Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND: Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. METHODS: Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. RESULTS: Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. CONCLUSION: COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. LEVEL OF EVIDENCE: Level III-prognostic study.

Two-Surgeon Multidisciplinary Approach to Pediatric Cervical Spinal Fusion: A Single-Institution Series and Review of the Literature.

BACKGROUND: A collaborative 2-surgeon approach is becoming increasingly popular in surgery but is not widely used for pediatric cervical spine fusions. The goal of this study is to present a large single-institution experience with pediatric cervical spinal fusion using a multidisciplinary 2-surgeon team, including a neurosurgeon and an orthopedic surgeon. This team-based approach has not been previously reported in the pediatric cervical spine literature. METHODS: A single-institution review of pediatric cervical spine instrumentation and fusion performed by a surgical team composed of neurosurgery and orthopedics during 2002-2020 was performed. Demographics, presenting symptoms and indications, surgical characteristics, and outcomes were recorded. Particular focus was given to describe the primary surgical responsibility of the orthopedic surgeon and the neurosurgeon. RESULTS: A total of 112 patients (54% male) with an average age of 12.1 (range 2-26) years met the inclusion criteria. The most common indications for surgery were os odontoideum with instability (n=21) and trauma (n=18). Syndromes were present in 44 (39%) cases. Fifty-five (49%) patients presented with preoperative neurological deficits (26 motor, 12 sensory, and 17 combined deficits). At the time of the last clinical follow-up, 44 (80%) of these patients had stabilization or resolution of their neurological deficit. There was 1 new postoperative neural deficit (1%). The average time between surgery and successful radiologic arthrodesis was 13.2±10.6 mo. A total of 15 (13%) patients experienced complications within 90 days of surgery (2 intraoperative, 6 during admission, and 7 after discharge). CONCLUSIONS: A multidisciplinary 2-surgeon approach to pediatric cervical spine instrumentation and fusion provides a safe treatment option for complex pediatric cervical cases. It is hoped that this study could provide a model for other pediatric spine groups interested in implementing a multi-specialty 2-surgeon team to perform complex pediatric cervical spine fusions. LEVEL OF EVIDENCE: Level IV-case series.

The Reliability of the AO Spine Upper Cervical Classification System in Children: Results of a Multi-Center Study.

BACKGROUND: There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children. METHODS: Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. RESULTS: Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters. CONCLUSION: Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification. LEVEL OF EVIDENCE: Level III.

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA.

BACKGROUND: Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery. METHODS: We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded. RESULTS: Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03). CONCLUSIONS: Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively. LEVEL OF EVIDENCE: Level II-retrospective prognostic study.

Pedicle Screw Placement in Adolescent Idiopathic Scoliosis: A Comparison between Robotics Coupled with Navigation versus the Freehand Technique.

(1) Background: Robotics coupled with navigation (RAN) is a modern surgical platform shown to increase screw placement accuracy during pediatric scoliosis surgery. Our institution uses a technique which combines the RAN platform for apical pedicle screw placement and the freehand (FH) technique for terminal pedicle screw placement during scoliosis surgery (termed hybrid technique). We question if the complementary use of the RAN technology affects intraoperative outcomes, relative to the FH-only approach. (2) Methods: 60 adolescent idiopathic scoliosis (AIS) patients, ages 11−19 at surgery, who were operated on from 2019 through 2020 by a single surgeon, were retrospectively reviewed. Patients were separated by surgery type (hybrid RAN or FH), matched on demographic and surgical factors, and their intraoperative outcomes were compared statistically. (3) Results: Hybrid RAN patients had more screws placed (p = 0.01) and were of a higher BMI percentile (p = 0.005). Controlling for the number of screws placed, BMI%, and initial curve magnitude, there were no statistical differences in estimated blood loss per screw (p = 0.51), curve correction (p = 0.69), complications (p = 0.52), or fluoroscopy time (p = 0.88), between groups. However, operative time was two minutes longer per screw for hybrid RAN patients (p < 0.001). (4) Conclusions: Hybrid RAN surgeries took longer than FH, but yielded comparable effectiveness and safety as the FH technique during the initial RAN adoption phase.

Intraoperative Use of Robotics With Navigation for Pedicle Screw Placement in Treatment of Pediatric High-grade Spondylolisthesis: A Preliminary Report.

BACKGROUND: Accurate pedicle screw placement is critical to surgically correct pediatric high-grade spondylolisthesis (HGS). The recent advent of robotics coupled with computer-assisted navigation (RAN) may represent a novel option to improve surgical outcomes of HGS, secondary to enhanced pedicle screw placement safety. This series presents the HGS-RAN technique adopted by our site, describing its surgical outcomes and feasibility. METHODS: Consecutive patients with a diagnosis of HGS (Meyerding grade III to V), operated on using RAN from 2019 to 2020 at a single-center were reviewed. Demographics, screw accuracy, sagittal L5-S1 parameters, complications, and perioperative outcomes were described. All patients were treated with instrumentation, decompression, posterior lumbar interbody fusion, and reduction. Robotic time included anatomic registration to end of screw placement. Screw accuracy-defined as a screw placed safely within the planned intrapedicular trajectory-was characterized by the Gertzbein-Robbins system for patients with additional 3-dimensional imaging. RESULTS: Ten HGS patients, with an average age of 13.7 years old, were included in the series. All 62 screws were placed without neurological deficit or complication. Seven patients had additional 3-dimensional imaging to assess screw accuracy (42 of 62 screws). One hundred percent of screws were placed safely with no pedicle breaches (Gertzbein-Robbins-grade A). Thirty screws (48%) were placed through separate incisions that were percutaneous/transmuscular and 32 screws (52%) were inserted through the main incision. There were statistically significant improvements in L5 slippage (P=0.002) and lumbosacral angle (P=0.002), reflecting successful HGS correction. The total median operative time was 324 minutes with the robotic usage time consuming a median of 72 minutes. Median estimated blood loss was 150 mL, and length-of-stay was a median 3 days. CONCLUSIONS: This case-series demonstrates that RAN represents a viable option for HGS repair, indicated by high screw placement accuracy, safety, and L5-S1 slippage correction. Surgeons looking to adopt an emerging technique to enhance safety and correction of pediatric HGS should consider the RAN platform. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Operative Treatment of Cervical Spine Injuries Sustained in Youth Sports.

BACKGROUND: Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports. METHODS: Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed. RESULTS: A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities. CONCLUSIONS: The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Variability in Antibiotic Treatment of Pediatric Surgical Site Infection After Spinal Fusion at A Single Institution.

BACKGROUND: Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis. METHODS: This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored. RESULTS: Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020. CONCLUSIONS: Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients. LEVEL OF EVIDENCE: Level III.

Performing Multiple Posterior Spinal Fusions in 1 Day: A Comparison of Perioperative Outcomes Between Morning and Afternoon Cases.

BACKGROUND: High-volume centers for idiopathic scoliosis (IS) have difficulty in scheduling posterior spinal fusions (PSFs) due to operating room availability, particularly during school vacation. A solution is for 1 surgeon to perform 2 PSF cases back-to-back. This study aims to compare morning and afternoon PSF cases performed by the same surgeon for perioperative outcomes. METHODS: A retrospective review of PSF cases for IS that occurred on the same day as another PSF by the same surgeon between January 2013 and December 2019 was conducted. Perioperative outcomes included surgical time, estimated blood loss, length of stay, and inpatient opioid consumption normalized by the patient's weight. Postoperative outcomes included complications, revision rate, curve correction, and patient-reported outcomes using the Scoliosis Research Society-30. RESULTS: A total of 95 patients (87% female), mean age 15.6 years, were analyzed, with 48 morning cases and 47 afternoon cases. The median follow-up was 1.9 years (range: 0.3 to 6.1 y). Tests for equivalency determined equivalence in median anesthesia and mean surgical duration (P=0.05). The groups had similar initial curve correction (P=0.43) and rate of complications at 90 days postoperative (2 in each group for a total of 4 complications). No significant differences were seen between Scoliosis Research Society-30 scores at 6 months or in those who have reached 2 years postoperative. CONCLUSIONS: Little literature exists on the safety of a surgeon performing 2 PSF cases in 1 day, particularly in regard to pain outcomes, 30- and 90-day complication rates, and quality of life measures. This study indicates that few differences in safety, pain, and quality of life outcomes may appear between morning and afternoon PSF cases. LEVEL OF EVIDENCE: Level II.

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Management of Fasciotomy Incisions After Acute Compartment Syndrome: Is Delayed Primary Closure More Feasible in Children Compared With Adults?

BACKGROUND: Recent adult literature has demonstrated that in the setting of acute compartment syndrome (ACS), if fasciotomy wounds are not closed after the first debridement, they are unlikely to be closed via delayed primary closure (DPC). The purpose of this study was to report the success of DPC through serial debridement in children with fasciotomy wounds secondary to ACS and to determine whether length of hospital stay is negatively affected by adopting a DPC strategy. METHODS: We identified all patients treated with fasciotomy for ACS (aged 0 to18 y). Patient, injury, and treatment characteristics were summarized by fasciotomy treatment type. Patients were grouped as: primary closure, DPC, and flap or skin graft (F/SG). For patients who required additional debridements after initial fasciotomy, treatment success was defined as closure by DPC (without requiring F/SG). Multivariable logistic regression was used to determine factors associated with additional surgeries, complications, and treatment success. RESULTS: A total of 82 children underwent fasciotomies for ACS. Fifteen (18%) patients were treated with primary closure at the time of their initial fasciotomy and were excluded from the remainder of the analysis, 48 (59%) patients underwent DPC, and 19 (23%) patients were treated with F/SG. The majority of delayed fasciotomy wounds were successfully closed by DPC (48/67, 72%) and the rate of successful closure remained consistent with each successive operative debridement. There were no differences across DPC and F/SG groups with respect to age, method of injury, or injury severity. Patients who underwent F/SG remained in the hospital for an average of 12 days compared with 8 days for those who underwent DPC (P<0.001). CONCLUSIONS: In the setting of ACS, pediatric fasciotomy wounds that are not closed after the first postfasciotomy debridement still have a high likelihood of being closed through DPC with serial surgical debridement. In children, persisting with DPC strategy for fasciotomy closure after ACS is more successful than it is in adults. LEVEL OF EVIDENCE: Level III.

Intraoperative Use of O-arm in Pediatric Cervical Spine Surgery.

INTRODUCTION: Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation. METHODS: A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure. RESULTS: A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws. CONCLUSIONS: Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position. LEVEL OF EVIDENCE: Level IV.

Acute Implant-related Complications in Pediatric Cervical Spine Fusion.

BACKGROUND: The use of modern rigid instrumentation in pediatric cervical fusions decreases the risk of implant-related complications, both acute and long term. However, previous studies have indicated that acute implant-related issues still occur in the adult population. Reports of pediatric acute implant complications, occurring within 3 months of surgery, are under-represented in the literature. The purpose of this study is to document the prevalence of acute implant-related complications in a pediatric cervical fusion population. METHODS: A retrospective review of instrumented cervical fusions from August 2002 to December 2018 was conducted. Acute implant-related complications were defined as malposition, fracture, or disengagement of cervical instrumentation, including screws, rods, and plates, within 90 days of surgery. RESULTS: A total of 166 cases were included (55% male individuals) with an average age at surgery of 12.5 years (SD, ±5.28). Acute implant-related complications occurred in 5 patients (3%). All 5 patients had a syndromic diagnosis: Loeys-Dietz (n=1), osteopetrosis (n=1), neurofibromatosis (n=1), trisomy 20 (n=1), and achondroplasia (n=1). One case involved asymptomatic screw protrusion, 1 case lateral mass screw pull-out, 2 more had screw-rod disengagement, and the last experienced dislodgement of the anterior plate. The median time until the presentation was 25 days (range, 1 to 79 d). All patients (n=5) required surgical revision. CONCLUSIONS: This case series suggests that the overall incidence of acute cervical implant failure is low. However, failure is more likely to occur in patients with underlying syndromes compared with patients with different etiologies. Intraoperative use of 3-dimensional computed tomography imaging is recommended to evaluate the screw position and potentially avoid later surgery.

Management of Gustilo-Anderson Type II and IIIA Open Long Bone Fractures in Children: Which Wounds Require a Second Washout?

INTRODUCTION: Timing of wound closure in pediatric Gustilo-Anderson grade II and IIIA open long bone fracture remain controversial. Our aims are (1) to determine the proportion of patients with these fractures whose wounds can be treated with early primary wound closure (EPWC); (2) to compare the complication rates between EPWC and delayed wound closure (DWC); and (3) to determine factors associated with higher likelihood of undergoing DWC. PATIENTS AND METHODS: At a level-1 pediatric trauma center, 96 patients (younger than 18 y) who sustained Gustilo-Anderson grade II and IIIA open long bone fractures (humerus, radius, ulnar, femur, or tibia) within a 10-year period (2006-2016) were included for this study. Decision for EPWC versus DWC was at the discretion of the attending surgeon at time of initial surgery. Data collection was via retrospective review of charts and radiographs. Particular attention was paid to the incidence of return to operating room rate, nonunion, compartment syndrome, and infection. Median follow-up duration was 7.5 months (interquartile range: 3.6 to 25.3 mo). All patients were followed-up at least until bony union. RESULTS: Overall, 81% of patients (78/96) underwent EPWC. Of the grade II fractures, 86% underwent EPWC. Four patients (5%) in the EPWC group and 1 patient (6%) in the DWC group had at least 1 complication. When controlling for mechanism of injury, Gustilo-Anderson fracture type and age, there was no difference in rate of complications between the EPWC and the DWC groups. Grade IIIA fractures and being involved in a motor vehicle accident were factors associated with a higher likelihood of undergoing DWC. CONCLUSION: The majority of grade II and IIIA pediatric long bone fractures may be safely treatable with EPWC without additional washouts. Future prospective research is required to further define the subgroups that can benefit from DWC. LEVEL OF EVIDENCE: Level IV-therapeutic, case cohort study.

Occipital Plate Fixation in the Pediatric Population.

BACKGROUND: Occipital plate fixation has been shown to improve outcomes in cervical spine fusion. There is a paucity of literature describing occipital plate fixation, especially in the pediatric population. The authors reviewed a case series of 34 patients at a pediatric hospital who underwent cervical spine fusion with occipital plate fixation between 2003 and 2016. This study describes how occipital plates aid the cervical spine union in a case series of diverse, complex pediatric patients. METHODS: Our orthopaedic database at our institution was queried for patients undergoing an instrumented cervical spine procedure between 2003 and 2016. Medical records were used to collect diagnoses, fusion levels, surgical technique, and length of hospitalization, neurophysiological monitoring, complications, and revision procedures. RESULTS: Thirty-four patients met the inclusion criteria. The mean age was 10.9 years (range, 3-21 y). Indications for surgery included cervical instability, basilar invagination, and os odontoideum. These indications were often secondary to a variety of diagnoses, including trisomy 21, Klippel-Feil syndrome, and rheumatoid arthritis. The mean length of hospitalization was 10 days (range, 2 to 80 d). There were no cases of intraoperative dural leak, venous sinus bleeding from occipital screw placement, or implant-related complications. Postoperative complications included 2 cases of nonunion. Eight patients (24%) had follow-up surgery, only 3 (9%) of which were instrumentation revisions. Both patients with nonunion had repeat occipitocervical fixation procedures and achieved union with revision. CONCLUSIONS: Occipital plate fixation was successful for pediatric cervical spine fusion in this diverse cohort. The only procedure-related complication demonstrated was delayed union or nonunion and implant loosening (4/34, 12%) and there were no plate-related complications. This novel case series shows that occipital plate fixation is safe and effective for pediatric patients with complex diagnoses. LEVEL OF EVIDENCE: Level IV-case series.

The Reliability of the AOSpine Thoracolumbar Classification System in Children: Results of a Multicenter Study.

BACKGROUND: The purpose of this study was to determine whether the new AOSpine thoracolumbar spine injury classification system is reliable and reproducible when applied to the pediatric population. METHODS: Nine POSNA (Pediatric Orthopaedic Society of North America) member surgeons were sent educational videos and schematic papers describing the AOSpine thoracolumbar spine injury classification system. The material also contained magnetic resonance imaging and computed tomography imaging of 25 pediatric patients with thoracolumbar spine injuries organized into cases to review and classify. The evaluators classified injuries into 3 primary categories: A, B, and C. Interobserver reliability was assessed for the initial reading by Fleiss kappa coefficient (kF) along with 95% confidence interval (CI). For A and B type injuries, subclassification was conducted including A0 to A4 and B1 to B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff alpha (αk) along with bootstrapped 95% CI. Imaging was reviewed a second time by all evaluators ~1 month later. All imaging was blinded and randomized. Intraobserver reproducibility was assessed for the primary classifications using Fleiss kappa and subclassification reproducibility was assessed by Krippendorff alpha (αk) along with 95% CI. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement. RESULTS: Twenty-five cases were read for a total of 225 initial and 225 repeated evaluations. Adjusted interobserver reliability was almost perfect (kF=0.82; CI, 0.77-0.87) across all raters. Subclassification reliability was substantial (αK=0.79; CI, 0.62-0.90). Adjusted intraobserver reproducibility was almost perfect (kF=0.81; CI, 0.71-0.90) for both primary classifications and for subclassifications (αk=0.81; CI, 0.73-0.86). CONCLUSIONS: The reliability for the AOSpine thoracolumbar spine injury slassification System was high amongst POSNA surgeons when applied to pediatric patients. Given a lack of a uniform classification in the pediatric population, the AOSpine thoracolumbar spine injury classification system has the potential to be used as the first universal spine fracture classification in children. 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.

Adverse Perioperative Events in Children with Complex Congenital Heart Disease Undergoing Operative Scoliosis Repair in the Contemporary Era.

Scoliosis is common in children with congenital heart disease (CHD) and may have deleterious effects on quality of life and hemodynamics. Relatively little is known about the outcomes of spinal fusion for scoliosis repair in children with complex CHD. We reviewed all cases of children with CHD undergoing first time spinal fusion excluding those with minor CHD between 1995 and 2015. Seventy-eight patients were identified and included in the study. 97.4% of patients included had undergone prior cardiac surgery and sixteen patients had single ventricle circulations. 17.9% of patients experienced a significant perioperative event defined as an aggregate of the presence of any of the following: need for early unanticipated reoperation, neurologic deficit, postoperative bleeding requiring intervention, end organ dysfunction, or death. There were no deaths in our cohort. 38.5% of patients experienced any adverse event, the majority of which were related to perioperative fluid shifts. Larger preoperative Cobb angle and longer length of spinal fusion were associated with increased risk of significant perioperative event while larger preoperative Cobb angle and longer length of spinal fusion, older age at time of surgery, single ventricle circulation, cyanosis and patients taking cardiac medications at the time of surgery were more likely to experience any adverse event. Operative repair of scoliosis in children with complex CHD has been performed without mortality over a 20-year period in a single institution, albeit with a higher rate of perioperative complication than is seen in the general pediatric population. Patients with large preoperative Cobb angles and cyanotic single ventricle circulations appear to be at the highest risk for perioperative complications.

C2 Translaminar Screw Fixation in Children.

BACKGROUND: Axis (C2) screw fixation has been shown to be effective in treating disorders that necessitate cervical stabilization. Although translaminar C2 screws have demonstrated clinical efficacy in adults, this technique has not yet been thoroughly investigated in children. This study describes the indications, technique, and results of translaminar C2 screw fixation in a case series of pediatric cervical spine disorders. METHODS: We searched the orthopaedic database at our institution for patients who had undergone a cervical spinal fusion that encompassed C2 between 2007 and 2017. Operative records were reviewed to determine if C2 screw fixation was performed and, if so, the type of C2 screw fixation. Clinical data with regard to patient age at surgery, diagnosis, procedure details, intraoperative complications, and postoperative complications were recorded. Preoperative and postoperative computer tomographic scans were reviewed to determine laminar measurements and containment, respectively. RESULTS: In total, 39 C2 translaminar screws were placed in 23 patients that met our inclusion criteria. The mean age was 12.6 years (range, 5.2 to 17.8 y) with a mean of 2 levels fused (range, 1 to 6). Diagnoses included 7 patients with instability related to skeletal dysplasia, 6 os odontoideum, 4 congenital deformities, 3 basilar invaginations, 2 cervical spine tumors, and 1 fracture. Indications for C2 translaminar screws included 14 cases with distorted anatomy favoring C2 translaminar screws, 6 cases without explicit reasoning for translaminar screw usage in the patient records, and 3 cases with intraoperative vertebral artery injury (1 sacrificed secondary to tumor load and 2 others injured during exposure because of anomalous anatomy). The vertebral artery injuries were not due to placement of any instrumentation. There were no screw-related intraoperative or postoperative complications and no neurological injuries. All patients demonstrated clinical union or healing on follow-up with no episodes of nonunion. CONCLUSIONS: Translaminar C2 screw fixation can be reliably used in the pediatric population. Our series contained no screw-related complications, no neurological injuries, and all patients demonstrated clinical union or healing. LEVEL OF EVIDENCE: Level IV-Case series.

Deep Surgical Site Infections Following Pediatric Cervical Spine Surgery.

OF BACKGROUND DATA: This is the first reported series looking specifically at factors associated with deep surgical site infections (SSI) following pediatric cervical spine surgery. OBJECTIVE: To identify risk factors present in pediatric patients who are at risk for SSI following cervical spine surgery. DESIGN: Level of evidence: level IV-retrospective case series. INTRODUCTION: To date there are no studies regarding SSI in pediatric cervical spine surgery and thus no benchmark data or risk factors have been identified. METHODS: Patients with acute deep SSIs occurring within 90 days of the index operation were identified. Patient and surgical characteristics were analyzed for possible predictors of SSI outcome using penalized likelihood logistic regression analysis. Characteristics analyzed included: age, diagnosis, comorbidity, levels fused, approach, implants used, allograft, halo, body mass index, revision, antibiotic dosing, and occipital plating. RESULTS: A total of 112 patients were included in the study at a mean age of 12.5 years (2 to 18 y). Comorbidities were present in 51 (46%) patients, 15 patients had a documented connective tissue disorder (CTD). The mean number of levels fused was 3.7 (2 to 7) and mean number of screws was 4.4 (2 to 11). Allograft was used alone in 48 patients, occipital plating in 28 patients, and a halo in 39 patients. Deep SSI occurred in 3 patients: two of which had a CTD (1 Trisomy 21, 1 Ehlers-Danlos) and 1 patient with postradiation cervical kyphosis. All were gram-positive infections requiring return to operating room with prolonged IV antibiotics. All patients recovered and fused with spinal implant retention. The incidence of deep SSI was 2.7%. It was determined that a CTD was the only significant predictor of SSI. Subjects with a CTD had 12 times the odds of SSI [odds ratio=12 (1.5, 137.0); P=0.02]. CONCLUSIONS: In our series of pediatric patients the incidence of a deep SSI was 2.7%. The only predictor of SSI was the presence of a CTD.