescent idiopathic scoliosis who was undergoing routine posterior spinal instrumentation and fusion. During placement of the fourth pedicle screw, the patient developed profound hypotension, tachycardia, and elevated airway pressures requiring intravenous epinephrine and phenylephrine for hemodynamic support. Surgery was aborted. Postoperative work-up demonstrated a positive ImmunoCAP study for bovine gelatin. Surgery was repeated 1 week later, without the use of FloSeal, and no episodes of hemodynamic instability. Case #2 was a 9-year-old female with juvenile idiopathic scoliosis who was undergoing a growing spine construct. As in Case #1, SurgiFlo was placed into 2 pedicle tracts after which there was profound hypotension, tachycardia, and elevated airway pressures. Resuscitative efforts included intravenous atropine and epinephrine with resolution. Surgery was aborted. Surgery was repeated 2 weeks later, without the use of SurgiFlo, with no episodes of hemodynamic instability. CONCLUSIONS: Given that the patient's symptoms were classic for anaphylaxis, and that the timing of the anaphylaxis immediately followed the administration of FloSeal and SurgiFlo we believe that FloSeal and SurgiFlo were the causes of the reactions. These are the first known reported cases of intraoperative anaphylaxis associated with FloSeal and SurgiFlo. On the basis of our experience, in order to avoid intraoperative cardiovascular events, we obtain preoperative ImmunoCAP testing and eliciting a thorough preoperative history about bovine-derived and porcine-derived gelatin products.

A treatment algorithm for stable slipped capital femoral epiphysis deformity.

The authors' current experience in the surgical treatment strategy of stable slipped capital femoral epiphysis deformities was reviewed. From this, a treatment algorithm was developed that could be utilized as a guide in the evaluation and treatment of future patients with slipped capital femoral epiphysis. The clinical parameters of patients' histories of symptoms, physical examinations, and radiographic assessments of slip severity were used in formulating the algorithm. The intent was to prepare a comprehensive algorithm providing necessary alternate treatment pathways for the variable slip deformity in accordance with the surgical experience/expertise of the treating surgeon.

Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery.

BACKGROUND: Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in "high risk" patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based "Best Practice" Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. METHODS: An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. RESULTS: Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible. CONCLUSIONS: In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI in high-risk children undergoing spinal fusion. LEVEL OF EVIDENCE: Not applicable.