Medical Malpractice in Pediatric Orthopaedics: A Systematic Review of US Case Law.

BACKGROUND: Compared with other orthopaedic subspecialties, pediatric orthopaedic surgeons are thought to be at greater risk for malpractice claims; however, there is scant research on this topic. The purpose of our study was to characterize publicly available malpractice cases pertaining to pediatric orthopaedics to determine the (1) most common specialties of the physicians implicated, (2) most common diagnoses involved, (3) rate of verdicts in favor of the plaintiff, (4) amount of indemnity payments resulting from all verdicts versus verdicts in which only an orthopaedic surgeon was involved, and (5) outcomes of cases that were appealed. METHODS: The Westlaw legal database was queried for jury verdicts, settlements, and appellate cases using the search terms "pediatric" AND "orthopaedic" from December 31, 1984, to January 1, 2016, yielding 176 appellate court cases and 189 jury reports/settlements. After excluding duplicate cases and those involving patients aged 21 years or older, 36 appellate and 84 jury reports/settlement cases remained for analysis. RESULTS: Lawsuits against orthopaedic surgeons and pediatricians were most common, in cases involving fracture diagnosis and misdiagnosis of developmental dysplasia of the hip, respectively. Of the 84 cases, 43 rulings favored the plaintiffs. The median (interquartile range) indemnity payment was $900,000 ($1.9 million), and for cases in which only the orthopaedic surgeon was named as the defendant, the median (interquartile range) indemnity payment was $675,000 ($827,000). Of the 34 appellate cases, 16 cases initially ruled in favor of the defendant were upheld and 13 were reversed/remanded. Five cases initially ruled in favor of the plaintiff were upheld, and none was reversed/remanded. CONCLUSIONS: Malpractice lawsuits named orthopaedic surgeons and pediatricians more often than physicians in other specialties. Orthopaedic surgeons were sued most often for management of fractures and pediatricians for mismanagement of developmental dysplasia of the hip. Nearly 51% of malpractice cases were ruled in favor of the plaintiff, with high indemnity payments. However, when cases that were ruled in favor of the physician were appealed, most verdicts were upheld. LEVEL OF EVIDENCE: Level IV.

External fixation and surgical fusion for pediatric cervical spine injuries: Short-term outcomes.

OBJECTIVE: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion. PATIENTS AND METHODS: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication. RESULTS: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001). CONCLUSION: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury.

Walking Out of the Curve: Thoracolumbar Kyphosis in Achondroplasia.

BACKGROUND: Thoracolumbar kyphosis (TLK) is common in infants with achondroplasia. Our goals were to examine the natural history of TLK and identify factors associated with persistent TLK. METHODS: We reviewed records of patients with achondroplasia seen by a board-certified orthopaedic surgeon at a tertiary care medical center between 1997 and 2013. Inclusion criteria were minimum 2-year follow-up and radiographs taken at time of presentation, within 6 months of walking age, and within 6 months of the first anniversary of walking age. We defined TLK as kyphosis of ≥20 degrees centered at T12 and L1. We assessed patient demographic characteristics, radiographic parameters (Cobb angle, apical vertebral translation, and apical vertebral wedging for vertebral height and width), and clinical parameters (developmental motor delay, hydrocephalus, presence of a ventriculoperitoneal shunt, and foramen magnum decompression). Developmental motor delay was defined as the inability to sit or ambulate independently by age 14 or 30 months, respectively. Associations between these factors and persistent TLK (ie, unresolved at final follow-up) were evaluated using logistic regression and χ, Fisher exact, and independent t tests. Significance was set at P<0.05. RESULTS: A total of 60 patients were included. Mean values were as follows: age at presentation, 10.9±7.0 months; length of follow-up, 5.7±3.6 years; initial curve, 43.8±11.0 degrees; independent sitting age, 12.6±5.5 months; and independent walking age, 21.1±7.8 months. At walking age and 1 year after walking age, 15% and 58% of patients, respectively, had spontaneous TLK resolution. In total, 30% of patients had persistent TLK at final follow-up. Apical vertebral translation (P=0.001), percentage of apical vertebral wedging for vertebral height (P=0.031), and developmental motor delay (P=0.043) were associated with unresolved TLK. CONCLUSIONS: In patients with achondroplasia, TLK resolved at walking age in 15% of patients and after a year of walking in 58% of patients. Earlier bracing may slow TLK progression in patients with achondroplasia and developmental motor delay. Patients with kyphotic curves between 20 and 40 degrees should be examined intermittently for progressive deformity or worsening symptoms of spinal cord compression. LEVEL OF EVIDENCE: Level II.

Low Prevalence of Anterior and Posterior Cruciate Ligament Injuries in Patients With Achondroplasia.

BACKGROUND: Anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries and their subsequent reconstructions are common in the general population, but there has been no research regarding ACL or PCL injuries in patients with achondroplasia, the most common skeletal dysplasia. Our goals were to (1) evaluate the prevalence of ACL and PCL injuries in adolescents and adults with achondroplasia, (2) compare this prevalence with that reported for the general population, (3) determine how many patients with ACL or PCL injuries underwent ligament reconstruction as treatment, and (4) determine patient activity levels as they relate to the rate of ACL/PCL injuries and reconstructions. METHODS: We reviewed medical records of 430 patients with achondroplasia seen in the senior author's clinic from 2002 through 2014. Demographic data were reviewed, as well as any documentation of ACL or PCL injury or reconstruction. We called all 430 patients by telephone, and 148 agreed to participate in our survey, whereas 1 declined. We asked these patients about their history of ACL or PCL injury or reconstruction, as well as current and past physical activity levels. RESULTS: No ACL or PCL injuries were found on chart review. One patient reached by telephone reported an ACL injury that did not require reconstruction. This yielded a theoretical prevalence of 3/430 (0.7%). Of the 148 patients surveyed, 43 (29%) reported low physical activity, 75 (51%) reported moderate physical activity, and 26 (17%) reported high physical activity. There was no significant difference in the rate of ACL injury when stratified by physical activity level (P=0.102). CONCLUSIONS: ACL and PCL injuries and reconstructions are extremely rare in patients with achondroplasia, which cannot be completely ascribed to a low level of physical activity. One possible explanation is that patients with achondroplasia, on an average, have a more anterior tibial slope compared with those without achondroplasia, which decreases the force generated within the ACL and may protect against ACL injury. Further research is needed to explore possible causes. LEVEL OF EVIDENCE: Level IV-retrospective review.

Factors associated with health-related quality of life (HRQOL) in adults with short stature skeletal dysplasias.

INTRODUCTION: Numerous factors associate with health disparities. The extent to which such factors influence health-related quality of life (HRQOL) among adults with short stature skeletal dysplasias (SD) is unknown. In an effort to update and clarify knowledge about the HRQOL of adults with SD, this study aimed to quantify HRQOL scores relative to the American average and assess whether specific indicators are associated with lower scores. METHODS: Members (>18 years) of Little People of America were invited to complete an online survey assessing HRQOL using the SF-12 supplemented with indicator-specific questions. SF-12 components (Physical Component Summary, PCS; Mental Component Summary, MCS) were compared to the standardized national American mean. Scores were divided at the median to identify factors associated with lower scores using multivariable logistic regression, adjusting for age, gender, race, education, and employment. RESULTS: A total of 189 surveys were completed. Mean and median PCS and MCS were below the national mean of 50 (p < 0.001). Advancing decade of age corresponded to a significant decline in PCS (p < 0.001) but not MCS (p = 0.366). Pain prevalence was high (79.4%); however, only 5.9% visited a pain specialist. Significant factors for lower PCS included age >40 years (p = 0.020), having spondyloepiphyseal dysplasia congenita (SED) or diastrophic dysplasia relative to achondroplasia (p = 0.023), pain (p < 0.001), and "partial" versus "full" health insurance coverage (p = 0.034). For MCS, significant factors included a lack of social support (p = 0.002) and being treated differently/feeling stigmatized by health care providers (p = 0.022). CONCLUSIONS: Individuals with SD face documented disparities and report lower HRQOL. Further research and interventions are needed to modify nuanced factors influencing these results and address the high prevalence of pain.

Intraoperative Neuromonitoring in Pediatric and Adult Spine Deformity Surgery.

STUDY DESIGN: Review of techniques and description of institutional clinical experience. OBJECTIVE: To provide a historical review and description of key neuromonitoring concepts, focusing on neurogenic motor-evoked potentials and descending neurogenic evoked potentials, and to review the authors' experience with neuromonitoring techniques in children and adults undergoing spinal deformity surgery. SUMMARY OF BACKGROUND DATA: The original form of neuromonitoring, the Stagnara wake-up test, remains the "gold standard" for detecting true neurological deficits. Multiple newer modalities involving cortical and muscular monitoring, such as somatosensory evoked potentials and motor evoked potentials, have been developed and are widely used. Descending and neurogenic evoked potentials are becoming more common for neuromonitoring in patients undergoing spinal deformity surgery. METHODS: A PubMed search for literature related to "neuromonitoring" was performed, and recent, as well as historical, articles were reviewed. Clinical experience regarding the use of neuromonitoring in adult and pediatric spinal deformity surgery was obtained from institutional experts. RESULTS: Although not regularly used, the Stagnara wake-up test remains the gold standard for detecting neurological injury. Somatosensory evoked potentials measure signals transmitted from the periphery to the cortex and have historically been widely used but are limited by delay, poor localization, and the inability to detect damage to motor tracts. Motor evoked potentials continue to be used widely and measure muscular activity after cortical stimulation, but they are difficult to interpret in patients with underlying motor disorders and cannot be continuously monitored. Newer techniques such as descending neurogenic evoked potentials and neurogenic motor evoked potentials monitoring are used at some high-volume centers. CONCLUSIONS: Familiarity with the history of neuromonitoring in spinal deformity surgery and an understanding of the physiological systems used for neuromonitoring provide a framework from which spine surgeons can select appropriate monitoring for their patients.

Prevalence of Scoliosis and Thoracolumbar Kyphosis in Patients With Achondroplasia.

STUDY DESIGN: Retrospective chart review, case series. OBJECTIVES: To determine the prevalence of scoliosis and kyphosis in patients with achondroplasia. SUMMARY OF BACKGROUND DATA: There is little published research on the prevalence of scoliosis and thoracolumbar kyphosis in patients with achondroplasia. METHODS: The authors retrospectively reviewed charts of 459 patients with achondroplasia who were seen by the senior author, an orthopedic surgeon, from 1999 through 2013, at a tertiary referral center. After excluding patients who presented after spinal surgery and those who were referred for specific non-spinal issues, 326 patients were included (71%). Cobb angles were measured on lateral and posteroanterior radiographs. Scoliosis was defined as curvature on posteroanterior radiographs greater than 10°; thoracolumbar kyphosis was defined as any kyphotic curvature with an apex between T11 and L2. These data were then stratified by sex, age group (0-2, 3-12, 13-19, 20-40, and >40 years), and severity: within normal limits (≤10°), mild (>10°-25°), moderate (26°-50°), and severe (>50°). RESULTS: The study population consisted of 176 males and 150 females with a mean age of 18 years. Scoliosis was observed in 60%. Thoracolumbar kyphosis was observed in 79%, with 52% exhibiting moderate to severe curvature. CONCLUSIONS: In these patients, the rates of scoliosis and kyphosis were 60% and 79%, respectively, which are much higher than the rates reported in the literature for the general population of children. LEVEL OF EVIDENCE: Level 3 or 4.

Visual loss after corrective surgery for pediatric scoliosis: incidence and risk factors from a nationwide database.

BACKGROUND CONTEXT: Perioperative visual loss (POVL) after spinal deformity surgery is an uncommon but severe complication. Data on the incidence and risk factors of this complication after corrective surgery in the pediatric population are limited. PURPOSE: The present study aimed to investigate nationwide estimates of POVL after corrective surgery for pediatric scoliosis. STUDY DESIGN: This is a retrospective study that uses a nationwide database. PATIENT SAMPLE: The sample includes 42,339 patients under the age of 18 who underwent surgery for idiopathic scoliosis. OUTCOME MEASURES: The outcome measures were incidence of POVL and risk factors. METHODS: Patients under the age of 18 who underwent elective surgery for idiopathic scoliosis between 2002 and 2011 were identified using the Nationwide Inpatient Sample database. The incidence of POVL (ischemic optic neuropathy, central retinal artery occlusion, or cortical blindness) was estimated after application of discharge weights. Demographics, comorbidities, and operative parameters were compared between patients with and without visual loss. A multivariate logistic regression was performed to identify significant risk factors for POVL development. No funds were received in support of this work. RESULTS: The incidence of POVL was 1.6 per 1,000 procedures (0.16%). Patients with visual loss were significantly more likely to be younger and male, have Medicaid as insurance, and undergo fusion of eight or more spinal levels compared with patients without visual loss. Following multivariate analysis, older patients (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.77-0.91) and female patients (OR: 0.08; 95% CI: 0.04-0.14) were significantly less likely to develop POVL compared with younger and male patients. On the other hand, having Medicaid as insurance (OR: 2.13;95% CI: 1.32-3.45), history of deficiency anemia (OR: 8.64; 95% CI: 5.46-14.31), and fusion of eight or more spinal levels (OR: 2.40; 95% CI: 1.34-4.30) were all independently associated with POVL. CONCLUSIONS: In this nationwide study, the incidence of POVL after scoliosis surgery in patients under the age of 18 was estimated at 0.16%, similar to the rate reported in adult patients. Cortical blindness accounted for all cases of POVL in the present study. Younger patients, patients with history of deficiency anemia, and patients undergoing long-segment fusions may be at increased risk of POVL after corrective surgery for pediatric scoliosis.

Implant-related Fractures in Children With Proximal Femoral Osteotomy: Blade Plate Versus Screw-side Plate Constructs.

BACKGROUND: Implant design may affect risk of fracture, especially in the proximal femur, which has been shown to have the highest risk of implant-related fracture (IRF). Blade plate (BPL) and screw-side plate (SSP) implants are used to stabilize proximal femoral osteotomies (PFOs). Our goal was to compare BPL and SSP constructs with regard to the rate, location, and timing of IRF in children undergoing PFOs. METHODS: We retrospectively reviewed clinical and radiographic records from 1 pediatric orthopaedic practice from 1995 through 2010. We identified 734 children 18 years or younger who underwent PFO with a BPL (480 patients) or an SSP (254 patients). Manufacture and style of implants were consistent throughout this period. There were no significant differences between the 2 groups in terms of mean age, sex, race, or diagnosis. The 2 groups were compared with respect to the rate, location, and timing of IRF. The t, Z, χ, and Fisher exact tests were used to analyze the data (statistical significance, P<0.05 for all analyses). RESULTS: The IRF rates were 2.9% and 1.6% in the BPL and SSP groups, respectively (P=0.27). The overall rate of IRF in all patients was 2.5%. Fractures distal to the implant occurred in 7 of 14 patients in the BPL group and 3 of 4 patients in the SSP group. There was no significant difference between the 2 groups in location of fracture with respect to the implant (P=0.78). The mean times to fracture were 3.8±2.9 and 2.4±2.3 years (P=0.39) in the BPL and SSP groups, respectively. CONCLUSIONS: The risk of IRF in children after PFO is substantial. Despite differences in design, there was no significant difference between BPL and SSP implants with respect to IRF risk. LEVEL OF EVIDENCE: Level III.

The Tibial Slope in Patients With Achondroplasia: Its Characterization and Possible Role in Genu Recurvatum Development.

BACKGROUND: Genu recurvatum, a posterior resting position of the knee, is a common lower extremity deformity in patients with achondroplasia and has been thought to be secondary to ligamentous laxity. To the best of our knowledge, the role of the tibial slope has not been investigated, and no studies describe the tibial slope in patients with achondroplasia. Our goals were to characterize the tibial slope in children and adults with achondroplasia, explore its possible role in the development of genu recurvatum, and compare the tibial slope in patients with achondroplasia to that in the general population. METHODS: We reviewed 252 lateral knee radiographs of 130 patients with achondroplasia seen at our clinic from November 2007 through September 2013. Patients were excluded if they had previous lower extremity surgery or radiographs with extreme rotation. We analyzed patient demographics and, on all radiographs, the tibial slope. We then compared the mean tibial slope to norms in the literature. Tibial slopes >90 degrees had an anterior tibial slope and received a positive prefix. Statistical analysis included intraclass and interclass reliability, Pearson correlation coefficient, and the Student t tests (significance, P<0.05). RESULTS: The overall mean tibial slope for the 252 knees was +1.32±7 degrees, which was significantly more anterior than the normal slopes reported in the literature for adults (7.2 to 10.7 degrees, P=0.0001) and children (10 to 11 degrees, P=0.0001). The Pearson correlation coefficient for mean tibial slope and age showed negative correlations of -0.4011 and -0.4335 for left and right knees, respectively. This anterior tibial slope produces proximal and posterior vector force components, which may shift the knee posteriorly in weightbearing. CONCLUSIONS: The mean tibial slope is significantly more anterior in patients with achondroplasia than in the general population; however, this difference diminishes as patients' age. An anterior tibial slope may predispose to a more posterior resting knee position, also known as genu recurvatum. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Evaluation of the Child with Short Stature.

Orthopedic surgeons frequently encounter short statured patients. A systematic approach is needed for proper evaluation of these children. The differential diagnosis includes both proportionate and disproportionate short stature types. A proper history and physical examination and judicious use of plain film radiography will establish the diagnosis in most cases. In addition to the orthopedic surgeon, most of these patients will also be evaluated by other specialists, including endocrinologists and geneticists. This article provides an overview of the evaluation of the child with short stature and offers several illustrative examples.

Is nonoperative treatment of pediatric type I open fractures safe and effective?

PURPOSE: There is limited literature on nonoperative treatment of open type I pediatric fractures. Our purpose was to evaluate the rate of infection in pediatric patients with type I open fractures treated nonoperatively at our institution without admission from the emergency department (ED). METHODS: We performed a retrospective chart review of all patients who sustained a type I open fracture of the forearm or tibia from 2000 through 2013. Forty patients fit the inclusion criteria: <18 years old with type I open fracture treated nonoperatively with irrigation and debridement, followed by closed reduction and casting of the fracture under conscious sedation in the ED. All patients were discharged home. The primary outcome was presence of infection. Secondary outcomes included occurrence of a delayed union, time to union, complications, and residual angulation. RESULTS: There were no reported or documented infections. There was one case of a retained foreign body (<1 cm) in a mid-diaphyseal forearm fracture, which was removed in clinic at 4 weeks after the patient developed a granuloma with no infectious sequela. There was one case of a delayed union; all patients eventually had complete bony union. There was minimal residual angulation in both upper and lower extremities at last follow-up. CONCLUSIONS: Nonoperative treatment of type I open fractures in pediatric patients can be performed safely with little risk of infection. This preliminary evidence may serve as a foundation for future prospective studies.

Spinal decompression in achondroplastic patients using high-speed drill versus ultrasonic bone curette: technical note and outcomes in 30 cases.

BACKGROUND: This manuscript describes the clinical and operative characteristics of achondroplastic children who undergo multilevel thoracolumbar decompressions using either the high-speed drill or the ultrasonic bone curette (BoneScalpel). METHODS: We retrospectively reviewed 30 thoracolumbar decompressions in achondroplastic patients at a single institution between 2008 and 2013. Patients were classified into either the high-speed drill cohort or the BoneScalpel cohort, depending on which instrument was utilized to perform the decompression. A technical note on the role of the ultrasonic bone curette in decompressing stenotic achondroplastic spines is also provided. RESULTS: In comparison with the high-speed drill cohort, the BoneScalpel cohort experienced less overall perioperative complications, including durotomy, cerebrospinal fluid leak, pseudomeningoceles, wound infection, and wound dehiscence. Although 45.0% of patients experienced a durotomy in the high-speed drill cohort, only 30.0% of patients experienced a durotomy in the BoneScalpel cohort (P = 0.694). In the high-speed drill cohort, the number of patients complaining of sensory disturbances, back pain, ataxia, incontinence, neurogenic claudication, radiculopathy, ataxia, and/or weakness decreased postoperatively. Similar results were observed in the BoneScalpel cohort. CONCLUSIONS: Although spinal decompression provides symptomatic resolution in patients with achondroplasia, intraoperative complications, in general, and durotomies, in particular, are common. Here, we report a decreased incidence in intraoperative durotomy and overall perioperative complication rates in the BoneScalpel cohort, although this did not reach the level of statistical significance. Nonetheless, the data demonstrate that the BoneScalpel is a safe and efficacious alternative to the high-speed drill in these challenging patients. LEVEL OF EVIDENCE: Level II-retrospective study.

Three-column osteotomies in the treatment of spinal deformity in adult patients 60 years old and older: outcome and complications.

STUDY DESIGN: Retrospective review. OBJECTIVE: To report and analyze the perioperative complications, radiographical results, and functional outcomes in elderly patients undergoing pedicle subtraction osteotomy (PSO) and/or vertebral column resection (VCR) procedures for spinal deformity correction. SUMMARY OF BACKGROUND DATA: To our knowledge, no studies have focused on 3-column osteotomies in the elderly. METHODS: We retrospectively reviewed prospectively collected data for 51 consecutive patients 60 years or older undergoing 3-column osteotomies for spinal deformity correction (PSO, 36 patients; VCR, 13 patients; PSO and VCR, 2 patients) and who had at least 2 years' follow-up. We analyzed the perioperative complications; the preoperative, postoperative, and final follow-up radiographical measurements; and the preoperative, postoperative, and final follow-up functional outcome scores (using the Scoliosis Research Society-22 questionnaire and Oswestry Disability Index). Hotelling's t2 test and the χ2 test were used for analysis (statistical significance, P < 0.05). RESULTS: There were 9 (18%) major complications (5 with PSO and 4 with VCR) and 20 (39%) minor complications (14 with PSO and 6 with VCR). Compared with preoperative values, improvement at 6 weeks after surgery averaged 16° (range, 0°-42°) in thoracic scoliosis, 14° (range, 2°-25°) in lumbar scoliosis, 9° (range, 5°-35°) in thoracic kyphosis, -24° (range, -12° to -68°) in lumbar lordosis, 2.4 cm (range, 0-12 cm) in coronal balance, and 6.9 cm (range, -2 to 20 cm) in sagittal balance. At final follow-up, improvements in the coronal and sagittal balance were maintained. By final follow-up, compared with preoperative state, there were significant improvements in all 5 Scoliosis Research Society-22 domains and in the Oswestry Disability Index. CONCLUSION: In the elderly patient, PSO and VCR can achieve significant restoration of sagittal and coronal balance and significant improvement in quality of life. However, both techniques can lead to serious complications and should be selectively used.

Clinical Results and Functional Outcomes in Adult Patients After Revision Surgery for Spinal Deformity Correction: Patients Younger than 65 Years Versus 65 Years and Older.

STUDY DESIGN: Retrospective comparison. OBJECTIVE: To compare complications and radiographic and functional outcomes of patients undergoing revision spinal deformity surgery, who were 40-64 years of age and 65 years of age or older. SUMMARY OF BACKGROUND DATA: The effect of age on radiographic and functional outcomes has not been well established in the literature for patients undergoing revision adult deformity surgery. The hypothesis was that the complications and radiographic and functional outcomes of younger and older adult patients would be comparable. METHODS: The authors retrospectively reviewed prospectively collected data on 109 consecutive patients (84 women and 25 men) undergoing revision spinal deformity surgery who were 40 years of age or older. All surgeries were performed at 1 institution by the senior author. Patients were divided into groups based on age: younger than 65 years of age (70 patients) or 65 years of age or older (39 patients), and complications and radiographic and functional outcomes were compared. All patients had at least 2 years' clinical follow-up. Hotelling's t2 test and the χ2 test were used to compare differences; statistical significance was set at p < .05. RESULTS: There was no significant difference between the 2 groups in major complications (p = .62), minor complications (p = .34), or reoperation rate (p = .08). Major correction was achieved in the coronal and sagittal planes in both groups after surgery. By final follow-up, patients in both groups had significant improvements from baseline in Oswestry disability index (p < .05) and in all Scoliosis Research Society-22 domains (p < .001); there was no significant difference in any domain score between groups (p > .05). CONCLUSIONS: Older adult patients undergoing revision deformity correction surgery achieved functional outcome benefits comparable to those in younger adults without significantly more complications. Surgeons should be aware of these factors when counseling patients regarding revision surgery for deformity correction.

Prevalence of Allograft Contamination During Intraoperative Processing for Spinal Deformity Correction Surgery.

STUDY DESIGN: Prospective study. OBJECTIVES: To prospectively evaluate bone allografts during spinal fusion surgery for 1) the rate of contamination as a result of perioperative preparation, and 2) the types of bacterial organisms that may be transmitted through the contaminated bone allograft. SUMMARY OF BACKGROUND DATA: Bone allografts are routinely used to enhance spinal arthrodesis procedures. Ready availability and lack of donor site morbidity make them valuable alternatives to iliac crest bone grafts. Reports of disease transmission of such organisms as hepatitis C, the human immunodeficiency virus, and a variety of bacterial pathogens through allograft bone implants raise concerns for patient and practitioner safety. METHODS: Our study population consisted of 50 consecutive (20 male and 30 female) patients (mean age at surgery, 15 years; range, 3-51 years) undergoing spinal deformity correction from May 2010 through October 2010, by 1 surgeon at 1 institution. The mean operative time was 297 minutes (range, 81-444 minutes), and the most commonly fused spinal levels were T5 to L4. During the procedure, the researchers prospectively obtained intraoperative microbial culture swabs from a container with freeze-dried allograft and from an empty identical control container. Aerobic and anaerobic bacterial culture growth was assessed for 7 days postoperatively. Each patient was observed for 6 weeks after surgery to ascertain any evidence of surgical-site infection. RESULTS: Microbial cultures showed bacterial growth in 4 cases: 1 allograft specimen (day 4, very light Staphylococcus aureus) and 3 control specimens (day 3, very light Enterococcus; day 4, very light S aureus; and day 6, Propionibacterium acnes). No patient showed signs of infection in the perioperative or 6-week postoperative period. CONCLUSIONS: Intraoperative allograft preparation is not a major source of bone allograft contamination during spinal surgery.

Is the 22 modifier worth it?

The 22 modifier is a Current Procedural Terminology code modifier that allows surgeons to receive additional reimbursement for complex procedures. The goal of this study was to evaluate the rate of, time to, and factors affecting reimbursement for 22-modifier cases filed by orthopedic surgeons. The authors reviewed the charts and billing data of the 150 noncharity spine and total joint replacement cases filed with a 22 modifier at 1 academic institution from 2004 through 2011. Of those 150 cases, 63 (42%) were reimbursed at a rate higher than the fee schedule. For all 150 cases, the mean amount and mean percentage of additional reimbursement were -$86±$1966 (P=.7) and 5.5%±37% (P=.04), respectively. The mean reimbursement time for private and public payers was 138±126 days (P<.001) and 118±129 days (P<.001), respectively (standard time, 30 and 15 days, respectively). The mean present values of the amount and percentage received compared with the fee schedule were -$144±$1966 (P=.8) and 4.1%±37% (P=.09), respectively (discount rate, 5%). Anatomic variant was the only cited reason that increased the probability of additional reimbursement (P=.016). Citing that the case required additional time had no bearing on additional reimbursement. The authors conclude that additional reimbursement with the 22 modifier is inconsistent, has significant payment delays, and is not worth the effort for total joint replacement or spine surgery.

Spica casting for pediatric femoral fractures: a prospective, randomized controlled study of single-leg versus double-leg spica casts.

BACKGROUND: At many centers, double-leg spica casting is the treatment of choice for diaphyseal femoral fractures in children two to six years old. We hypothesized that such patients can be effectively treated with single-leg spica casting and that such treatment would result in easier care and better patient function during treatment. METHODS: In a prospective, randomized controlled study, fifty-two patients two to six years old with a diaphyseal femoral fracture were randomly assigned to be treated immediately (after consent was obtained) with a single-leg (twenty-four patients) or double-leg (twenty-eight patients) spica cast. Serial radiographs were evaluated for maintenance of fracture reduction with respect to limb length, varus/valgus angulation, and procurvatum/recurvatum angulation. After cast removal, the performance version of the Activities Scale for Kids questionnaire and a custom-written survey were administered to the parents so that they could evaluate the ease of care and function of the children during treatment. Means were compared between treatment groups with use of Student t tests. P values of <0.05 were considered significant. RESULTS: All limbs healed in satisfactory alignment. The children treated with a single-leg spica cast were more likely to fit into car seats (p < 0.05) and fit more comfortably into chairs (p < 0.05). Caregivers of patients treated with a single-leg cast took less time off work (p < 0.05). There were no major complications. CONCLUSIONS: Treatment of pediatric femoral fractures with a single-leg spica cast is effective and safe, and postfracture patient care is facilitated. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Implant-related fractures in children: a 15-year review.

BACKGROUND: To our knowledge, there are no comprehensive clinical studies of implant-related fractures in children. Our goal was to identify the incidence, skeletal location, and associated diagnoses of implant-related fractures. METHODS: We reviewed our institutional database to identify cases of implant insertion (7584 cases) in patients less than 18 years old from January 1, 1995 through December 31, 2009. We calculated the overall incidence of these fractures and stratified the incidence by skeletal location and preoperative diagnoses. Fisher exact test was used to ascertain differences in fracture incidence. Risk ratios were calculated when appropriate. Significance was set at P<0.05. RESULTS: There were 25 cases of implant-related fractures: 22 in the femur, 2 in the tibia, and 1 in the radius. The overall incidence of implant-related fracture was 0.33%; the incidence by skeletal location was: femur, 0.89%; tibia, 0.1%; and radius, 0.14%. Associated diagnoses were cerebral palsy (9 cases), hip dysplasia (3 cases), spina bifida (2 cases), and avascular necrosis (1 case); 10 cases were associated with "other diagnoses," which included various skeletal syndromes (5 cases) and traumatic fractures (5 cases). The incidences of implant-related fractures by diagnoses were: cerebral palsy, 1.1%; hip dysplasia, 1.1%; spina bifida, 1.3%; and avascular necrosis, 0.35%. The incidence of implant-related fracture in the "other diagnoses" group was 0.16%, and the incidence of fracture in otherwise healthy patients was 0.084%. The femur was 15.2 times more likely to fracture than other bones (P<0.001). Diagnoses of cerebral palsy, hip dysplasia, spina bifida, and avascular necrosis were 6.1 times more likely to be associated with implant-related fractures than the "other diagnoses" (P<0.001). The mean time to fracture in the study was 2.8 years. The overall implant removal rate at our institution was 24.3%, and it varied significantly by patient diagnosis (P<0.01). CONCLUSIONS: Skeletal location and preoperative diagnosis should be factors of consideration in a surgeon's decision about removing implants to prevent implant-related fractures. LEVEL OF EVIDENCE: Prognostic Level III.

Sagittal spinopelvic parameters in children with achondroplasia: identification of 2 distinct groups.

OBJECT: Spinopelvic parameters in children with achondroplasia have not been described. Because they observed a unique sagittal spinopelvic phenotype in some achondroplastic children with very horizontal sacrums, the authors sought to quantify the spinopelvic parameters in a pediatric patient population. METHODS: A retrospective review was performed to identify all children (age range 1 month-10 years) with a diagnosis of achondroplasia between 2004 and 2009. Clinical and radiographic data were analyzed for age, sex, lumbar lordosis (LL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Differences among these variables were analyzed using a 2-tailed, unpaired Student t-test. RESULTS: Forty children, 23 males and 17 females, with achondroplasia were identified during the study period. The mean age was 2.6 years. Two groups of patients were identified based on PT (that is, negative or positive tilt and horizontal or not horizontal sacrum). A negative PT was identified in all children with an extremely horizontal sacrum. Seventeen children had a negative PT (mean -16.6°), and the mean parameters in this group were 65.4° for LL, 31.7° for TLK, 18.5° for TK, 43.3° for SS, and 26.4° for PI. Twenty-three children had a positive PT (mean 17.9°), and the mean parameters in this group were 53.4° for LL, 41.5° for TLK, 9.6° for TK, 30.8° for SS, and 43.8° for PI. A statistically significant difference was observed for LL (p = 0.01), TLK (p = 0.05), SS (p = 0.006), PT (p = 0.006), and PI (0.0002). CONCLUSIONS: Spinopelvic parameters in achondroplasia are potentially dichotomous. The future implications of this observation are not known and will need to be explored in future long-term studies that follow pediatric patients with achondroplasia through adulthood.