New Classification for Pediatric Proximal Fifth Metatarsal Fractures.

Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared.

Epidemiology and management of appendicular fractures occurring in neonatal intensive care patients.

AIM: To describe the epidemiology and management of appendicular fractures occurring in the neonatal ICU in a large series of patients treated a single, quaternary care neonatal intensive care unit. METHODS: Patients <1 years old with appendicular fractures treated from 2012 to 2016 at a quaternary-level NICU were identified. Bivariate testing compared fractures, work-up and management based on designated mechanism (presumed birth-related vs unknown). In patients with unknown mechanism, factors with potential fracture association were analysed in a descriptive fashion. RESULTS: Eighty-five fractures (54 patients) were included. Mechanistic cohorts differed by birthweight (P < .001) and gestational age at birth (P < .001). Presumed birth-related fractures were more commonly upper extremity (P < .001), solitary (P = .001) and radiographically diagnosed in the acute state (<.001). The biochemical profile of the cohorts differed significantly. The prevalence of factors with potential fracture association was high in patients with unknown mechanism. Only one patient required surgery, while all others resolved with minimal orthopaedic intervention. CONCLUSION: Findings indicate these injuries rarely require operative intervention and that two distinct injury profiles appear to exist based on fracture mechanism. Steroid use, ventilation use, diuretic use, nutritional supplementation and recent bedside procedures were common among patients without known fracture mechanism. LEVEL OF EVIDENCE: Level III-Retrospective Cohort Study.

Getting the Message: The Declining Trend in Opioid Prescribing for Minor Orthopaedic Injuries in Children and Adolescents.

BACKGROUND: Opioids constitute the fastest-growing drug problem among children and adolescents in the United States. Recent heavy media coverage on the opioid prescription epidemic has garnered increased attention from prescribers and policymakers. The purpose of this study was to analyze trends in opioid prescribing for nonoperatively managed pediatric fractures and dislocations in order to examine changes in opioid-prescribing patterns across various U.S. regions. METHODS: A retrospective review of the national Pediatric Health Information System (PHIS) database comprising 42 pediatric hospitals was performed to identify pediatric fractures and dislocations presenting to the emergency department (ED) or outpatient clinics from 2004 to 2017. We included patients with the 10 most frequently encountered diagnoses who were nonoperatively managed and were discharged home the same day. To account for hospital variation, we utilized a mixed-effects logistic regression model. RESULTS: The final cohort included 134,931 patients, with a mean age (and standard deviation) of 12.57 ± 2.00 years (range, 10 to 18 years); 69.23% of patients were male. Overall, 51.69% of patients were prescribed at least 1 opioid dose during their ED or clinic visits. Of the patients receiving opioids, 72.04% were male and 54.10% were insured through a private insurance plan. When prescription trends were compared according to regions, children were more likely to be prescribed opioids in the South (71.37% more likely) and the Midwest (26.17% more likely) than in the Northeast. CONCLUSIONS: Although the opioid prescription rates in all 4 regions have decreased dramatically over the years, some regions were quicker than others in responding to the opioid epidemic. A significant interregional variability in opioid-prescribing practices still exists, but an overall downward trend in opioid prescription rates for acute pain management in conservatively treated pediatric fractures and dislocations is evidence of progress in tackling the opioid crisis. CLINICAL RELEVANCE: Opioid-related misuse is a national epidemic and reducing the use of opioids in pediatric orthopaedic procedures is critical. Although regional variability in opioid-prescribing practices still exists, an overall downward trend in opioid prescription rates for acute pain management in conservatively treated pediatric fractures and dislocations is evidence of progress in tackling the opioid crisis.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome.

BACKGROUND: Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients. METHODS: An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification. RESULTS: A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission. CONCLUSIONS: Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Could have tethered: predicting the proportion of scoliosis patients most appropriate for thoracic anterior spinal tethering.

BACKGROUND: Posterior spinal fusion (PSF) has proven to be a safe, reliable technique to treat spinal deformities in adolescents. In recent early reports, vertebral body tethering (VBT) is showing promise as a method to modulate growth, driving scoliosis correction, while offering the potential added benefit of maintaining some flexibility in the instrumented segment. With recent FDA humanitarian device exemption (HDE) approval, VBT is poised to become more widely available as a treatment for a subset of current PSF candidates. Our aim was to use approved criteria from a recent FDA IDE to determine who could have been tethered in the years preceding approval. METHODS: A retrospective analysis was performed of patients with idiopathic scoliosis treated with PSF or VBT at a large pediatric spine center from 1/1/2016 to 6/25/2019. Tethering indications followed the criteria outlined by an ongoing FDA IDE: age 8-16, Sanders bone age ≤ 4, primary thoracic curve between 35° and 60°, and lumbar curve < 35°. Risser sign and triradiate cartilage status were also employed to ascertain skeletal maturity in the absence of Sanders score. RESULTS: Of the 359 patients (78.6% female) who underwent PSF or VBT for idiopathic scoliosis, 75 (20.9%) met IDE criteria for VBT (57 had PSF and 18 had VBT). 284 were not appropriate for thoracic VBT: 77 (21.4%) had a non-thoracic primary curve, 80 (22.3%) were too mature at presentation, 36 (10.0%) had a lumbar curve > 34°, 9 (2.5%) had a main thoracic curve out of range, and 1 had a proximal thoracic curve > 40°. 81 patients (22.6%) had multiple exclusionary criteria. CONCLUSIONS: After decades with a successful treatment for AIS (PSF), we are at an inflection point: VBT is conditionally approved by the FDA as an HDE device, unleashing more widespread use. Many pediatric spine surgeons will want to know what proportion of PSFs will someday be VBTs. If FDA IDE criteria are used to ensure that a VBT candidate has an appropriate maturity stage and scoliosis deformity pattern, 20.9% of our 359 surgical range patients would have qualified for thoracic VBT. LEVEL OF EVIDENCE: Level III.

Morphometric analysis of the proximal thoracic pedicles in Lenke II and IV adolescent idiopathic scoliosis: an evaluation of the feasibility for pedicle screw insertion.

PURPOSE: Pedicles on the concave side of the proximal thoracic (PT) curve in adolescent idiopathic scoliosis (AIS) patients with Lenke II and IV deformities tend to be narrow and dysplastic, making pedicle screw (PS) insertion challenging. The aim of this study was to evaluate the feasibility for PS placement in these patients using pedicle chord length, diameter, and channel morphology. METHODS: In this retrospective study, 56 consecutive AIS patients with Lenke II or IV curves who underwent instrumented posterior spinal fusion (PSF) were studied. The mean age at surgery was 14.8 years and the mean PT curve measured 45°. Two independent investigators evaluated all visible pedicles from T1 to T6 vertebral levels using axial images from intraoperative computed tomography-guided navigation recording the pedicle: (1) maximum transverse diameter 'd' at the isthmus, (2) maximum chord length 'l', and (3) qualitative assessment of the channel morphology (types A-D). RESULTS: Two hundred and sixty-eight concave and 264 convex pedicles were measured. The mean 'd' of the concave pedicles at T3 and T4 was < 3.0 mm, compared to > 5.0 mm for the convex counterparts (p < 0.001). Of all concave pedicle channels, 48% had morphology characteristics that were riskier for PS cannulation (type C or D) compared to 2% of all convex pedicle channels (type A or B) (p < 0.001). CONCLUSION: Almost half of all concave pedicles have morphologic characteristics that make them too small to accommodate a PS. Though PSs could be inserted using an in-out-in technique in these patients, alternative fixation anchors may improve strength and safety.

An Intrinsic Role of Beta Oscillations in Memory for Time Estimation.

The neural mechanisms underlying time perception are of vital importance to a comprehensive understanding of behavior and cognition. Recent work has suggested a supramodal role for beta oscillations in measuring temporal intervals. However, the precise function of beta oscillations and whether their manipulation alters timing has yet to be determined. To accomplish this, we first re-analyzed two, separate EEG datasets and demonstrate that beta oscillations are associated with the retention and comparison of a memory standard for duration. We next conducted a study of 20 human participants using transcranial alternating current stimulation (tACS), over frontocentral cortex, at alpha and beta frequencies, during a visual temporal bisection task, finding that beta stimulation exclusively shifts the perception of time such that stimuli are reported as longer in duration. Finally, we decomposed trialwise choice data with a drift diffusion model of timing, revealing that the shift in timing is caused by a change in the starting point of accumulation, rather than the drift rate or threshold. Our results provide evidence for the intrinsic involvement of beta oscillations in the perception of time, and point to a specific role for beta oscillations in the encoding and retention of memory for temporal intervals.