What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study.

Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

BACKGROUND: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

BACKGROUND: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. PURPOSE: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. RESULTS: At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). CONCLUSION: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

Do Year-Out Programs Make Medical Students More Competitive Candidates for Orthopedic Surgery Residencies?

OBJECTIVE: As orthopedic surgery residency programs are becoming more competitive, medical students interested in orthopedics are increasingly completing "year-out" programs. This study sought to evaluate student and faculty perceptions of these programs. DESIGN: A survey evaluating baseline characteristics was disseminated to directors of year-out programs identified through postings on the orthopedics forum, Orthogate.org. A second survey was sent to all program directors (PDs) of accredited US orthopedic residencies, while a final survey was distributed to participants identified by year-out PDs. SETTING: Ninety-six orthopedic year-out programs at 56 institutions were contacted. PARTICIPANTS: Twenty-six year-out programs, 72 PDs of ACGME-accredited orthopedic residencies, and 34 year-out participants from 6 programs completed our questionnaires. RESULTS: 73.1% (19) year-out program provided funding to participants, averaging $30,368. 84.6% (22) reported >75% match rates into orthopedics for participants. 65.4% (17) of programs selected students between their MS3/MS4 school years. 4.2% (3) of residency PDs agreed or strongly agreed that year-out programs were important factors for consideration in residency programs, compared with 82.4% (28) of year-out participants and 69.2% (18) of year-out PDs (p < 0.001). 58.8% (2) of year-out participants cited completion of a year-out for improving the chance of matching into any orthopedic residency, while 85.3% (29) wanted to be more competitive for top programs. The average Step 1 score was 248, which was insignificantly different from the national average for matched orthopedic applicants. CONCLUSIONS: Orthopedic year-out programs have dramatically increased in number over the last 20 years. Most of these programs are funded, 1-year clinical research fellowships with relative match success for participants pursuing orthopedic residencies. While year-out PDs and students consider participation in such programs to be an important factor for residency applications, and often participate in them in order to improve their competitiveness for matching at desired programs, residency PDs overall hold different views.

Analysis of Outcomes in Living Donor Liver Transplants Involving Reconstructive Microsurgeons.

BACKGROUND: Living donor transplantation is becoming increasingly popular as a modality for patients necessitating liver transplantation. Hepatic artery thrombosis (HAT) remains the most feared acute postoperative complication associated with living-donor liver transplantation. Preoperative planning, including scheduling reconstructive microsurgeons to perform the hepatic artery anastomosis using a surgical microscope or loupes, can decrease HAT rates. METHODS: A retrospective review of two reconstructive microsurgeons at a single institution was performed to analyze postoperative outcomes of adult and pediatric live donor liver transplants where reconstructive microsurgeons performed the hepatic artery anastomosis. One surgeon utilized the surgical microscope, while the other surgeon opted to use surgical loupes for the anastomosis. RESULTS: A total of 38 patients (30 adult and eight pediatric) met inclusion criteria for this study, and average patient age in the adult and pediatric population studied was 48.5 and 3.6 years, respectively. Etiologies of adult patients' liver failure were most commonly cholestatic (43%), followed by alcohol (23%), hepatitis C virus-related cirrhosis (17%), and nonalcoholic steatohepatitis (7%), while etiologies of pediatric liver failure were most commonly cholestatic (62.5%). None of the patients (0%) experienced acute postoperative HAT. On average, 22 and 25 months of postoperative follow-up was obtained for the adult and pediatric cohorts, respectively, and only one adult patient was found to have any liver-related complication. CONCLUSION: A collaborative relationship between reconstructive microsurgeons and transplant surgeons mitigates the risk of HAT and improves patient outcomes in living donor liver transplantation.

Lawnmower Injuries in Children: A National 13-Year Study of Urban Versus Rural Injuries.

INTRODUCTION: Although the American Academy of Orthopaedic Surgery, American Academy of Pediatrics, and Pediatric Orthopedic Society of North America have established lawnmower safety guidelines, a notable number of injuries continue to occur. We sought to elaborate on the epidemiology of lawnmower injuries in the pediatric age group and compare urban versus rural injuries. METHODS: The Pediatric Health Information System database was queried for patients of 1 to 18 years of age from 2005 to 2017 who presented with a lawnmower injury. Results were computed using bivariate tests and multinomial regressions. RESULTS: A total of 1,302 lawnmower injuries were identified (mean age 7.7 ± 5.1 years, range 1 to 18 years; 78.9% males). Incidence rates by region, adjusted for regional case volume, were 2.16 injuries per 100,000 cases in the South, 2.70 injuries per 100,000 cases in the Midwest, 1.34 injuries per 100,000 cases in the Northeast, and 0.56 injuries per 100,000 cases in the Western United States. After stratifying and adjusting for total case volume by locale (urban/rural), it was found that urban areas had an incidence rate of 1.47 injuries per 100,000 cases, whereas rural areas had a rate of 7.26 injuries per 100,000 cases. Rural areas had higher rates of infection and higher percentages of patients requiring inpatient stay. The surgical complication rate in rural areas was 5.5% as compared to 2.6% in urban areas. Based on urban/rural status, a significant difference was observed with the age group, length of stay, income, surgical complication, and presence of infection at the bivariate level with P < 0.05. Rural areas had an overall amputation rate of 15.5% compared with 9.6% in urban areas, with rural patients being 1.7 times more likely to undergo an amputation (P < 0.05). CONCLUSION: The findings of this study show that numerous geographic and locale disparities exist in pediatric lawnmower injuries and reveal the need for improved safety awareness, especially in at-risk rural populations.