Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND: Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. METHODS: Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. RESULTS: Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. CONCLUSION: COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. LEVEL OF EVIDENCE: Level III-prognostic study.

Spinal osteoid osteoma in the pediatric population: A management algorithm and systematic review.

Purpose: The purpose of this study is to develop an accessible step-wise management algorithm for the management of pediatric spinal osteoid osteomas (OOs) based on a systematic review of the published literature regarding the diagnostic evaluation, treatment, and outcomes following surgical resection. Methods: A systematic review of the literature was conducted on PubMed to locate English language studies reporting on the management of pediatric spinal OOs. Data extraction of clinical presentation, management strategies and imaging, and treatment outcomes were performed. Results: Ten studies reporting on 85 patients under the age of 18 years presenting with OOs were identified. Back pain was the most common presenting symptom, and scoliosis was described in 8 out of 10 studies, and radicular pain in 7 out of 10 studies. Diagnostic, intraoperative, and postoperative assessment included radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), bone scans, and frozen section. Treatment options varied, including conservative management, open surgical resection with or without intraoperative imaging, and percutaneous image-guided treatment. All included studies described partial or complete resolution of pain in the immediate postoperative period. Conclusions: The proposed algorithm provides a suggested framework for management of pediatric spinal OOs based on the available evidence (levels of evidence: 3, 4). This review of the literature indicated that a step-wise approach should be utilized in the management of pediatric spinal OOs.

Vascular Injury After Scoliosis Correction in Ehlers-Danlos Syndrome: Proceed With Caution.

Ehlers-Danlos syndrome (EDS) is a rare inherited connective tissue disorder characterized by collagen synthesis disruption, resulting in joint hyperlaxity, skin and vascular fragility, and bleeding diathesis. Patients with EDS are susceptible to spinal deformities, with scoliosis accounting for up to 23.4% of musculoskeletal abnormalities. Conservative management is often trialed initially; however, severe scoliosis can lead to significant sagittal imbalance and cardiopulmonary compromise. Surgical intervention for scoliosis correction in patients with EDS presents unique challenges because of tissue fragility and an increased risk of vascular and wound complications. This case report discusses a 20-year-old man with type II EDS and scoliosis, who experienced retroperitoneal compartment syndrome, significant left lower extremity weakness, and loss of sensation after scoliosis correction surgery. The report also provides an overview of the existing literature on scoliosis surgery outcomes in patients with EDS, highlighting the need for heightened vigilance and cautious surgical approaches.

Osteochondroma of the Tibial Tubercle Masquerading as Osgood-Shlatter Disease: A Case Report.

Background: Osteochondromas are a relatively common primary bone tumor, which may share common clinical features with Osgood-Schlatter disease (OSD). A limited number of cases have described tumors misdiagnosed as OSD. Case Presentation: We report the case of an 11-year-old male with a sessile osteochondroma of the tibial tubercle and concomitant involvement of the distal extension and attachment of the patellar tendon into the tibial periosteum. A prior diagnosis OSD had been made. The lesion was resected and repair of the extensor mechanism was required at the time of surgery. The patient was followed for 20 months postoperatively and had restoration of knee function with minimal pain, as demonstrated by a PEDI-IKDC score of 94.6 at 19-month. Conclusion: This is a rarely reported case of benign tumor masquerading as OSD requiring excisional biopsy with extensor mechanism repair.

The Effects of Body Mass Index and Spine Flexibility on Surgical Outcomes for Patients With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the relationship between body mass index (BMI), spine flexibility index (FI), and their combined effects on adolescent idiopathic scoliosis (AIS) surgical outcomes. BACKGROUND: BMI and FI are two factors considered during presurgical planning for AIS correction, but there is sparse research about their relationship. We hypothesize that AIS patients with increased BMI may be associated with decreased FI-a combination which could lead to worsened surgical outcomes. MATERIALS AND METHODS: AIS patients ages 11 to 19 at surgery, who underwent posterior fusion at a single center from 2011 to 2017, were reviewed. Patients without proper radiographs to assess FI, or a previous spine surgical history, were excluded. FI was categorized as stiff (FI<50) or flexible (FI≥50), and patients were separated by major curve region. BMI was categorized as underweight (less than fifth percentile), healthy weight (fifth-85th percentile), overweight (85th-95th percentile), or obese (>95th percentile). Regression analysis was conducted to test BMI and FI's effects on intraoperative, immediate postoperative, and two-year postoperative outcomes. RESULTS: A total of 543 patients (82% female), with an average age of 14.9 years, were included. In all, 346 patients had available two-year data. A 10% increase in BMI was associated with a 1.3% decrease in FI for patients with major thoracolumbar/lumbar curves ( P =0.01). Obese patients were most likely to have a postoperative complication ( P =0.003) or a two-year complication ( P =0.04). Revision surgery occurred after 58% of postoperative complications (15/26) and 80% of two-year complications (4/5). FI was negatively associated with initial curve magnitude ( P <0.001), operative time ( P =0.02), and blood loss ( P =0.02). Overweight patients with flexible curves were 10.0 times more likely to sustain a postoperative complication than healthy weight patients with stiff curves ( P =0.001). CONCLUSIONS: Elevated BMI was associated with decreased FI in patients with major thoracolumbar/lumbar curves. Patients with a high BMI and high FI were associated with the greatest risk of postoperative complication.

Antegrade Elastic Intramedullary Nailing Insertion Technique Results in Higher Incidence of Symptomatic Implants in Pediatric Ulnar Fractures.

Retrograde and antegrade nailing techniques are the two options available to a surgeon when using elastic stable intramedullary nailing; however, the literature comparing these two nailing techniques is scarce. Thus, we conducted a retrospective review of all pediatric and adolescent ulnar fractures treated with elastic stable intramedullary nailing at our facility. We hypothesize that the clinical outcomes (implant and wound complications) and the time between surgery and radiographic union will be similar for both techniques. Methods: A retrospective chart review of pediatric ulnar fracture patients treated at our facility was performed. Demographic and health information associated with the injury were collected, and the clinical outcomes of the two techniques were compared. Results: A total of 53 patients with 54 fractures were included in this study. Antegrade nail insertion was used to treat 59.2% fractures. Radiographic union was achieved in all patients. Nail insertion technique was not associated with postoperative wound complications, time to radiographic union or implant removal, or significant deficits in upper extremity rotation (P > 0.05). Antegrade nailing resulted in a symptomatic implantation 3.97 times more frequently than compared with retrograde nailing (P = 0.036). Discussion: Antegrade nailing demonstrates a similar healing profile but higher implant complications compared with the retrograde nailing technique in pediatric ulnar fractures.

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011.

INTRODUCTION: Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011). METHODS: A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey. RESULTS: Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001). DISCUSSION: Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011. LEVEL OF EVIDENCE: Level IV. Type of evidence: therapeutic.

Impact of Insurance Status on Time to Evaluation and Treatment of Meniscal Tears in Children, Adolescents, and College-Aged Patients in the United States.

BACKGROUND: The meniscus is vital for load bearing, knee stabilization, and shock absorption, making a meniscal tear a well-recognized sport-related injury in children and young adults. An inverse relationship between the quality and value of orthopaedic care provided and the overall treatment cycle exists in which delayed meniscal tear treatment increases the likelihood of unfavorable outcomes. Although a majority of children and young adults have health insurance, many athletes within this demographic still face significant barriers in accessing orthopaedic services because of insurance type and household income. PURPOSE: To determine the impact of insurance status and socioeconomic markers on the time to orthopaedic evaluation and treatment as well as the rate of surgical interventions for meniscal tears in children and young adult athletes in the United States. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We conducted a retrospective review of all patients ≤22 years of age who presented to our institution between 2008 and 2016 and who were diagnosed with meniscal tears. Patients were categorized based on insurance and socioeconomic status. Dates of injury, referral, evaluation by an orthopaedic surgeon, and surgery were also recorded. Chi-square and regression analyses were utilized to determine the significance and correlation between the influencing factors and time to referral, evaluation, and surgery. RESULTS: Publicly insured, commercially insured, and uninsured patients comprised 49.4%, 26.6%, and 24.1%, respectively, of the 237 patients included in this study. Insurance status was predictive of time to orthopaedic referral, initial evaluation, and surgery (P < .01). Uninsured and publicly insured patients experienced significant delays during their orthopaedic care compared with commercially insured patients. However, no correlation was found between insurance status or household income and the rate of surgical interventions. CONCLUSION: Publicly insured and uninsured pediatric and college-aged patients faced significant barriers in accessing orthopaedic services, as demonstrated by substantially longer times between the initial injury and referral to an orthopaedic evaluation and surgery; however, these socioeconomic factors did not affect the rate of surgical management. Clinical competency regarding the effects of socioeconomic factors on the time to orthopaedic care and efforts to expedite care among underinsured and underserved children are vital for improving patient outcomes.

Management of Pediatric Tibial Shaft Fractures.

Diaphyseal tibia fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity and size. Treatment strategies include closed reduction and cast immobilization, flexible nails, uniplanar or multiplanar external fixation or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, although all fractures should have minimal rotational malalignment and less than 1 cm of shortening. Stable union generally occurs in 3 to 4 weeks for the common toddler's fracture and 6 to 8 weeks in other fracture patterns. Complications such as compartment syndrome are possible with both open and closed injuries, and nonunions, although rare, are more common in patients treated with external fixation or flexible nailing. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

The alpha angle as a predictor of contralateral slipped capital femoral epiphysis.

PURPOSE: Contralateral hip involvement in slipped capital femoral epiphysis (SCFE) is common. Femoral head-neck asphericity, as measured by an elevated alpha angle, has not previously been assessed with respect to SCFE risk. Our aim was to assess the utility of the alpha angle in predicting contralateral SCFE. METHODS: We retrospectively reviewed 168 patients (94 males) managed surgically for unilateral SCFE between 2001 and 2013 who had a minimum of 18 months follow-up. The alpha angle, the posterior sloping angle (PSA), and the modified Oxford score were recorded for every patient at the time of initial SCFE presentation. Follow-up clinical records and radiographs were assessed to determine the presence of absence of contralateral SCFE. RESULTS: Forty-five patients (27 %) developed a contralateral SCFE. Patients who developed a contralateral SCFE had a significantly higher alpha angle (51° vs 45°, p < 0.001) than patients who did not develop a contralateral SCFE. There was no significant difference in PSA or modified Oxford score (both p > 0.10) between patients who developed a contralateral SCFE and those who did not. Using a proposed alpha angle of 50.5° as a threshold for prophylactic fixation, 26 (58 %) of the 45 cases of contralateral SCFE in our study would have been prevented and 18 (15 %) of 123 patients would have undergone fixation unnecessarily. CONCLUSIONS: We found the alpha angle to positively correlate with contralateral SCFE risk. Patients with significantly elevated alpha angles may be at greater risk of contralateral SCFE and benefit from further investigation or prophylactic hip fixation.

Surgical Reconstruction of Metatarsal Type Preaxial Polydactyly Using an Amalgamating Osteotomy.

BACKGROUND: Polydactyly of the foot is a relatively common condition. Approximately 15% of cases are preaxial, with one third of these cases involving duplication of the metatarsal [metatarsal type preaxial polydactyly (MTPP)].Surgical reconstruction of polydactyly is indicated to improve shoe tolerance. Reconstruction of MTPP has traditionally involved resection of the hypoplastic lateral ray in addition to soft tissue reconstruction to correct hallux varus. Poor postoperative results have frequently been reported, primarily due to residual hallux varus. We present a novel surgical technique for the treatment of children with MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy that permits retention of the stable medial metatarsotarsal joint while avoiding the complication of residual hallux varus. METHODS: This was a retrospective case series describing the surgical technique of an amalgamating osteotomy in the treatment of patients with MTPP and a cosmetic lateral hallux. The surgical technique involves corresponding metatarsal osteotomies of the medial and lateral halluces, with amalgamation of the metatarsals and ablation of the residual medial hallux, without the need for extensive soft tissue reconstruction. Clinical and radiologic outcomes were evaluated at a minimum of 2 years postoperatively in 2 patients who underwent this technique. RESULTS: Two children, 1 female and 1 male, underwent an amalgamating osteotomy at the age of 31 and 18 months, respectively. At latest follow-up, 7.3 and 2.8 years after osteotomy, respectively, both patients displayed an excellent functional result according to the Phelps and Grogan clinical outcome scale. Plain radiographs in both cases demonstrated a well-aligned first ray with no growth abnormality and no hallux varus. CONCLUSIONS: We have presented a novel surgical technique for the reconstruction of MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy without extensive soft tissue reconstruction. This simple technique maintains the stable medial metatarsotarsal joint, permits ongoing longitudinal metatarsal growth, and avoids the complication of hallux varus. LEVEL OF EVIDENCE: Level IV-case series.

Quality, Safety, Value: From Theory to Practice Management What Should We Measure?

Over the past 35 years the health care community and in particular orthopaedic surgery, has undergone a transformation from retrospective case-series-based expert opinion to randomized prospective clinical trials. During this transition, orthopaedic surgeons have become very skilled in the measurement of physician-derived outcomes (radiographic angles, complications, recurrences, and mortality); however, these are not patient-centered outcomes and they are of little importance to our patients' satisfaction. Moving forward outcome measurement needs to be restructured to focus more on patient-reported outcomes. This paper outlines why outcome measurement is important, reviews outcome strategies that have been used historically, introduces a new outcome measurement tool and identifies strategies for future implementation and measurement of health care quality and value within pediatric orthopaedics.

Meniscal and chondral injuries associated with pediatric anterior cruciate ligament tears: relationship of treatment time and patient-specific factors.

BACKGROUND: Anterior cruciate ligament (ACL) tears are commonly associated with meniscal and chondral injuries. Although lateral meniscal tears are commonly associated with acute ACL injuries, the chronically ACL-deficient knee is associated with an increased rate of medial meniscal injury. These associations have been described in the adult knee literature. PURPOSE: To evaluate the relationship of elapsed time from injury with the incidence of meniscal and chondral injuries noted at the time of surgical treatment for ACL tears in pediatric patients. The effect of age, gender, weight, and mechanism of injury was also evaluated. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective chart review of pediatric patients undergoing primary arthroscopic ACL reconstruction between January 2005 and January 2011 was performed. The presence of meniscal tear, chondral injury, number of days from injury to treatment, age, weight, gender, and mechanism of injury were recorded. The data were analyzed for associations between elapsed time before surgery as well as patient-specific factors with rates of meniscal and chondral injuries. RESULTS: Three hundred seventy pediatric patients who underwent primary ACL reconstruction were included. Two hundred forty-one were treated ≤150 days (early) from injury, and 129 were treated >150 days (delayed) from injury. Ninety-one (37.8%) patients in the early treatment group and 69 (53.5%) patients in the delayed treatment group had medial meniscal tears (MMTs) (P = .014; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.12-2.83). Lateral meniscal tear (LMT) rates were similar (56.0% and 57.4%) in each group. Age >15 years also influenced the presence of MMTs (P = .033; OR, 1.6; CI, 1.04-2.54). Increased patient weight was associated with an increased rate of MMTs and LMTs. Fifty-four of 170 (31.8%) patients weighing ≤65 kg and 106 of 200 (53%) weighing >65 kg had MMTs (P < .001; OR, 2.2; CI, 1.36-3.42). Eighty-two of 170 (48.2%) patients weighing ≤65 kg and 127 of 200 (63.5%) weighing >65 kg had LMTs (P < .018; OR, 1.7; CI, 1.10-2.68). The presence of chondral injury was significantly associated with the presence of meniscal tear in the same compartment of the knee. CONCLUSION: Pediatric patients treated >150 days after injury for ACL tears have a higher rate of MMT than those treated ≤150 days after injury. Increased age and weight are independently associated with a higher rate of MMT. Patients with ACL tears and an MMT or LMT are more likely to have a chondral injury in that particular compartment than those without meniscal tears.