Evaluation of Patient Satisfaction Surveys in Pediatric Orthopaedics.

BACKGROUND: Patient satisfaction survey scores are increasingly being tied to incentive compensation, impact how we practice medicine, influence decisions on where patients seek care, and in the future may be required for accreditation. The goal of this study is to compare the results of an internal distribution of patient satisfaction surveys at the point of care to responses received by mail in a hospital-based, high-volume pediatric orthopaedic practice. METHODS: A pediatric outpatient survey is used at our institution to evaluate patient satisfaction. Surveys are randomly mailed out to families seen in our clinic by the survey vendor, and the results are determined on a quarterly basis. We distributed the same survey in a similar manner in our clinic. The results of the surveys, external/mailed (EXM) versus internal/point of care (INP) over the same 3-month time period (second quarter 2013) were compared. The survey questions are dichotomized from an ordinal scale into either excellent (9 to 10) or not excellent (0 to 8) commonly used in patient satisfaction methodology. We evaluated the raw data from the INP surveys for the question on provider rating by evaluating the mean score, the standard excellent response (9 to 10), and an expanded excellent response (8 to 10). RESULTS: Response rate was 72/469 (15.4%) for EXM, and 231/333 (69.4%) for INP. An excellent response for the "rating your provider" question was 72.2% (EXM) versus 84.8% (INP) (P=0.015). Our analysis of the raw data (INP) has a mean rating of 9.42. The expanded scale (8 to 10) for an excellent response increased the provider rating to 94.4% (P=0.001). Waiting time response within 15 minutes was the only item that correlated with rating of provider (P=0.02). For the majority of the items, the INP responses were consistently higher than the EXM responses, including 6/7 responses that were statistically significant (P<0.05). CONCLUSIONS: As mandated by the Centers for Medicare and Medicaid Services, patient satisfaction surveys will be important in determining health care outcomes. Properly designed and administered surveys provide robust measures of quality. Our study reinforces methodological concerns about patient satisfaction surveys distributed in a high-volume pediatric subspecialty practice. Further research is needed to evaluate the patients' health care experience and true quality of care in pediatric subspecialty ambulatory settings.

Diagnosis and initial management of musculoskeletal coccidioidomycosis in children.

BACKGROUND: Coccidioidomycosis is an invasive fungal infection caused by the inhalation of aerosolized spores of Coccidioides spp., which reside in the arid soil of the southwestern United States and northern Mexico. Approximately two thirds of cases are asymptomatic, and the remainder usually present with mild flu-like symptoms. Dissemination of coccidioidomycosis is rare, and can lead to extrapulmonic diseases including meningitis, osteomyelitis, and skin and soft-tissue involvement. The purpose of this study is to report our experience with musculoskeletal coccidioidomycosis in children. METHODS: This was a retrospective chart review of patients with musculoskeletal infection with Coccidioides spp. at a tertiary care pediatric hospital from 1997 to 2010, identified by a search of ICD-9 codes and hospital diagnoses. Demographic and clinical data were collected from medical records, including the age of the patient, sex, white blood cell count, immunocompetence, length of stay, location of involvement, and initial treatment. In total, 20 children were identified with musculoskeletal coccidioidomycosis. The mean age was 12.3 years (range, 2 to 17 y) at time of diagnosis. Diagnostic criteria included positive imaging tests (plain film+MRI), serologic positive titers, and/or biopsy with positive cultures. RESULTS: The most common presenting symptom was bone pain (100%); only 3 (15%) patients had accompanying signs/symptoms of pulmonary infection. Only 2 (5%) patients had a white blood cell count >15×10/L (5%). Locations of infection included the foot (28%), knee (14%), spine (12%), forearm (10%), lower leg (6%), and other sites (30%). Fluconazole was the most common antifungal agent used (75%). Surgical intervention was required in 10 (50%) patients. CONCLUSIONS: This is the first series that has described musculoskeletal coccidioidomycosis exclusively in children. This study suggests that the initial presentation of this disease can be nonspecific and difficult to recognize in children. Clinicians should consider this diagnosis when faced with a musculoskeletal infection in children from the southwestern United States and northern Mexico. LEVEL OF EVIDENCE: IV (case series).

Independent analysis of a clinical predictive algorithm to identify methicillin-resistant Staphylococcus aureus osteomyelitis in children.

BACKGROUND: The number of serious, life-threatening musculoskeletal infections in children due to methicillin-resistant Staphylococcus aureus (MRSA) infections is increasing. The early identification of the bacteria causing osteomyelitis is critical to determine the appropriate antibiotic treatment. A recent study proposed a clinical algorithm to predict which infections were caused by MRSA by stratifying basic clinical values at the time of admission for children with osteomyelitis. The purpose of this study is to apply that predictive algorithm on an independent patient population to determine its wider applicability. METHODS: This was a retrospective chart review at a tertiary care children's hospital. All children who were treated for a culture-positive osteomyelitis were identified over a 3-year period. The previously reported predictors, determined by multivariate regression analysis, of MRSA infection (temperature >38°C, hematocrit <34%, white blood cell count >12,000/µL, and C-reactive protein >13 mg/L) were determined for each patient. The number of positive predictors was then correlated with the percentage of cases that were MRSA positive. RESULTS: A total of 58 patients with culture-positive osteomyelitis were identified from 2008 to 2010. Sixteen of the infections were caused by MRSA (overall 26%). The percentage of patients with MRSA osteomyelitis according to the number of risk factors were as follows: all 4 risk factors, 50% (1 out of 2 patients); 3 risk factors, 42% (5 out of 12 patients); 2 risk factors, 21% (4 out of 19 patients); 1 risk factor, 50% (6 out of 12 patients); and 0 risk factor, 0% (0 out of 13 patients). CONCLUSIONS: The previously reported clinical predictive algorithm had a relatively poor diagnostic performance in this independent patient population. Specifically, the percentages of MRSA were the same for 1 risk factor compared with 4 (50%). Differences in bacteria strain, host responses, and a variety of other confounding variables could be responsible for these differences. Specific genetic markers may be the best early test to identify MRSA infections in the future. LEVEL OF EVIDENCE: Level III-case-control series.

Missed fractures in paediatric trauma patients.

Missed fractures and other occult musculoskeletal injuries are common in paediatric trauma patients despite the thorough evaluation with standard trauma protocols. Several factors have been identified that contribute to the risk of failing to identify these injuries during the initial resuscitation and assessment of the paediatric trauma patient. These include patient-related, clinical, technical, and radiological causes. Preventive strategies have been proposed to minimize these overlooked injuries and their potential long-term consequences. A timely review of this problem is appropriate to continually improve the quality of care delivered to paediatric trauma patients.

An Early Evaluation of Remote Site Visits for ACGME Program Applications.

Background: Prior to the COVID-19 pandemic, accreditation site visit interviews occurred in-person. In response to the pandemic, the Accreditation Council for Graduate Medical Education (ACGME) developed a remote site visit protocol. Objective: To perform an early assessment of the remote accreditation site visits for programs applying for initial ACGME accreditation. Methods: A cohort of residency and fellowship programs that had remote site visits was evaluated from June to August 2020. Surveys were sent to program personnel, ACGME accreditation field representatives, and executive directors following the site visits. Comparison of accreditation decisions (Initial Accreditation or Accreditation Withheld) was completed for matched residency or fellowship programs having in-person site visits in 2019. Results: Surveys were sent to all program personnel from the 58 residency and fellowship programs that had remote site visits for new program applications, as well as the accreditation field representatives who performed the remote visits. The survey response rate was 58% (352 of 607). Ninety-one percent of all respondents were extremely or very confident that remote site visits provided a thorough assessment of proposed residency or fellowship programs. Fifty-four programs having remote site visits were matched by specialty to programs having had in-person program application site visits in 2019. Forty-six programs that had remote site visits received Initial Accreditation, and 52 programs that had in-person site visits in 2019 received Initial Accreditation (P=.093, 95% CI 0.91-22.38). Conclusions: Most program personnel and accreditation field representatives were confident that remote site visits conducted for program applications provided fair and thorough assessments of the program.

Pulmonary embolism following an ankle fracture in a 9-year-old boy: a case report.

Venous thromboembolism following trauma is an uncommon event in childhood and associated pulmonary embolus after routine lower extremity fracture is exceedingly rare. We present a case report of postoperative pulmonary embolus following an open reduction and internal fixation of a Salter-Harris IV medial malleolus fracture in a 9-year-old boy. Four days after open reduction and percutaneous pin fixation of the ankle fracture, the child began to experience chest pain and shortness of breath. Computed tomographic angiography demonstrated a pulmonary embolus, and he was started on anticoagulation therapy. The child had no medical history, family history, nor known risk factors for venous thromboembolism other than the fracture, and a thrombophilic work-up revealed no coagulopathies or other blood disorders. He was treated with Coumadin for three months. His orthopedic course was uneventful; the fracture healed and he returned to normal function. This appears to be the first case reported in the literature of a significant pulmonary embolus after a routine ankle fracture in a child. While insufficient to warrant deep venous thrombosis prophylaxis in all children, this case report suggests that a venous thromboembolic event can occur even in uncomplicated fractures in children.

Bedside ultrasound in the diagnosis of pediatric clavicle fractures.

OBJECTIVE: The objective of the study was to determine the diagnostic accuracy of pediatric emergency physicians in diagnosing clavicle fractures by bedside ultrasound (US). METHODS: This was a prospective study of pediatric emergency department (ED) patients with suspected clavicle fractures conducted in a tertiary-care, freestanding pediatric hospital. A convenience sample of patients younger than 17 years underwent bedside US for detection of clavicle fracture by pediatric emergency physicians with limited US training. Ultrasound findings were compared with standard radiographs, which were considered the criterion standard. Pain scores using the validated color analog scale (0-10) were determined before and during US. Total length of stay in the ED, time to US, and time to radiograph were recorded. RESULTS: Fifty-eight patients were enrolled, of which 39 (67%) had fracture determined by radiograph. Ultrasound interpretation gave a sensitivity of 89.7% (95% confidence interval [CI], 75.8%-97.1%) and specificity of 89.5% (95% CI, 66.9%-98.7%). Positive and negative predictive values were 94.6% (95% CI, 81.8%-99.3%) and 81.0% (95% CI, 58.1%-94.5%), respectively. Positive and negative likelihood ratios were 8.33 and 0.11, respectively. Pain scores averaged 4.7 before US and 5.2 during US (P = 0.204). There was a statistically significant difference between mean time to US (76 minutes) and mean time to radiograph (107 minutes) (P < 0.001). CONCLUSIONS: Pediatric emergency physicians with minimal formal training can accurately diagnose clavicle fractures by US. In addition, US itself is not associated with an increase in pain and may reduce length of stay in the ED.

Periosteal entrapment in distal femoral physeal fractures: harbinger for premature physeal arrest ?

We report on two patients who sustained Salter-Harris II fractures of the distal femur with physeal widening after being tackled in football games. Preoperative MRI indicated entrapped periosteum at the physeal fracture site for both patients. Both patients underwent open reduction of the physeal fracture with removal of the entrapped periosteum and achieving an anatomic reduction. Follow-up MRI's revealed premature physeal arrest. Subsequent procedures were performed to address sequelae of premature physeal arrest. The presence of physeal widening and entrapped periosteum may reflect high-energy trauma to the physis. This can result in injury to both the epiphyseal blood supply and to the physeal cartilage (germinal zone) resulting in physeal arrest despite anatomic reduction after removal of the entrapped periosteum. Upon literature review, pre-operative MRI demonstrating entrapped periosteum has not been previously reported. We hypothesize that the presence of entrapped periosteum following distal femoral physeal fractures may be associated with an increased risk for premature physeal arrest.

Case report: Mesenchymal chondrosarcoma of the lumbar spine in a child.

BACKGROUND: Chondrosarcomas of the spine constitute 4% to 10% of all primary spinal bone tumors and approximately 70% of the cases occur during the second or third decade of life. Mesenchymal chondrosarcoma is a rare aggressive variant of chondrosarcoma. The prognosis of mesenchymal chondrosarcoma is usually poor with a tendency for late local recurrence and metastasis. CASE DESCRIPTION: We describe a case of primary mesenchymal chondrosarcoma affecting the L5 vertebra of a 9-year-old girl. The patient underwent a staged circumferential resection of the tumor after three rounds of neoadjuvant chemotherapy. The patient had additional chemotherapy and radiation therapy as an intralesional margin was achieved during the procedure. At 9 years followup, the patient was asymptomatic, neurologically intact, and remained in remission. LITERATURE REVIEW: We identified only four previously published cases of spinal mesenchymal chondrosarcoma in childhood, two of which had relatively early recurrence and poor survival, and two survived but with only short followup. PURPOSES AND CLINICAL RELEVANCE: As the clinical and radiographic findings of mesenchymal chondrosarcoma are nonspecific, the diagnosis of this rare tumor requires careful histopathologic review of the specimens. We suggest the differential diagnosis of every primary intraspinal tumor include tumors of mesenchymal origin. The prognosis is apparently not uniformly poor.

Tibia vara deformity after below knee amputation and synostosis formation in children.

BACKGROUND: Progressive varus deformity of the tibia in pediatric patients after transtibial and Syme amputations has not been reported in a series. A distal tibia to fibula synostosis, created surgically to minimize the risk of terminal overgrowth or occurring spontaneously, was noted in most patients. The goals of this study are to address the causes of the deformity, the implications for prosthetic wear, and potential treatment options. METHODS: Twelve patients identified from the juvenile amputee database at 2 centers developed progressive varus deformity of the residual limb. One patient had bilateral involvement. A distal tibia-fibula synostosis was noted in 12 (92%) of the residual limbs, and in one, a fibrous union was suspected. The level of amputation was trans-tibial in 10 patients, and Syme amputation in 3 patients. Two patients had acquired trans-tibial level of amputation from congenital constriction band syndrome. Nine of the patients (75%) were between the ages of 3 and 5 years at the time of injury. RESULTS: The mean proximal medial tibial angle was 80.5 degrees (range, 75-85 degrees). Ten of the patients underwent procedures to correct the mechanical axis and resolve or prevent problems with prosthetic fitting. Four patients has proximal tibial osteotomies (HTO), 2 oblique closing wedge osteotomies, 1 shaft osteotomy, and 4 lateral proximal tibial hemi-epiphyseodesis. In 2 patients, no correction was recommended. CONCLUSIONS: The presence of a distal tibia-fibula synostosis in pediatric amputee patients may contribute to the risk of developing a progressive varus deformity and should be monitored during a child's growth. Distal tibiofibular synostosis may disrupt normal differential longitudinal growth and may contribute to this progressive angular deformity. Severe deformity may require prosthetic modifications or operative correction to provide for a normal mechanical axis. Lateral hemiepiphyseodesis of the proximal tibia can be effective if the deformity is detected early. We do not recommend creation of a synostosis in the young child for terminal growth. LEVEL OF EVIDENCE: Level 4.

Burst fractures of the thoracic and lumbar spine in children and adolescents.

BACKGROUND: Burst fractures are rare in the pediatric population. There is limited information available on the best treatment for these injuries. The aims of our study were to evaluate the risk of spinal cord injury (SCI) and the potential for neurologic recovery associated with pediatric burst fractures; to compare sagittal alignment between nonoperative and operative treatment; and to determine whether functional outcomes are improved after surgery. METHODS: All pediatric patients who sustained thoracic or lumbar burst fractures at 2 institutions between 1991 and 2005 were identified. The medical records were reviewed for patient demographics, injury, treatment, and outcomes. Health Survey data were collected from a subset of patients in both the operative and nonoperative groups. RESULTS: Thirty-seven patients met the inclusion criteria. There were 17 male patients and 20 female patients, with an average age of 14.6 years (range, 6 to 18 y). Nine patients were treated nonoperatively and 28 patients were treated operatively. The nonoperative group was treated with hyperextension casting or bracing and showed progression of kyphotic deformity from 16.1 degrees at injury to 23.1 degrees at final follow-up. In patients treated operatively, the kyphotic deformity improved from 17.1 degrees at presentation to 7.2 degrees at final follow-up. Twenty-four patients were neurologically intact at presentation, whereas 13 presented with neurologic deficit. Six of 13 patients with SCI had some improvement. The risk of SCI was highest in patients with thoracic-level fractures. The risk of SCI did not correlate with canal compromise. There were no significant differences in functional outcome between the 2 groups. CONCLUSIONS: The risk of neurologic injury in pediatric burst fractures of the spine may be more closely related to the level of injury (thoracic) than the degree of spinal canal compromise. Prognosis for recovery of neurologic injury is related to the severity of the initial neurologic injury. LEVEL OF EVIDENCE: Prognostic level 2.

The Effect of Two Attending Surgeons on the Outcomes of Posterior Spine Fusion in Children With Cerebral Palsy.

BACKGROUND: Posterior spinal fusion (PSF) in children with cerebral palsy (CP) carries a high risk of complications and morbidity. The purpose of this study is to investigate the impact of using two attending surgeons on blood loss, operative time, and complications in this fragile population. METHODS: This was a prospective, matched cohort analysis of patients with CP who underwent PSF with two attending surgeons. These were matched with a control group that had a single-surgeon team, assisted by a senior resident or PA. The groups were compared using paired Student t tests and chi-square tests. RESULTS: 50 patients were included in the study (25 study and 25 matched controls), determined by our power analysis. There was no statistical difference in the mean age, preoperative major curve angle, major curve angle correction, or use of antifibrinolytics. The two-surgeon group decreased surgical time from 5.25 to 3.3 hours (p = .000002), and estimated blood loss from 1,238 to 865 mL (p = .009). The complication rate decreased from 33% to 8% (p=.034). Length of stay was also decreased from 6.5 days to 5.35 (p = .02). CONCLUSIONS: Although confounding variables were present, this study demonstrates that the use of a two-surgeon team during spinal surgery for patients with cerebral palsy could have a role in reducing operative time, blood loss, complication rates, and hospital length of stay. Overall, these factors and any improved operating room efficiencies may lead to lasting improved patient outcomes. LEVEL OF EVIDENCE: Level III, retrospective, comparative study.

Entrapment of the flexor digitorum profundus following paediatric forearm fractures.

The complications of closed and open reduction of paediatric both-bone forearm fractures have been well established. These include malunion, refracture, neurovascular insult, compartment syndrome, infection, and soft tissue/nerve entrapment. We describe two cases of small and ring finger flexion contractures as a complication of closed and operative treatment of healed paediatric both-bone forearm fractures. In both instances, tethering of the flexor digitorum profundus and fibrotic scar tissue interposed at the ulna fracture site was noted at the time of exploration. Evidence of a characteristic fracture pattern at the time of injury, persistent ulnar cortical defect after fracture healing, and delayed identification of the contractures following cast removal are key features in identifying and treating these complications.

Congenital constriction band with pseudoarthrosis of the tibia: a case report and literature review.

A passive constriction phenomenon has been proposed to explain the development of congenital pseudoarthrosis of the tibia. We report a case of congenital pseudoarthrosis of the tibia in a child with congenital constriction band syndrome, successfully treated with soft tissue release (cutaneous and deep) only, restoring normal periosteal blood supply and enabling gradual correction of the angular osseous deformity and reformation of the intramedullary canal.

Role of Computed Tomography in the Classification of Pediatric Pelvic Fractures-Revisited.

OBJECTIVES: To determine the need for computerized tomography (CT) scans in the assessment of pediatric pelvic fractures. DESIGN: Retrospective Chart Review. SETTING: Level-1 Pediatric Trauma Center. PATIENTS/PARTICIPANTS: Thirty pediatric trauma patients with pelvic fractures who have obtained both a radiograph and CT scan. MAIN OUTCOME MEASUREMENTS: Fleiss Kappa coefficient to compare interreliability. RESULTS: The average age of the patients was 7 years (range 1-13 years). Seventeen were males and 13 were females. The Torode and Zieg classification included 3 type I, 6 type II, 13 type III, and 8 type IV. The Kappa value for interobserver agreement comparing radiographs was 0.453, and for CT was 0.42. Three patients (10%) were treated with a spica cast, and none required surgery for their pelvic fracture. Four patients (11%) demonstrated liver, spleen, or kidney injuries on CT. Out of those 4, 1 had indications for laparotomy and drain placement, 1 died secondary to shock, and 2 were treated conservatively. CONCLUSIONS: The results of this study demonstrated that plain radiographs alone can be used to classify and manage most pediatric fractures, confirming Silber previous findings. Furthermore, we recommend the specific instances of Schreck and Haasz et al in which CT scans should be used, sparing the general pediatric population unnecessary radiation. Such cases include patients with an abnormal abdominal or pelvic examination, complex fracture patterns, displacement greater than 1 cm, femur deformities, hematuria, Glasgow Coma Scale <13, hemodynamic instability, an aspartate aminotransferase > 200 U/L, an Hct < 30%, or an abnormal chest x-ray.

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants.

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force "inconclusive" determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

Back pain in Duchenne muscular dystrophy: steroids are not always the culprit.

We report on a child with Duchenne muscular dystrophy on prolonged corticosteroid treatment who presented with back pain and was subsequently found to have a monostotic fibrous dysplasia lesion of the spine. It is the intent of this case report to emphasize the need to maintain a high index of suspicion for other potential causes of back pain in Duchenne muscular dystrophy besides vertebral compression fractures.

Adjunctive Pain Control Methods Lower Narcotic Use and Pain Scores for Patients With Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion.

STUDY DESIGN: This was a retrospective review of patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF). OBJECTIVES: To determine whether the use of adjunctive pain medications (bupivacaine pump, dexmedetomidine, and ketorolac) will reduce the need for opioids, reduce postoperative pain, and shorten length of hospital stay in patients with AIS undergoing PSF. SUMMARY OF BACKGROUND DATA: Posterior spinal fusion and instrumentation for AIS can cause significant postoperative pain. Adjunctive pain control modalities, including the use of ketorolac, dexmedetomidine, and subcutaneous bupivacaine pumps, all can lessen the effects of postoperative pain. METHODS: Retrospective review of adolescents aged 10-18 years with AIS receiving PSF surgery over the past 10 years at a tertiary care children's hospital. All patients with AIS undergoing PSF were included in the study. Patients older than 18 or younger than 10 years and those undergoing PSF for other diagnoses, including neuromuscular scoliosis, congenital scoliosis, and kyphosis, were excluded from the study. Patients' pain was managed postoperatively with adjunctive medications in addition to intravenous and oral opioids. Variables of interest were local anesthetic bupivacaine delivered through a subcutaneous pump, sedative/analgesic dexmedetomidine, and ketorolac. Primary outcomes analyzed were normalized opioid requirement after surgery, visual analog scale (VAS) pain scores, and length of stay in the hospital. RESULTS: A total of 196 children were analyzed with no significant differences in demographics. Univariate analysis showed that all 3 adjunct medications improved outcomes. A multivariate regression model of the outcomes with respect to the 3 medication variables of interest was built, showing that the bupivacaine pump significantly reduced normalized opioid requirement by 0.98 mg/kg (p = .001) and reduced VAS pain scores by 0.67 points (p = .004). Dexmedetomidine significantly reduced the average VAS pain scores in the first 24 hours by 0.62 points (p = .005). CONCLUSIONS: Use of the bupivacaine pump provided improved analgesia with lower pain scores, lower opioid requirements, and a lower length of stay.

Hip reconstruction is more painful than spine fusion in children with cerebral palsy.

PURPOSE: Concerns about pain control in patients with cerebral palsy (CP) are especially anxiety provoking for parents, given the fact that spasticity, communication issues, and postoperative muscle spasms are significant problems that make pain control difficult in these patients. A better understanding of the magnitude and quality of the pain these patients experience after our surgical procedures would better prepare the patients and their families. The purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and spinal fusion. Specifically, the study will compare pain scores and the amount of narcotics used between the two groups. MATERIALS AND METHODS: This is a retrospective chart review of a consecutive series of children with CP (GMFCS levels IV and V) over a 5-year period undergoing hip reconstruction (femoral osteotomy, pelvic osteotomy, or both) and posterior spinal fusion (PSF) at a tertiary-care pediatric hospital. The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics to morphine equivalents. The secondary end point was the documentation of pain with standard pain scores at standard time points postoperatively. Adverse effects related to pain management were documented for both groups. Student's t-tests were utilized to statistically compare differences between the groups, with significance determined at p < 0.05. RESULTS: Forty-two patients with CP who underwent hip reconstruction (mean age 8.8 years) were compared to 26 patients who underwent PSF (mean age 15.4 years). The total opioid used, normalized by body weight and by days length of stay (DLOS), in the hip group was 0.49 mg morphine/kg/DLOS, compared to 0.24 for the spine group (p = 0.014). The mean pain score for the hip group was 1.52, compared to 0.72 for the spine group (p = 0.013). There were no significant differences in the occurrence of adverse effects related to pain management between the two groups. CONCLUSION: Patients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. The knowledge that hip reconstruction is more painful than PSF for patients with CP will better prepare families about what to expect in the postoperative period and will alert providers to supply better postoperative pain control in these patients. LEVEL OF EVIDENCE: III (case control series).