Surgical prophylaxis in pediatric orthopedic patients with penicillin allergy: a multicentered retrospective prognostic study.

Up to 20% of orthopedic surgeons still avoid the use of cephalosporins in patients with penicillin allergies despite its reported safety in the adult and general surgery pediatric population. The primary objective is to determine the incidence of adverse effects and allergic reactions when using cephalosporins in pediatric orthopedic patients labeled as penicillin-allergic as compared to those without previously reported penicillin allergy. A multicenter retrospective chart review was performed across three level 1 trauma centers from January 2013 to February 2020 to identify penicillin-allergic as well as non-penicillin-allergic pediatric patients treated for orthopedic injuries. Data were collected regarding patient demographics, antibiotic administered, timing of antibiotic administration, reported drug allergy, and described allergic reaction. Postoperative or intraoperative allergic reactions to antibiotics, surgical site infections, and complications were recorded. A total of 2289 surgeries performed by four fellowship-trained surgeons were evaluated. Eighty-five patients diagnosed with penicillin allergy were identified and underwent 95 surgeries and 95 patients without previously reported penicillin allergy underwent 95 surgeries. One patient, with a documented history of anaphylaxis to cefazolin, sustained an anaphylactic reaction intraoperatively to cefazolin. There were no other reported reactions, surgical site infections, or complications. There was no statistically significant difference in rate of allergic reaction in patients with previously reported penicillin allergy treated with cefazolin and those with no previous reported reaction (P > 0.05). Prophylaxis with cephalosporins is not associated with increased risk for allergic reaction. Cephalosporins can be safely administered to pediatric patients with penicillin allergy undergoing orthopedic intervention. Level of evidence: Level II, Multicenter Retrospective Prognostic Study.

Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America.

Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler's fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic.

Effect of hyaluronic acid hydrogels containing astrocyte-derived extracellular matrix and/or V2a interneurons on histologic outcomes following spinal cord injury.

One reason for the lack of regeneration, and poor clinical outcomes, following central nervous system (CNS) injury is the formation of a glial scar that inhibits new axon growth. In addition to forming the glial scar, astrocytes have been shown to be important for spontaneous SCI recovery in rodents, suggesting some astrocyte populations are pro-regenerative, while others are inhibitory following injury. In this work, the effect of implanting hyaluronic acid (HA) hydrogels containing extracellular matrix (ECM) harvested from mouse embryonic stem cell (mESC)-derived astrocytes on histologic outcomes following SCI in rats was explored. In addition, the ability of HA hydrogels with and without ECM to support the transplantation of mESC-derived V2a interneurons was tested. The incorporation of ECM harvested from protoplasmic (grey matter) astrocytes, but not ECM harvested from fibrous (white matter) astrocytes, into hydrogels was found to reduce the size of the glial scar, increase axon penetration into the lesion, and reduce macrophage/microglia staining two weeks after implantation. HA hydrogels were also found to support transplantation of V2a interneurons and the presence of these cells caused an increase in neuronal processes both within the lesion and in the 500 µm surrounding the lesion. Overall, protoplasmic mESC-derived astrocyte ECM showed potential to treat CNS injury. In addition, ECM:HA hydrogels represent a novel scaffold with beneficial effects on histologic outcomes after SCI both with and without cells.

PTEN hamartoma of the soft tissue: the initial manifestation of an underlying PTEN hamartoma tumor syndrome in a 4-year-old female.

A 4-year-old female was referred to pediatric orthopedic surgery for left leg pain and limping for 3 months following a motor vehicle collision. Recently, the patient's mother had noted left knee swelling and dragging of the left leg when walking. Past medical history was significant for hip dysplasia with slight leg length discrepancy. The patient was otherwise healthy. Physical examination was remarkable for left pre-patellar soft tissue fullness with normal range of motion. There was no warmth or tenderness. Subsequent ultrasound revealed a heterogeneous soft tissue mass superior and medial to the patella with a moderate degree of internal vascularity. MR exhibited a heterogeneous soft tissue mass with heterogeneous signal on both T1- and T2-weighted images centered within the vastus medialis obliquus muscle infiltrating the quadriceps tendon. Excisional biopsy was performed with a histopathologic diagnosis of fibroadipose tissue with anomalous vessels, suggestive of phosphatase and tensin homolog (PTEN) hamartoma of the soft tissue (PHOST). The patient was found to be positive for the PTEN gene mutation on genetic testing. The child was also determined to be macrocephalic, a major criterion for PTEN hamartoma tumor syndrome (PHTS). The geneticist advised the patient to undergo yearly physical examinations and early, routine surveillance for several malignancies occurring with PHTS. This case report presents the ultrasound and MRI appearance of a rare benign tumor typically appearing in pediatric patients. The strong association between PHOST and other soft tissue malignancies and the resulting need for life-long surveillance make PHOST an important pathology to recognize.

The Fate of the Neuromuscular Hip After Spinal Fusion.

BACKGROUND: The goals of treatment of neuromuscular scoliosis are to achieve a balanced spine and level pelvis with most constructs including pelvic fixation. However, the pelvis can become a stiff "end vertebra" that prevents compensatory mechanisms to adjust to hip deformities in this patient population. The purpose of this study is to determine the frequency of hip pathology and surgery after spinal fusion in this patient population. METHODS: We performed a retrospective chart and radiographic review of cerebral palsy patients who underwent posterior spinal fusion (PSF) at our institution from 2005 to 2011. We collected radiographic data of preoperative and postoperative pelvic obliquity and hip reduction status and position (up, level, down). We further evaluated patients requiring hip surgery (containment or salvage). RESULTS: Of 47 patients with an average follow-up of 3.5 years after spinal fusion, 21 (45%) underwent a hip procedure. Thirty-eight patients (81%) demonstrated or developed hip subluxation/dislocation. Hip pathology occurred more often in the up hip, but the pathologic down hip more often underwent a hip surgery. Eight new hip subluxation/dislocations occurred after spine surgery. Three (38%) of the new postoperative subluxation/dislocations required hip surgery; all had pelvic obliquity <6 degrees. Eleven patients underwent hip surgery before PSF, 7 were varus femoral osteotomies for subluxation, whereas 5 hips required salvage. In follow-up after PSF, none of these had a new dislocation. Ten patients required hip surgery after PSF at a mean of 1.6 years after PSF. Eight patients had a salvage procedure for painful hip and 2 varus femoral osteotomies for subluxations. CONCLUSIONS: In our cerebral palsy patients who underwent PSF, 45% of these patients required a hip procedure. In the patients who had containment before PSF, the hips maintained reduction after spinal fixation. After correction of pelvic obliquity, 17% of patients had new-onset hip subluxation/dislocation after PSF. Postoperative subluxation/dislocation was not dependent on whether the hip was up or down preoperatively. LEVEL OF EVIDENCE: IV, Retrospective.