2015-2021 Industry Payments to Pediatric Orthopaedic Surgeons: Analysis of Trends and Characteristics of Top-earning Surgeons.

BACKGROUND: Analysis of industry payments to pediatric orthopaedic surgeons last occurred in 2017. We investigated payments to pediatric orthopaedic surgeons from 2015 to 2021 to understand surgeon characteristics associated with increased industry payments. METHODS: Open Payments Database datasets from 2015 to 2021 were queried for nonresearch payments to pediatric orthopaedic surgeons. Annual aggregates and subcategories were recorded. For surgeons receiving payments in 2021, the Hirsch index (h-index), gender, and US census division were found using the Scopus database, Open Payments Database, and online hospital profiles, respectively. χ 2 , Fisher exact, Mann-Whitney U , and t tests were used to compare surgeons in the top 25%, 10%, and 5% payment percentiles to the bottom 75%, 90%, and 95%, respectively. RESULTS: Payments rose 125% from 2015 to 2021. Education, royalties, and faculty/speaker increased most, while travel/lodging, honoraria, charitable contributions, and ownership interest decreased. Only royalties increased from 2019 to 2021. In 2021, of 419 pediatric orthopaedic surgeons receiving industry payments, men received greater median aggregate payments than women ($379.03 vs. $186.96, P =0.047). There were no differences in gender proportions between the top 75% and bottom 25% ( P =0.054), top 10% and bottom 90% ( P =0.235), and top 5% and bottom 95% ( P =0.280) earning comparison groups. The h-index was weakly positively correlated with industry payments ( rs =0.203, P <0.001). Mean h-indices in the 75th ( P <0.001, 95% CI: 2.62-7.65), 90th ( P =0.001, 95% CI: 3.28-13.03), and 95th ( P =0.005, 95% CI: 4.25-21.11) percentiles were significantly higher. Proportions of surgeons from the Middle Atlantic and West South Central in the 90th ( P =0.025) and 95th percentiles ( P =0.033), respectively, were significantly lower compared to all other regions. A higher proportion of surgeons from the Pacific were placed in the 90th ( P =0.004) and 95th ( P =0.024) percentiles. CONCLUSIONS: Industry payments to pediatric orthopaedic surgeons rose from 2015 to 2021. Most categories fell from 2019 to 2021, which may be related to the SARS-CoV-19 pandemic. In 2021, though gender was not related to aggregate payment percentile, location in select US census divisions and h-index was. LEVEL OF EVIDENCE: Level II-Retrospective study.

Two AIS Cases, 2 Surgeons, 1 Operating Room, 1 Day: Faster and Safer Than 1 Case in a Day.

BACKGROUND: To lessen surgical times for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion (PSIF), our department developed a quality improvement initiative where 2 AIS cases were completed in 1 day by the same 2 surgeons operating together in 1 operating room (OR). We describe the results of this initiative, comparing operative times and outcomes to cases of these surgeons operating individually. METHODS: From 2017 to 2023, patients aged 10 to 18 years with AIS undergoing PSIF were prospectively enrolled for "Two Spine Tuesday." Patients were matched by age, sex, curve severity, and number of levels fused to historical AIS controls. Outcomes included surgery time, total OR time, estimated blood loss (EBL), volume of cell saver transfused, allogenic blood transfusion, length of stay, 90-day readmissions, Clavien-Dindo-Sink Complication Classification System complication rates, and percentage who achieved the minimal clinically important difference (MCID) for SRS-22. RESULTS: Fifty-five patients composing the 2-spine group (group 2) were compared with 55 historical sex-matched and age-matched controls (group 1). Major coronal curve and average number of levels fused were similar between groups. Overall surgery time (203 vs. 296 min, P<0.001), total OR time (P<0.001), and EBL (400 vs. 550 mL, P<0.001) were lower for group 2. Group 2 had fewer complications [n=17 (31%) vs. n=28 (51%), P=0.03]. CONCLUSIONS: Performing 2 AIS cases in 1 OR by 2 surgeons the same day resulted in shorter surgery times, less total time in the operating room, lower complication rates, and less blood loss compared with single-surgeon matched controls. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young.

BACKGROUND: Firearm injuries are a significant cause of morbidity and mortality for children in the United States. The purpose of this study is to investigate the 22-year experience of pediatric firearm-related musculoskeletal injuries at a major pediatric level 1 hospital and to analyze the risk of adverse outcomes in children under 10 years of age. METHODS: An institutional review board-approved, retrospective cohort analysis was conducted on pediatric firearm-related musculoskeletal injuries at our institution from 1995 to 2017. A total of 189 children aged 0 to 18 years were identified using International Classification of Diseases, 9th Revision/10th Revision codes, focusing on musculoskeletal injuries by firearms. Exclusion criteria were primary treatment at an outside hospital, isolated nonmusculoskeletal injuries (eg, traumatic brain injury), and death before orthopaedic intervention. Two cohorts were included: age below 10 years and age 10 years and above. Primary outcome measure was a serious adverse outcome (death, growth disturbance, amputation, or impairment). Standard statistical analysis was used for demographic data, along with linear mixed models and multivariable logistic regression for adverse outcome. RESULTS: Of the 189 children, 46 (24.3%) were below 10 years of age and 143 (75.7%) were 10 years and above. Fifty-two (27.5%) of the total group had an adverse outcome, with 19 (41.3%) aged below 10 years and 33 (23.1%) aged 10 years and above (P=0.016). Adverse outcomes were 3 deaths, 17 growth disturbances, 7 amputations, and 44 impairments. For those below 10 years of age, rural location (P=0.024), need for surgical treatment (P=0.041), femur injury (P=0.032), peripheral nerve injury (P=0.006), and number of surgeries (P=0.022) were associated with an adverse outcome. CONCLUSIONS: Over one fourth of survivors of musculoskeletal firearm injuries had an adverse outcome. Children 10 years and above represent the majority of firearm injuries in our population; however, when injured, those below 10 years are more likely to have an adverse outcome. LEVEL OF EVIDENCE: Level III.

Pediatric Orthopaedists Are Not Immune: Characterizing Self-reported Burnout Rates Among POSNA Members.

BACKGROUND: There are no published data characterizing burnout rates for pediatric orthopaedic surgeons. The primary purpose of this study was to identify the rates of self-reported personal and team burnout among members of the Pediatric Orthopaedic Society of North America (POSNA). A secondary aim was to determine whether specific demographic variables were more likely to be associated with self-reported burnout. METHODS: During its 2018 annual meeting, the POSNA Wellness Taskforce launched a web-based survey in which members were asked to respond to 2 previously validated questions related to personal and team burnout. The survey was distributed by a closed POSNA membership e-mail list and responses were analyzed anonymously. Descriptive statistics were calculated. Pearson χ testing was used to analyze differences in burnout rates as a function of age and sex. RESULTS: A total of 615 POSNA members completed the survey, a 47% response rate. Overall, 38% reported personal burnout and 46% reported team burnout. Women were more likely to report both personal (P<0.001) and team burnouts (P<0.005). Members aged 40 to 59 years were more likely to report personal burnout, irrespective of sex (P<0.001). Members aged 50 to 59 years were more likely than those in other age groups to report team burnout (P<0.001). There was no significant association found between the presence of burnout and either race, ethnicity, LGBTQ status, or educational background. CONCLUSIONS: As a group, pediatric orthopaedists report moderately high rates of both personal and team member burnout. Individual-specific factors such as age and sex may play an important role in determining one's risk for experiencing burnout. Recognizing that burnout affects a significant minority of POSNA members is a crucial first step. LEVEL OF EVIDENCE: Level III.

Why Irrigate for the Same Contamination Rate: Wound Contamination in Pediatric Spinal Surgery Using Betadine Versus Saline.

BACKGROUND: The risk of surgical site infection in pediatric posterior spine fusion (PSF) is up to 4.3% in idiopathic populations and 24% in patients with neuromuscular disease. Twenty-three percent of pediatric PSF tissue cultures are positive before closure, with a higher rate in neuromuscular patients. Our primary aim was to evaluate the feasibility of a complete randomized controlled trial to study the efficacy of surgical site irrigation with povidone-iodine (PVP-I) compared with sterile saline (SS) to reduce the bacterial contamination rate before closure in children undergoing PSF. METHODS: One hundred seventy-five subjects undergoing PSF were enrolled in a multicenter, single-blind, pilot randomized controlled trial. We recruited patients at low-risk (LR) and high-risk (HR) for infection 3:1, respectively. Before closure, a wound culture was collected. Nonviable tissues were debrided and the wound was soaked with 0.35% PVP-I or SS for 3 minutes. The wound was then irrigated with 2 L of saline and a second sample was collected. RESULTS: One hundred fifty-three subjects completed the protocol. Seventy-seven subjects were allocated to PVP-I (18 HR, 59 LR) and 76 to SS (19 HR, 57 LR). Cultures were positive in 18% (14/77) of PVP-I samples (2 HR, 12 LR) and in 17% (13/76) of SS samples (3 HR, 10 LR) preirrigation and in 16% (12/77) of PVP-I samples (5 HR, 7 LR) and in 18% (14/76) of SS samples (4 HR, 10 LR) postirrigation. Eight percent (3/37) HR subjects (1 PVP-I, 2 SS) experienced infection at 30 days postoperative. No LR subjects experienced infection. CONCLUSIONS: Positive cultures were similar across treatment and risk groups. The bacterial contamination of wounds before closure remains high regardless of irrigation type. A complete randomized controlled trial would be challenging to adequately power given the similarity of tissue positivity across groups. LEVEL OF EVIDENCE: Level II-pilot randomized controlled trial.

The Pediatric Orthopaedic Society of North America (POSNA) Adopts a Member Health and Wellness Charter.

The Pediatric Orthopaedic Society of North America took actions to address the well-being of its members. The epidemic of physician burnout interferes with the delivery of high-quality care that our patients and families need and deserve, and at the same time places the care-providers at an increased risk of depression and suicide. The actions taken by Pediatric Orthopaedic Society of North America serve as a model for other professional medical societies to emulate.

Growth-Friendly Spine Surgery in Escobar Syndrome.

BACKGROUND: The aims of this study were to characterize the spinal deformity of patients with Escobar syndrome, describe results of growth-friendly treatments, and compare these results with those of an idiopathic early-onset scoliosis (EOS) cohort to determine whether the axial stiffness in Escobar syndrome limited correction. METHODS: We used 2 multicenter databases to review the records of 8 patients with EOS associated with Escobar syndrome who had at least 2-year follow-up after initiation of growth-friendly treatment from 1990 to 2016. An idiopathic EOS cohort of 16 patients matched for age at surgery (±1 y), postoperative follow-up (±1 y), and initial curve magnitude (±10 degrees) was identified. A randomized 1:2 matching algorithm was applied (α=0.05). RESULTS: In the Escobar group, spinal deformity involved 7 to 13 vertebrae and ranged from no vertebral anomalies in 3 patients to multiple segmentation defects in 6 patients. Mean age at first surgery was 5 years (range, 1.4 to 7.8 y) with a mean follow-up of 7.5 years (range, 4.0 to 10 y). Mean major curve improved from 76 degrees at initial presentation, to 43 degrees at first instrumentation, to 37 degrees at final follow-up (both P<0.001). Mean pelvic obliquity improved from 16 degrees (range, 5 to 31 degrees) preoperatively to 4 degrees (range, 0 to 8 degrees) at final follow-up (P=0.005). There were no differences in the mean percentage of major curve correction between the idiopathic EOS and Escobar groups at the immediate postoperative visit (P=0.743) or final follow-up (P=0.511). There were no differences between the cohorts in T1-S1 height at initial presentation (P=0.129) or in growth per month (P=0.211). CONCLUSIONS: Multiple congenital fusions and spinal curve deformity are common in Escobar syndrome. Despite large areas of congenital fusion, growth-friendly constructs facilitate spinal growth and improve curve correction. These results are comparable to those in idiopathic EOS. LEVEL OF EVIDENCE: Level III-case-control study.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures.

BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (ß=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.

Current Issues Affecting the Practice of Pediatric Orthopaedic Surgeons: Results of the 2014 Workforce Survey of American Academy of Pediatrics Section on Orthopaedics.

INTRODUCTION: The opinions of the pediatric orthopaedic workforce are shaped by market forces, regulatory processes, and local experience. The purpose of this report is to summarize the findings of the recent Workforce Survey of the American Academy of Pediatrics (AAP) Section on Orthopaedics (SOOr). This submission has been reviewed and approved by the Board of Directors of the Pediatric Orthopaedic Society of North America (POSNA). METHODS: In 2014, the AAP generated a survey to assess perceptions of pediatric orthopaedic surgeons about current issues that affect practice. The survey was sent to 856 POSNA and 141 AAP-SOOr members. Responses were topically organized to report current workforce composition, practice patterns, and perceptions about electronic medical records (EMRs). RESULTS: Responses were collected from August to December, 2014, from 496 (50%) survey recipients including 83 of 141 (59%) AAP-SOOr members and 413 of 856 (48%) POSNA members. Analyses were restricted to the 397 respondents who reported that they are currently practicing pediatric orthopaedics. Nearly all of these (390/391, 100%) indicated that they provide direct patient care and work an average of 60 hours per week. Many (105/378, 28%) indicated that they would soon limit their practice or retire. A majority (299/394, 76%) indicated that they face competition in their geographic area, predominantly due to pediatric orthopaedic subspecialists (269/299, 90%). Major business changes had recently occurred or were anticipated by 21% of participants. Respondents reported that use of EMR makes them less efficient (252/397, 63%) and interferes with the patient-physician relationship (172/397, 43%). DISCUSSION: This workforce survey suggests that pediatric orthopaedic surgeons are concerned with challenges of competition despite concurrent increasing volume and complexity of referrals. External processes such as EMR changes are perceived to negatively impact practice efficiency and satisfaction.

Current State of the Opioid Epidemic as it Pertains to Pediatric Orthopaedics From the Advocacy Committee of the Pediatric Orthopaedic Society of North America.

INTRODUCTION: The opioid epidemic in the United States has reached crisis proportions. Urgent response is needed. Hydrocodone in combination with acetaminophen is the most prescribed drug in the United States. The most common source of opioids available for misuse is the unused portions of postoperative prescriptions. Among high school seniors, 80% of those who reported nonmedical use of prescription opioids previously had legitimate prescriptions but recreationally used leftover doses. Roughly one-quarter of patients do not take any of their postoperatively prescribed opioids and the remainder take one-third to two-thirds of the prescribed doses. METHODS: A summary of the literature is presented beginning from historical perspective to current status and pertinent strategies in dealing with this complicated problem. This review includes data from an electronic survey of the members of the Pediatric Orthopaedic Society of North America (POSNA) with regard to the prescriptions they would provide for 7 treatment scenarios. RESULTS: Strategies for the preoperative, intraoperative, and postoperative phases of management of pain as well as strategies for education, research, and advocacy are presented. The Pediatric Orthopaedic Society of North America survey yielded 264 respondents. The 3 most commonly used opioid medications were hydrocodone, oxycodone, and acetaminophen with codeine, in that order, for most of the scenarios. The time period covered by postoperative prescriptions varied considerably. CONCLUSIONS: The magnitude of this problem is overwhelming. Education of care providers, patients and families, standardization of narcotic prescribing practices which incorporate patient characteristics, and appropriate plans for disposal of unused narcotics are immediate concepts to consider in correcting this problem. Long-term issues to tackle will be changing patient a family expectations, legislation, and obtaining additional resources directed towards this issue.

The POSNA-COUR International Scholar Program. Results of the First 7 Years.

BACKGROUND: The Pediatric Orthopedic Society of North America (POSNA)-Children's Orthopedics in Underserved Regions (COUR) International Scholar Program was initiated in 2007 to provide educational opportunities for emerging leaders who treat children with orthopaedic conditions in resource-challenged environments worldwide. Financial support is available each year for 4 to 6 orthopaedic surgeons to attend either the POSNA Annual Meeting or the International Pediatric Orthopedic Symposium. The scholars are also encouraged to visit selected centers for observerships during their trip. Since 2007 there have been 41 international scholars who have participated in the program. We wished to assess the impact of the program and to obtain feedback to improve the experience for future participants. METHODS: A 23-question web-based survey was created and sent to 38 past scholars from 22 countries who have participated in the program by July 2013. The responses were gathered online and the data were analyzed for the 24 (62%) respondents from 18 countries who completed the survey. RESULTS: Of the respondents, 16/24 (66%) reported that their current practice is comprised of at least 75% pediatrics. Twelve of 24 (52%) were fellowship trained in pediatric orthopaedics, typically outside of North America. All scholars found the meeting they attended to be very useful and have subsequently made changes to their clinical practice. Nineteen of 24 (82%) did a premeeting or postmeeting observership. Twenty-two of 24 (92%) participants have remained in contact with POSNA members they met at the meeting, with 86% of respondents stating that they have subsequently consulted POSNA members on management of patients. Sixty-two percent of the scholars had a POSNA member visit them following the scholarship and 29% have since returned to visit POSNA members for further clinical observerships. Twenty-one of 24 (91%) have had the opportunity to share the knowledge they gained with others in their region through lectures, surgical demonstrations, and/or clinical training. A common response from the scholars was that the scholarship program was a truly transformative life experience that provided them with an opportunity to receive the highest quality of professional education. The main challenges that these scholars report are lack of available fellowship/subspecialty training in their region, patients' inability to pay, and excessive physician workload. All of the respondents expressed interest in arranging a POSNA cosponsored regional meeting. CONCLUSIONS: Since 2007, the POSNA-COUR international scholar program has been a fruitful resource for orthopaedists practicing in resource-challenged environments worldwide. It has provided unique training for the scholars and has further enabled them to teach others in their region. The program has thus far succeeded in fostering lasting relationships that have led to continued educational exchanges. LEVEL OF EVIDENCE: Level IV-case series.

Addressing the Global Disparities in the Delivery of Pediatric Orthopaedic Services: Opportunities for COUR and POSNA.

The burden of musculoskeletal conditions, especially injuries, is increasing in low-income and middle-income countries. Road traffic injuries have become epidemic. There are multiple barriers to accessing surgical services at both the individual (utilization) and the health system (availability) levels, and deficiencies in education and training of health providers. Specialty societies such as the Pediatric Orthopaedic Society of North America (POSNA) have an opportunity to play an important role through teaching and training. The POSNA Children's Orthopedics in Underserved Regions (COUR) committee has supported the Visiting Scholars Program, which invites surgeons from the developing world to attend a scientific meeting and facilitates the scholar's visit to North American pediatric orthopaedic centers. POSNA members have held global educational courses that support an educational exchange between lecturers and attendees. The COUR web site allows for submission of trip reports that document successes and obstacles experienced by members performing overseas clinical care and teaching. The web site also provides educational resources relevant to providing care in these environments. POSNA collaborates with other societies, such as the American Academy of Orthopaedic Surgeons and the Society of Military Orthopaedic Surgeons, to provide education in disaster management. In addition to increasing member involvement, specialty societies have the opportunity for continued data collection from overseas care, application of US registry data to disease processes in the developing world, and further collaboration with one another.

Sitting sagittal balance is different from standing balance in children with scoliosis.

BACKGROUND: Several variables can have effect on sagittal balance. The changes that occur between standing and sitting have been inadequately studied, especially in the, pediatric population. METHODS: Preoperative sagittal radiographs were obtained in both standing and sitting positions for 26 patients with idiopathic scoliosis before spinal fusion and instrumentation. Standard measurements of thoracic kyphosis, lumbar lordosis, sacral slope (SS), pelvic incidence, pelvic tilt, and lumbar intervertebral angles were, recorded. Differences were compared between positions using 2-sided paired t tests. RESULTS: When moving from standing to a seated position, the spine loses 5-degree thoracic kyphosis (P=0.007), 29-degree lumbar lordosis (P<0.0001), and the sacrum rotates 20 degrees (P<0.0001) to a more vertical position. The greatest change in sitting sagittal balance occurs due to increased pelvic tilt with decreased SS. The next greatest change is increased forward flexion of the lowest 2 lumbar vertebrae, 6.5 degrees between L4-L5 (P<0.0001) and 5.9 degrees between L5-S1 (P<0.0001). Flexion occurs throughout the lumbar spine but its magnitude decreases in the more proximal lumbar segments, 1.6 degrees between L1-L2 (P=0.028). The sagittal vertical axis also moves more anterior by 44 mm (P<0.0001). CONCLUSIONS: Sitting significantly straightens the spine with decreases of thoracic kyphosis, lumbar lordosis, and SS. The majority of the changes occur in the lumbar spine and pelvis. As humans spend much of their time sitting, this difference should be considered when spinal instrumentation is performed. These findings may be important to those who only sit, especially when instrumentation is extended to the pelvis. LEVEL OF EVIDENCE: Level II--retrospective prognostic study.

Surgical technique: proximal extension of instrumentation using sublaminar bands for salvage of postoperative proximal junctional failure in pediatric patients.

PURPOSE: Proximal junctional failure is a complication that can occur following posterior spine surgery with instrumentation. The ability to surgically revise this complication is important for the spine surgeon, yet there is little literature on the topic, especially for pediatric patients. METHODS: The technique we describe involves proximal extension of the existing instrumentation using paired levels of sublaminar bands that allows for a smooth transition of forces at the junction of instrumented and non-instrumented regions of the spine. RESULTS: The results of this technique have been promising with a case series demonstrating improved radiographic and clinical outcomes for eight children at a minimum of 1 year follow-up. CONCLUSION: This a reliable, effective, and safe technique for salvage of PJF in children that uses posterior osteotomies and proximal extension of the instrumentation using sublaminar bands, resulting in gradual load sharing correction to restore sagittal balance.

Time-Dependent Bacterial Contamination of a Surgical Suction Tip.

Background: No in vitro surgical study has evaluated the time-dependent contamination of surgical suction tips compared with controls. Our purpose was to determine the difference in suction tip bacterial contamination rates between suction-positive and suction-negative tips. Materials and Methods: A matched-pair analysis of the contamination of surgical suction tips over a six-hour period was performed in two clean operating rooms. One suction tip was connected to standard wall suction (suction-positive group), with a matched control tip not connected to wall suction (suction-negative group). At time zero and then at hourly intervals for six hours, the distal 3 cm of suction tips were removed, placed in nutrient broth for 48 hours, then plate cultured. One hundred tips were collected for each time interval. Results: Eighty-two of 700 (11.7%) suction tips had bacterial contamination. Sixty-three (18.0%) of 350 suction-positive tips were contaminated, with 19 (5.4%) of the 350 suction-negative tips contaminated (χ2 = 26.7, p < 0.001). Suction tip contamination was time-dependent with the first significant difference between groups occurring after two hours of continuous suction (χ2 = 4.0, p = 0.04). Contamination rate in the suction-positive group increased significantly after one hour compared with time-zero controls (χ2 = 7.1, p = 0.008). There was no significant difference in frequency of positive cultures over time in the suction-negative group compared with time-zero controls. Conclusions: This is the first controlled laboratory study suggesting a time-dependent increase in positive suction tip cultures. From our data, operating room staff should have an awareness that suction tips represent a potential source of bacterial concentration. We recommend that when not in use, suction tip valves be closed if this feature is available, that hosing be manipulated to cease suction when not needed, that suckers be disconnected from tubing, or that suckers be exchanged at frequent intervals. Doing so may reduce bacterial contamination on the suction tip.

Transiliac-Shortening Osteotomy to Treat Ischial Pressure Injury due to Fixed Pelvic Obliquity: A Case Report.

CASE: A 17-year-old adolescent boy with Gross Motor Function Classification System 5 cerebral palsy and neuromuscular scoliosis underwent posterior spinal fusion and segmental spinal instrumentation from T3 to the pelvis. He developed a right ischial pressure injury a few months postoperatively, which persisted despite nonoperative measures. He subsequently underwent an ipsilateral transiliac-shortening osteotomy 16 months after spinal surgery to treat his residual pelvic obliquity and the ischial pressure injury, which healed completely. At the 1-year follow-up visit, there were no further signs of pressure injury. CONCLUSION: This case report describes transiliac-shortening osteotomy as a viable treatment option for non-healing ischial pressure injuries secondary to fixed pelvic obliquity.

The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis.

BACKGROUND: Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis. METHODS: This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into "short" (< 6 h) or "long" (≥ 6 h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors. RESULTS: After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100 cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225 cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5 days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003). CONCLUSIONS: Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6 h may have safety and efficacy advantages over longer times. LEVEL OF EVIDENCE: III.

BrAIST-Calc: Prediction of Individualized Benefit From Bracing for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. OBJECTIVE: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. MATERIALS AND METHODS: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration. RESULTS: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. CONCLUSION: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.

Concave rod first vs. convex rod first in AIS instrumentation with differential rod contouring: computer modeling and simulations based on ten AIS surgical cases.

PURPOSE: To assess biomechanical differences between AIS instrumentations using concave vs. convex rod first. METHODS: Instrumentations of ten AIS patients were simulated first with major correction maneuvers using the concave rod then with convex rod. Correction maneuvers were concave/convex rod translation, followed by apical vertebral derotation and then convex/concave rod translation. The concave/convex rods were 5.5/5.5 and 6.0/5.5 mm diameter Co-Cr and contoured to 35°/15°, 55°/15°, 75°/15° and 85°/15°, respectively. RESULTS: Differences in simulated thoracic Cobb angle (MT), thoracic kyphosis (TK) and apical vertebral rotation (AVR) were less than 5° between the two techniques; mean bone-screw force difference was less then 15N (p > 0.1). Increasing differential contouring angle from 35°/15° to 85°/15°, the MT changed from 14 ± 7° to 15 ± 8°, AVR from 12 ± 4° to 6 ± 5°, TK from 23 ± 4° to 42 ± 4°, and bone-screw forces from 159 ± 88N to 329 ± 170N (P < 0.05). Increasing the concave rod diameter from 5.5 to 6 mm, the mean MT correction improvement for both techniques was less than 2°, the AVR correction was improved by 2°, the TK increased by 4° and bone-screw force increased by about 25N (p < 0.05). CONCLUSION: There was no significant difference in deformity corrections and bone-screw forces between the two techniques. Increasing differential contouring angle and rod diameter improved AVR and TK corrections with no significant effect on the MT Cobb angle. Although this study simplified the complexity of a generic surgical technique, the main effects of a limited number of identical steps were replicated for each case in a systematic manner to analyze the main first-order effects.

Biomechanical analysis of rod contouring in posterior spinal instrumentation and fusion for 3D correction of adolescent idiopathic scoliosis.

PURPOSE: To biomechanically evaluate 3D corrective forces and deformity correction attributable to key parameters of rod contouring in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Computerised patient-specific biomechanical models of six AIS cases were used to simulate PSF and evaluate the effects of 5.5-mm cobalt-chrome rod contouring angle (concave-convex angles: 30°-15°, 45°-15° and 60°-15°), length (spanning 4 and 7 vertebrae), and apex location (T7, T9). 3D correction and bone-implant forces were computed and analysed. RESULTS: By increasing the concave rod contour from 30° to 60°, thoracic kyphosis (TK) increased from 18° ± 2° (15°-19°) to 24° ± 2° (22°-26°), apical vertebra rotation (AVR) correction increased from 41% (SD8%) to 66% (SD18%) whilst the main thoracic curve (MT) correction decreased from 68% (SD6%) to 56% (SD8%). With a contouring length of 4 vs. 7 vertebrae, the resulting TK, AVR and MT corrections were 22° ± 1° (19°-26°) vs. 19° ± 10° (15°-22°), 57% (SD18%) vs. 50% (SD26%) and 59% (SD1%) vs. 69% (SD35%), respectively. With the rod contouring apex at T7 (vs. T9), AVR corrections were 69% (SD19%) vs. 44% (SD9%), with no significant difference in TK and MT corrections, and with comparatively 67% of screw pull-out forces. Corrective forces were more evenly shared with fixation on 7 vs. 4 vertebrae. CONCLUSION: Rod contouring of a greater angulation, over a shorter portion of the rod, and more centred at the apex of the main thoracic curve apex improved AVR correction and allowed greater restoration of TK, but resulted in significantly higher screw pull-out forces and came at the expense of less coronal plane correction.