Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND: Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS). METHODS: A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05. RESULTS: A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223). CONCLUSION: Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Coaching and Surgical Performance.

Surgical coaching is a form of mentoring that can improve surgical performance. While professional athletes have coaching their entire career, other professions, such as medicine, law, and education, are expected to manage their own improvement in performance over their careers. Methods of surgical coaching and the pros and cons of coaching to improve surgical performance and improve patient safety will be presented.

Outcomes and Cost of Reduction of Overriding Pediatric Distal Radius Fractures.

BACKGROUND: This study compared radiographic outcomes of pediatric patients undergoing closed reduction of 100% displaced distal radius fractures to a historical, published cohort treated with casting alone. We also examined the expense associated with sedated reduction. METHODS: Single-center, retrospective cohort study examining radiographic outcomes following reduction of 100% translated distal radius fractures in 50 consecutive pediatric patients. Radiographic outcomes were compared with a historical cohort published by Crawford and colleagues. Charges associated with emergency department (ED) and clinic visits were compared between the reduction cohort and a comparison cohort of 13 patients with fractures not requiring reduction. RESULTS: Forty-nine children (mean age 4.7 y) were included in this study. Duration of casting averaged 51 days and ED visit duration was 6.6±2.5 hours. Mean sagittal and coronal angulation at time of injury were 16.4 and 15.6 degrees, respectively, and were 13.2 and 9.4 degrees at the time of final follow-up. All fractures achieved radiographic union. Eighteen patients underwent a total of 21 unexpected cast changes. No patients required repeat sedation or surgical management.Angulation after casting was significantly better in the reduction cohort compared with the casting-only cohort initially, however, at final follow-up, both coronal and sagittal angulation were significantly worse in the reduction cohort compared with the casting-only cohort (coronal angulation 8.59 vs. 0.75, P<0.0001; sagittal angulation 13.49 vs. 2.2, P<0.0001).Charge analysis compared 46 patients in the reduction cohort to 13 patients with unreduced fractures from the same institution during the same time period. Mean clinic charges were similar ($1957 vs. $2240, P=0.3008). ED charges were higher in the reduction cohort compared with the nonreduction cohort ($7331 vs. $3501, P<0.001), resulting in higher total charges in the reduction cohort ($9245.04 vs. $5740.99, P<0.001). CONCLUSIONS: While closed reduction of 100% translated distal radius fractures in the pediatric population improves angulation initially, casting alone may provide similar or better radiographic outcomes, expedited care, reduced patient exposure to the risks of procedural sedation, and avoidance of ED charges associated with procedural sedation. LEVEL OF EVIDENCE: Level III-therapeutic.

When Will You Succeed Casting Patients With Early-onset Scoliosis? Prospective Evaluation of Predictive Radiographic Parameters.

BACKGROUND: In a recent retrospective study, in cast correction of the major curve correlated with final curve size in patients with early-onset scoliosis treated with casting. We therefore sought to perform a prospective study with controlled methodology to determine if there are parameters associated with reduction of coronal deformity. METHODS: A prospective, observational study was conducted between 2014 and 2019 at selected sites willing to comply with a standard radiographic and follow-up protocol. Radiographic data was collected at time points of precast, in traction, initial in-cast, and at minimum 1 year follow-up. Multivariate linear regression models were utilized to control for potential confounders using a stepwise procedure. Twenty-nine patients met inclusion criteria. RESULTS: On multivariate analysis, traction major curve (P=0.043) and initial in-cast (P=0.011) major curve Cobb angles were independently associated with final out of cast major curve Cobb angle. The only factor that was independently associated with failure to cure (<15-degree major curve) was traction major curve Cobb angle (P=0.046). A threshold traction major curve Cobb angle of 20 degrees was found to have good accuracy with 81% sensitivity and 73% specificity (receiver operator curve area: 0.869, P<0.001). A traction major curve Cobb angle over 20 degrees would accurately predict failure of casting treatment to cure scoliosis in 79% of cases. A threshold in-cast major curve Cobb angle of 21 degrees was found to have slightly less accuracy than traction with 69% sensitivity, 82% specificity, and 74% accuracy (receiver operator curve area: 0.830, P=0.004). CONCLUSIONS: Radiographic measurements in traction and initially in the cast are predictive of curve size at follow-up for children with early-onset scoliosis treated with casting. The standardization and utility of traction films should be further explored. LEVEL OF EVIDENCE: Level II.

The Song Classification Is Reliable and Guides Prognosis and Treatment for Pediatric Lateral Condyle Fractures: An Independent Validation Study With Treatment Algorithm.

BACKGROUND: Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients. METHODS: A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality. RESULTS: Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%). CONCLUSION: This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes. LEVEL OF EVIDENCE: Level IV.

Financial Analysis of Closed Femur Fractures in 3- to 6-Year-Olds Treated With Immediate Spica Casting Versus Intramedullary Fixation.

BACKGROUND: Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds. METHODS: An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room. RESULTS: A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention. CONCLUSIONS: Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Minimally Displaced Humeral Lateral Condyle Fractures: Immobilize or Operate When Stability Is Unclear?

BACKGROUND: Either casting or in situ fixation (to prevent displacement) are recommended for minimally displaced pediatric lateral condyle fractures of indeterminate stability with ≤2 mm lateral displacement and narrowed fracture extension to the epiphyseal articular cartilage. This study compares casting only, acute prophylactic in situ pinning, and surgery if casting fails due to displacement. METHODS: In total, 738 fractures at a level 1 trauma center between 2008 and 2014 were reviewed. All fractures were assigned a Song classification and Song 2 fractures followed to union were analyzed. Worsening displacement was defined as an increase in Song stage. Patients were grouped per treatment: (1) cast only; (2) in situ pinning; or (3) closed or open reduction percutaneous pinning after displacement during attempted cast treatment. RESULTS: In total, 139 fractures were included and 45 (32%) underwent surgery. Among 114 fractures intended for casting, only 20 (18%) displaced and needed surgery. This implies 82% of fractures prophylactically pinned in situ may have remained stable in a cast. On average, displaced fractures were noted 6.5 (2 to 13) days after presentation and required 1 extra clinic visit and week of immobilization without increased complications. Surgeons chose open reduction percutaneous pinning more often for displaced fractures. CONCLUSIONS: Our data estimate 82% of Song 2 fractures never meaningfully displace in a cast. Meaningful displacements occur in <2 weeks. Benefits of prophylactic pinning include 1 less x-ray and clinic visit in exchange for a clinically insignificant lateral cortex reduction and inherent surgical risks. Compliance, surgical scheduling, and a higher rate of open reduction after displacement should influence early treatment decisions. LEVEL OF EVIDENCE: Level III.

A New Radiographic Classification System for Developmental Hip Dysplasia is Reliable and Predictive of Successful Closed Reduction and Late Pelvic Osteotomy.

BACKGROUND: The Tonnis radiographic classification of developmental dysplasia of the hip (DDH) has been used as a prognostic indicator for patients with walking-age DDH. The International Hip Dysplasia Institute (IHDI) classification, a new radiographic classification system, has been proposed to be more reliable by its creators. We sought to validate its reliability using independent observers, to compare it to the Tonnis method, and to assess its prognostic significance in a large cohort of patients. METHODS: A consecutive series of walking-age DDH patients were examined radiographically and classified by the Tonnis and IHDI schemes by 3 independent observers. Interobserver agreement was determined using the Kappa method. Clinical data were collected on patients with regard to success of closed reduction, need for later pelvic osteotomy, and presence of subsequent radiographic avascular necrosis (AVN). The prognostic value of the Tonnis and IHDI classifications to predict these clinical outcomes was determined. RESULTS: A total of 287 hips were available for analysis of the classification schemes. In total, 235 hips underwent attempted closed reduction and were eligible for analysis of successful closed reduction, and 131 hips had >4-year follow-up and were utilized for analysis of late pelvic osteotomy and AVN. Both classifications showed excellent interobserver reliability and in general, there was nonstatistically significant better reliability for the IHDI versus the Tonnis classification. In multivariate analysis, both IHDI and Tonnis classifications were found to be predictive of successful closed reduction and need for late pelvic osteotomy. Both methods showed trends toward being predictive of AVN rate, without statistical significance. CONCLUSIONS: The IHDI classification is subjectively more facile to use and has excellent interrelater agreement for classifying the radiographic severity of DDH. It is also reliable in predicting success of closed reduction and need for late pelvic osteotomy. SIGNIFICANCE: practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. SIGNIFICANCE: Practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. LEVEL OF EVIDENCE: Level III.

Soft Tissue Injury Severity is Associated With Neurovascular Injury in Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Neurovascular injury in pediatric supracondylar fractures (SCHFx) has been associated with fracture classification but not with soft tissue injury. The purpose of this study is to correlate clinical soft tissue damage to neurovascular injuries in SCHFx. METHODS: This is an institutional review board approved prospective study from January 2010 through December 2013 of 748 operatively treated pediatric SCHFx. Prospective data were gathered both preoperatively and intraoperatively regarding detailed neurovascular examination as well as soft tissue status, with qualitative descriptives for swelling (mild/moderate/severe), ecchymosis, abrasions, skin tenting, and skin puckering. RESULTS: A total of 7.8% of patients (41/526) had a nonpalpable radial pulse preoperatively. Compared with those with a palpable pulse, a nonpalpable pulse was associated with severe elbow swelling (P<0.0001), tenting (P=0.0085), puckering (P=0.0011), ecchymoses (P<0.0001), and open fracture (P=0.044). Ten patients had a loss of a palpable pulse from initial orthopaedic consult to time of surgery, and when compared with the patients who did not have a loss of pulse, this was associated with swelling severity (P=0.0001) and ecchymosis (P=0.053). A total of 14% of patients (71/526) had a neurological injury preoperatively, and this was associated with severe elbow swelling (P<0.0001), tenting (P=0.0008), puckering (P=0.0077), and ecchymoses (P<0.0001) when compared with patients who did not have a neurological injury. In total, 17 patients had a decline in their neurological examination from the time of initial orthopaedic consult to the time of surgery, and this was associated with severe elbow swelling (P=0.0054) and ecchymoses (P=0.011). After multivariate logistic regression analysis, severe swelling and ecchymoses were significantly associated with a nonpalpable pulse as well as neurological injury (P<0.05). No patient had compartment syndrome. CONCLUSIONS: Soft tissue injury, as measured by swelling, ecchymosis, puckering, and tenting, had a clinically significant association with neurovascular compromise in pediatric SCHFx, and assessment of soft tissue injury is as important as the radiographic appearance when examining these patients. The physical examination signs of soft tissue injury may play a factor in determining urgency of surgical treatment in these fractures. LEVEL OF EVIDENCE: Level II-therapeutic.

Complications Associated With Epiphysiodesis for Management of Leg Length Discrepancy.

BACKGROUND: Epiphysiodesis is well-established surgical treatment for the management of leg length discrepancy (LLD) in children; however, a variety of complications may occur. This study evaluates the nature, rate, and potential risk factors of complications associated with epiphysiodesis in a large patient population treated in 1 institution. METHODS: We evaluated the medical and radiographic records of 863 children who had lower extremity epiphysiodesis to manage LLD between 1980 and 2011. RESULTS: Sixty patients (7.0%) incurred complications of some type. Twenty-three patients (2.7%) had perioperative complications unrelated to physeal growth; all resolved without surgical treatment. These included 2 patients with transient intraoperative complications (laryngospasm and allergic rash), 7 with transient neurological symptoms (5 cutaneous nerve dysesthesia or numbness and 2 peroneal nerve neuropathies), and 14 with postoperative knee stiffness which resolved with therapy. Thirty-seven patients (4.3%) developed physeal growth-related complications, including 6 patients who developed overcorrection of leg length inequality (3 had contralateral epiphysiodesis to prevent overcorrection, while 3 declined), and 31 patients who developed angular deformity and/or continued growth of the physis. Of these 31 patients, 15 had reexploration of the epiphysiodesis site, 6 underwent corrective osteotomy, while in 10, no treatment was undertaken. Compared with patients who did not develop angular deformity, these 31 patients had significantly greater LLD (5.6 vs. 3.7 cm, respectively, P<0.01), were younger (10.7 vs. 11.7 in girls; 12.4 vs. 13.5 in boys; P<0.01), and were more likely to have a congenital etiology for their LLD (P<0.01). CONCLUSIONS: Epiphysiodesis is a safe and effective procedure for the correction of leg length inequality. The rate of complications in this study was 7.0%, the most prevalent being the development of angular deformity. Congenital etiology, younger age, and larger limb length inequalities were risk factors for the development of angular deformity. Both surgeons and families should be aware of nature and rate of complications associated with epiphysiodesis. LEVEL OF EVIDENCE: Level IV.

Overhead Bryant's Traction Does Not Improve the Success of Closed Reduction or Limit AVN in Developmental Dysplasia of the Hip.

BACKGROUND: Preoperative Bryant's overhead traction before closed reduction (CR) in developmental dysplasia of the hip (DDH) remains controversial and its success in increasing CR rates and reducing avascular necrosis (AVN) rates has not been specifically reported in a large cohort. METHODS: IRB-approved retrospective study of patients (below 3 y)who were treated with attempted CR for idiopathic DDH from 1980 to 2009. Successful CR was defined as a hip that remained reduced and did not require repeat CR or open reduction. Patients were grouped by age, hip instability [Ortolani positive (reducible) vs. fixed dislocation], and Tonnis classification and rates of successful CR were compared between groups with P<0.05. RESULTS: A total of 342 hips were included with a mean age of 0.9 years (0.2 to 2.8 y) and a mean follow-up of 10.4 years (2.0 to 27.7 y). There were 269 hips with fixed dislocations and 73 Ortolani-positive hips. Traction was used in 276 hips. There was no difference in traction utilization in the 3 age groups (below 1, below 1.5, and below 2 y) for either Ortolani-positive hips (P=0.947) or fixed dislocations (P=0.943). There was no difference in achieving a successful CR comparing traction (60.9%) and no-traction groups (60.6%) (P=1.00). For Ortolani-positive hips, traction did not improve the incidence of a successful CR for any age group: below 1 year: P=0.19; below 1.5 years: P=0.23; and below 2 years: P=0.25. Similarly, fixed dislocation patients had no benefit from traction: below 1 year: P=0.76; below 1.5 years: P=0.82; and below 2 years: P=0.85. Tonnis classification did predict success of CR but had no influence on traction success. There was no difference in the rate of AVN between the traction (18%) and no-traction (8%) groups for all patients (P=0.15). CONCLUSIONS: In this retrospective series, preoperative Bryant's traction does not improve the rate of a successful CR for patients with DDH and has no protective effect on the development of AVN of the femoral head. These results suggest that Bryant's overhead traction may not be warranted for patients below 3 years of age with DDH. LEVEL OF EVIDENCE: Level III.

The Oswestry Disability Index is reflective of pain interference and mobility in children.

PURPOSE: The 9-item Oswestry Disability Index version 2.1a (ODI-9) has never been formally validated in children. Our primary purpose was to evaluate the ODI-9 using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference (PI) and Mobility Computer Adapted Test (CAT) and Pain Catastrophizing Scale for Children (PCS-C) as anchors to determine concurrent validity in children. METHODS: We retrospectively reviewed cross-sectional patient-reported outcomes data using a convenience sample of children referred to a tertiary pediatric orthopedic institution for any spine condition from April 2021 to April 2022. The ODI-9, PI, and Mobility were completed at clinic intake in 2,097 children (1453 girls, 644 boys) aged 14.2 ± 2.6 years (range 5-18 years) during the same visit. The ODI-9 was administered when children or caregivers responded "yes" to the presence of back pain. The PCS-C was administered only when pain intensity was rated as "very severe" or "the worst imaginable" on Item 1 of the ODI-9 (n = 51). RESULTS: Average ODI-9 scores were 18.3% ± 14.8%, indicating minimal disability (ODI-9 ≤ 20%). Moderate, statistically and clinically significant associations were seen between the ODI-9 and PI (r = 0.68, p < 0.001), the ODI-9 and Mobility (r = - 0.68, p < 0.001), and the ODI-9 and PCS-C (r = 0.59, p < 0.001). CONCLUSION: Worse ODI-9 scores correlate with worse PROMIS PI scores, worse PROMIS Mobility scores, and worse PCS-C scores. The associations were moderate (PROMIS PI [r = 0.68], PROMIS Mobility [r = - 0.68], PCS-C [r = 0.59]).

Back pain and disability according to early onset scoliosis etiology in children younger than 10 years.

PURPOSE: To determine caregiver-reported back pain prevalence, disability, pain interference, and associations with curve magnitude in early onset scoliosis (EOS) using the Oswestry Disability Index (ODI) and Patient Reported Outcome Measurement Information Systems (PROMIS) measures. METHODS: A single-center, retrospective review was performed in children below 10 years of age according to EOS etiology. Caregiver-reported back pain prevalence, ODI, PROMIS Pain Interference, Mobility, and Anxiety measures, and curve magnitude were recorded as part of routine clinic appointments. RESULTS: A total of 1212 patients with EOS (588 idiopathic, 295 congenital, 217 neuromuscular, 112 syndromic) ages 6.6 ± 2.7 were included; 23% had caregiver-reported back pain. Neuromuscular EOS patients had the highest prevalence of back pain (29%). ODI scores were higher in neuromuscular (48%) and syndromic (35%) patients than congenital (20%, p < 0.05) and idiopathic (16%, p < 0.01) patients. Neuromuscular patients also had higher PROMIS Pain Interference scores (53.3) compared to idiopathic (41.6, p < 0.001) and syndromic (45.0, p = 0.016) patients. A higher curve was associated with the presence of back pain (39° vs. 30°, p < 0.001) and had positive correlations with ODI scores (r = 0.38, p < 0.001) and PROMIS Pain Interference scores (r = 0.34, p < 0.001). CONCLUSION: Approximately one in five children with EOS under the age of 10 have caregiver-reported back pain, with the neuromuscular EOS type exhibiting higher pain prevalence, interference, and disability scores. Larger curve magnitude is associated with an increased prevalence of caregiver-reported back pain, increased disability, and increased pain interference. LEVEL OF EVIDENCE: 3 - case-control study.

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

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

Angelman and Prader-Willi Syndromes: Sister Imprinting Disorders With High Complication Rates Following Spinal Deformity Surgery.

We sought to examine the modern surgical treatment of spinal deformity associated with sister imprinting disorders, Prader-Willi syndrome (PWS) and Angelman syndrome (AS), with emphasis on the specific complications encountered in these patient populations. Fifteen patients with PWS and 5 patients with AS who underwent surgical intervention for spinal deformity between 2000 and 2018 were identified. Postoperative complications were classified using the modified Clavien-Dindo-Sink (CDS) system and further categorized into specific subtypes including excessive drainage, dehiscence, implant failure, infection, and delayed wound healing. Perioperative and final follow-up radiographic data were analyzed. Mean age at surgery was 12.9 years (range, 4-21 years) with mean follow-up of 46.1 months (range, 1-145 months). There were postoperative complications in 17 patients (85%). Ten major complications (CDS ≥ 3) occurred in 9 patients (45%). These included 5 infections requiring reoperation, 1 seroma requiring drainage, 2 severe cervical-thoracic deformities requiring reoperation, 1 implant failure requiring reoperation, and 1 death secondary to fungal sepsis and thromboembolic disease. Eight additional patients (40%) had minor complications (CDS 1 or 2). Eight intraoperative complications occurred in 5 patients (25%), including loss of neuromonitoring signals and cerebrospinal fluid leaks. Surgical intervention for scoliosis in PWS and AS continues to have high complication rates secondary to medical and behavioral comorbidities found in these patient populations. The exact etiology of the high complication rates encountered cannot be definitively stated, but both syndromes frequently present with a number of unique features that may predispose patients to develop surgical complications. [Orthopedics. 2023;46(4):e223-e229.].

The evolving stall rate of magnetically controlled growing rods beyond 2 years follow-up.

PURPOSE: Magnetically controlled growing rods (MCGR) have become the dominant distraction-based implant for the treatment of early onset scoliosis (EOS). Recent studies, however, have demonstrated rising rates of implant failure beyond short-term follow-up. We sought to evaluate a single-center experience with MCGR for the treatment of EOS to define the rate of MCGR failure to lengthen, termed implant stall, over time. METHODS: A single-center, retrospective review was conducted identifying children with EOS undergoing primary MCGR implantation. The primary endpoint was the occurrence of implant stalling, defined as a failure of the MCGR to lengthen on three consecutive attempted lengthening sessions with minimum of 2 years follow-up. Clinical and radiographic variables were collected and compared between lengthening and stalled MCGRs. A Kaplan-Meier survival analysis was conducted to assess implant stalling over time. RESULTS: A total of 48 children met inclusion criteria (mean age 6.3 ± 1.8 years, 64.6% female). After a mean 56.9 months (range of 27 to 90 months) follow-up, 25 (48%) of children experienced implant stalling at a mean of 26.0 ± 14.1 months post-implantation. Kaplan-Meier survival analysis demonstrated that only 50% of MCGR continue to successfully lengthen at 2 years post-implantation, decreasing to < 20% at 4 years post-implantation. CONCLUSION: Only 50% of MCGR continue to successfully lengthen 2 years post-implantation, dropping dramatically to < 20% at 4 years, adding to the available knowledge regarding the long-term viability and cost-effectiveness of MCGR in the management of EOS. Further research is needed to validate these findings.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients.

Purpose: Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Methods: Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. Results: A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Conclusions: Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Level of evidence: Retrospective level III.

Incidence and Risk Factors for Concurrent Syndromic Diagnosis in Presumed Idiopathic Developmental Dysplasia of the Hip.

BACKGROUND: Infants referred for developmental dysplasia of the hip (DDH) may have a previously unidentified concomitant diagnosis of syndromic pathology. Our purpose was to examine the incidence of syndromic pathology in infants referred to a tertiary center with presumed idiopathic DDH and identify risk factors and difference in treatment courses between idiopathic and nonidiopathic cohorts. METHODS: A retrospective analysis of a prospective cohort of infants younger than 3 years who were evaluated for DDH between 2008 and 2013 with a minimum 2-year follow-up. The clinical history and treatment were noted to determine the incidence and nature of concomitant syndromic diagnoses, after a confirmed diagnosis of DDH. RESULTS: There were 202 patients: 177 were females (87.6%). Thirteen patients (6.4%) were later diagnosed with a neurologic/syndromic diagnosis. The workup leading to additional diagnosis was initiated by the orthopaedic surgeon in 8 of 13 patients (61.5%). Half of the referrals (4 of 8) made to other specialists were because of an abnormal treatment course (three-failure of typical DDH treatment and one-relapsed clubfeet). 7 of the 8 referrals were made because of developmental delays and decreased tone. 5 of the 13 nonidiopathic patients had other orthopaedic problems. The syndromic diagnoses included three cerebral palsy, two Kabuki syndrome, one Down syndrome, one myopathy, and one neuropathy. The diagnosis was made at an average of 2.3 years (0.04 to 4.7). No notable difference was observed in the incidence of the four known risk factors for DDH in syndromic patients compared with the idiopathic group. The syndromic patients required more open reductions (P = 0.002). DISCUSSION: By the age of 3 years, 6% of the patients treated for DDH were found to have a syndrome or neurologic abnormality, and the referral for workup was made by the treating surgeon greater than 60% of the time.

Pain Catastrophizing Influences Preoperative and Postoperative Patient-Reported Outcomes in Adolescent Idiopathic Scoliosis.

BACKGROUND: Patients with adolescent idiopathic scoliosis (AIS) often report chronic back pain; however, there is inadequate research on psychological factors associated with pain in this patient population. Pain catastrophizing, a psychological factor that describes a pattern of negative thoughts and feelings about pain, has been associated with poorer responses to medical treatment for pain. The purpose of this study was to report the prevalence of pain catastrophizing in the AIS population and assess its relationship with preoperative and postoperative self-reported outcomes. METHODS: In this prospective cohort study of consecutive patients undergoing posterior spinal fusion (PSF) for AIS, patients experiencing clinically relevant pain catastrophizing, defined as a Pain Catastrophizing Scale for Children (PCS) score in the 75th percentile or higher, were compared with patients with normal PCS scores. Preoperative and 2-year postoperative Scoliosis Research Society Society Questionnaire-30 (SRS-30) scores were correlated with the preoperative PCS score. RESULTS: One hundred and eighty-nine patients underwent PSF for AIS, and 20 (10.6%) were considered to be experiencing pain catastrophizing. Despite comparable demographic and radiographic variables, pain catastrophizing was associated with significantly lower preoperative scores than were found in the normal-PCS group in all SRS-30 domains, including pain (2.98 versus 3.95; p < 0.001), appearance (2.98 versus 3.48; p < 0.001), activity (3.51 versus 4.06; p < 0.001), mental health (3.12 versus 4.01; p < 0.001), and total score (3.18 versus 3.84; p < 0.001), except satisfaction (3.72 versus 3.69; p > 0.999). At 2 years, the pain catastrophizing group experienced significant improvement from their preoperative scores in most SRS-30 domains, including a large clinically relevant improvement in pain (from 2.98 preoperatively to 3.84 postoperatively; p < 0.001) and the total score (from 3.18 to 3.85; p < 0.001), but continued to have lower scores than the normal-PCS group for pain (3.84 versus 4.22; p = 0.028) and the total score (3.85 versus 4.15; p = 0.038). Receiver operating characteristic (ROC) curve analysis indicated that an SRS-30 pain score of <3.5 has good sensitivity for predicting pain catastrophizing (PCS ≥75th percentile). CONCLUSIONS: In this cohort, patients with AIS who exhibited pain catastrophizing experienced significant improvement in self-reported health 2 years after PSF. However, they did not have the same levels of self-reported health as the normal-PCS group. Pain catastrophizing may be identifiable by lower preoperative SRS-30 pain scores. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.